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Faster union and functional recovery with early mobilization of ulnar fractures

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Faster union and functional recovery with early mobilization of ulnar fractures

Vol: 2| Issue: 9| Number:27| ISSN#: 2564-2537
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:3
Journal Level of Evidence:N/A

A systematic review of the non-operative treatment of nightstick fractures of the ulna

Bone Joint J. 2013 Jul;95-B(7):952-9. doi: 10.1302/0301-620X.95B7.31669

Contributing Authors:
XZ Cai SG Yan G Giddins

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27 studies (1629 fractures) were evaluated in this meta-analysis/systematic review to compare conservative treatments- immobilization, bracing, or early mobilization- for nightstick fractures of the ulna. Early mobilization produced the shortest radiological time to union and lowest mean rate of non-union, while above-or below-elbow immobilization and braces had the longest time of union and higher mean rates of non-union. No differences were seen in the non-union or delayed union rates between early mobilization and the 3 forms of immobilization.

Publication Funding Details +
Non-Industry funded
Grants from Zhejiang Provincial Natural Science Foundation of China (Y2110239), National Natural Science Foundation of China (81101345), and Zhejiang Key Program Science and Technology (2011C13033)
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.




Accessing Data


Analysing Data





Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Nightstick fractures are isolated fractures of the ulna. They have high rates of complications, non-unions, delayed unions, residual angulation, and loss of movement. Immobilization in above elbow cast has been the standard treatment for stable fractures, but studies argue that early mobilization might be a better option. Due to the lack of methodological quality in previous studies, this systematic review was conducted on newer material to determine the best conservative treatment for nightstick fractures.

What was the principal research question?

How do conservative treatments for nightstick fractures of the ulna, such as immobilization, bracing, or early mobilization, compare to one another?

Study Characteristics -
Data Source:
A search was conducted by 3 authors (XZC, SGY, GG) on EMBASE, OVID, Scopus, ISI Web of Science, Cochrane Library, Clinical Trial Grade Center, Google, and Chinese VIP Database up to November 27, 2012 with no language or year restrictions. Additional searches were conducted on the Clinical Trial Registry, Current Controlled Trials, Trials Central, Centre Watch, Google Scholar, orthopaedic association websites, and conference proceedings. Reference lists were also searched.
Index Terms:
The search terms were ('Ulnar Fractures' [Mesh]) OR ('Ulna' AND 'Fractures') OR (nightstick fracture)
Study Selection:
Two independent authors searched for randomized controlled trials, non-randomised or quasi-randomised controlled trials, prospective cohort trials, or retrospective comparative studies reporting conservative treatment of isolated ulnar fractures by use of above- or below-elbow casts, bracing, splints, bandages, slings or nothing. Studies had to report at least one of the following outcomes: clinical/radiological time to union, return to work, the rate of non- and delayed union, the function of the wrist, forearm or elbow, subjective satisfaction, loss of movement, deformity or other complications. Disagreements were resolved through discussion.
Data Extraction:
Two independent reviewers extracted patient demographics, fracture morphology, review criteria (follow-up, loss to follow-up, methodology), study design, level of evidence, intervention and assessment of outcome. Original authors were contacted for missing data. Methodological quality of studies was independently evaluated by Critical Appraisal Skills Programme (CASP). All Disagreements were evaluated by the K test and resolved by discussion.
Data Synthesis:
Data analysis was conducted by STATA 12.0 (Stata Corp, College Station, Texas). Rates of delayed and nonunion were represented as means. The chi-squared and Fisher’s exact tests detected difference with cut-off value for a statistically significant difference of 0.017. Radiological times to union and functional assessment data were not pooled. Begg’s test was used for publication bias, with significance of p </= 0.05.

What were the important findings?

  • 27 studies (1629 fractures) (3 RCTs, 3 prospective cohort, 8 retrospective cohort studies, and 13 case series) were selected by two independent authors.
  • 20 studies reported mean time to radiological union. 6 stated mean times to clinical union. 24 studies reported low or very low rates of delayed or nonunion.
  • Early mobilization had the shortest mean time to radiological union and the lowest mean rate of nonunion, while above- and below-elbow immobilization had the longest mean times to radiological union and the highest mean rate of nonunion.
  • No significant difference was seen between early mobilization and the 3 immobilization methods for nonunion (above-elbow vs early mobilization, p = 0.142; below-elbow vs early mobilization p = 0.456; bracing vs early mobilization, p = 1.0) or in delayed union (above-elbow vs early mobilization, p = 1.0; below-elbow vs early mobilization, p = 0.456; bracing vs early mobilization p = 0.063).
  • 19 studies reported functional assessment. 4 studies with above- and below-elbow casts indicated good or excellent function in < 70% of patients, compared to >90% in all studies with early mobilization.
  • Loss of movement was the most common complication.
  • No significant publication bias was seen in in the nonunion rate for above-elbow immobilization and below elbow immobilization, or in the delayed union rate for above-elbow immobilization (all p>0.05).

What should I remember most?

The study indicated that early mobilization had a trend towards faster union rates and better functional recovery, compared to immobilization in treatment of stable night stick fractures. The differences, however, were not significant. There were no observed differences between different types of immobilization.

How will this affect the care of my patients?

The authors recommend early immobilization as a cheaper and more convenient method, for better results. Because of high publication biases of the studies, further larger randomized controlled trials need to be contributed to the body of evidence.

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