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Journal of Orthopaedic Surgery 2015;23(1):24-8
Factors associated with one-year outcome after distal radial fracture treatment Jonathan Cowie,1 Raymond Anakwe,2 Margaret McQueen3
Victoria Hospital Kirkcaldy, Kirkcaldy, United Kingdom St. Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom 3 Edinburgh Orthopaedic Trauma Unit, Edinburgh, United Kingdom 1 2
ABSTRACT Purpose. To identify factors that affect functional outcome one year after distal radial fracture treatment. Methods. 521 women and 121 men aged 16 to 92 (mean, 59) years with distal radial fractures underwent external fixation (n=123), open reduction and internal fixation (n=63), a combination of both (n=10), distal radial osteotomy for symptomatic malunion (n=90), or casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia. The indication for surgery (rather than casting) was metaphyseal instability. Radiographic evaluation (dorsal angulation, radial shortening, carpal malalignment, and malunion) was made before and after treatment and after fracture healing. Functional evaluation (range of movement, grip strength, and activities of daily living) was made at a mean of 16 (range, 6–54) months after injury. Results. After multiple regression analysis, poorer functional score was associated with increasing age (p<0.001), dorsal angulation after healing (p<0.016),
presence of volar comminution (p=0.005), and pain (p<0.001). Poorer grip strength was associated with non-dominant side injury, increasing age, dorsal angulation after healing, positive ulnar variance, comminution, and pain (all p<0.001). Predicted malunion showed colinearity with age (r=0.657), dorsal comminution (r=0.694), and dorsal angulation (r=0.626). Conclusion. Understanding factors associated with outcome helps surgeons to make the treatment decision for distal radial fracture to achieve optimum outcome. Key words: radius fractures; treatment outcome
INTRODUCTION More than 70 000 distal radial fractures occur each year in the United Kingdom.1,2 Distal radial fractures may compromise independent functioning, particularly in older patients.3,4 Open reduction and internal fixation with volar locked plates enables anatomic restoration.5,6 Nonetheless, anatomic restoration may
Address correspondence and reprint requests to: Jonathan Cowie, Victoria Hospital Kirkcaldy, Kirkcaldy, United Kingdom. Email: [email protected]
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Factors associated with one-year outcome after distal radial fracture treatment
not be associated with good functional outcome.7,8 Non-injury factors such as age, injury compensation, education, and comorbidities also affect patient-rated outcome.9,10 This study aimed to identify factors that affect functional outcome one year after distal radial fracture treatment. MATERIALS AND METHODS Between January 2003 and July 2007, 521 women and 121 men aged 16 to 92 (mean±standard deviation, 59±17) years with distal radial fractures after a fall from standing height (n=486), a fall from a height (n=57), sporting activity (n=54), road traffic accident (n=32), or other (n=13) underwent external fixation (n=123), open reduction and internal fixation (n=63), a combination of both (n=10), distal radial osteotomy for symptomatic malunion (n=90), or casting with (n=194) or without (n=162) prior closed manipulation under regional anaesthesia. The indication for surgery (rather than casting) was metaphyseal instability. Patients with intra-articular displacement requiring open reduction were excluded. The mean age of the women was higher than that of the men (63 years vs. 41 years). According to the AO classification,11 fractures were classified as type A (n=262), type B (n=50), or type C (n=299); data for 31 patients were missing. 499 patients had dorsal (n=388), volar (n=33), or both (n=78) metaphyseal comminution; data for 6 patients were missing. 160 patients had carpal malalignment; data for 148 patients were missing. Radiographic evaluation of the injured and opposite wrists was made before and after treatment and after fracture healing; data for 39 patients were missing. Dorsal angulation was defined as the degrees from the neutral position, with volar tilt in negative degrees.12 Radial shortening was defined as the vertical distance between the ulnar border of the distal radius and the most distal point of the head of the ulna.13 Carpal malalignment was defined as the dorsal or volar displacement of the longitudinal axis of the capitate in relation to the long axis of the radius.4 Malunion was defined as a dorsal angle of >0º with carpal malalignment, a volar angle of <15º with carpal malalignment, radial shortening of >3 mm, or a combination of these. Functional evaluation of both hands and wrists was made by a physiotherapist at a mean of 16 (range, 6–54) months after injury. Measurement was expressed as a percentage of the opposite uninjured side. Pain at rest was measured using a visual analogue scale (VAS). The range of movement was
measured using a goniometer. Flexion, extension, pronation, supination, and radial and ulnar deviation were measured in triplicate and the mean was used to minimise intra-observer bias. The hand grip strength was measured using the second grip handle of the Jamar hand dynamometer.14,15 The strength was adjusted by 10% for the non-dominant hand.16 Chuck, key, and pinch grip strengths were also measured. The functional score for activities of daily living was assessed using a validated system.17 Raw scores were converted into percentages of the uninjured side. The percentage of the functional score on the opposite uninjured side was tested for association with each factor separately by Spearman rank correlation or Kruskal-Wallis tests. Multiple ordinal logistic regression was used to test which factors predicted the difference in score between the injured and opposite sides after adjusting for one another. Multiple linear regression for each of the 11 quantitative measurements of the functional score was carried out using the value on the injured side as the dependent variable. A stepwise approach was used in which only those with independent predictive significance were retained. Distribution of scores of 5 functional tests were highly skewed and were analysed using parametric methods after logarithmic transformation. According to equations to predict the probability of malunion and carpal malalignment,18 the correlations for probability of carpal malalignment and malunion were calculated for functional score and grip strength using Spearman rank correlation testing. RESULTS The mean dorsal angulation improved from 13.9º (range, -33º–56º) to 3.3º (-43º–48º) [p<0.001] and the mean ulnar variance improved from 2.1 (range, -0.6– 28) mm to 1.9 (-0.6–12) mm (p<0.001). Complications developed included complex regional pain syndrome (n=12), carpal tunnel syndrome (n=17), pin site infection (n=19), and mal-union (n=44). The mean functional score was 97% of the opposite normal side. 589 patients had a functional score of ≥90%, 53 scored <90%, and 3 scored <50%. Poorer functional score was associated with increasing age (p<0.001, Spearman rank correlation), female sex (p=0.026, Kruskal-Wallis test), dorsal angulation after healing (p<0.001, Spearman rank correlation), presence of volar comminution (p=0.002, Kruskal-Wallis test), positive ulnar variance after healing (p=0.031, Spearman rank correlation), lowenergy injury (p=0.026, Kruskal-Wallis test), and pain
Journal of Orthopaedic Surgery
J Cowie et al. Table Factors associated with grip strength
Factor Injury side Age Injury force Final dorsal angulation Volar comminution Dorsal comminution Original ulnar variance Pain
2.1 to 4.4 -1.2 to -0.4 -5.5 to -0.8 -1.1 to -5.1 -4.2 to -0.7 -4.0 to -1.5 -0.7 to -0.3 -2.2 to -1.7
(p<0.001, Kruskal-Wallis test). After multiple regression analysis, increasing age (p<0.001), dorsal angulation after healing (p<0.016), presence of volar comminution (p=0.005), and pain (p<0.001) remained significant for poorer scores. The mean grip strength was 73.5% of the uninjured side. 442 patients regained ≥50% and 273 regained ≥75% of grip strength. Poorer grip strength was associated with non-dominant side injury, increasing age, dorsal angulation after healing, positive ulnar variance, comminution, and pain (all p<0.001, Table). Better grip strength was associated with low-energy injuries, no comminution, and less shortening. The mean supination and pronation of the injured arms at follow-up were 84.2º and 78.5º, respectively, which were both 97% those of the opposite arm. Decreased supination was associated with dorsal comminution (p=0.005, Spearman rank correlation), complex regional pain syndrome (p=0.015, Spearman rank correlation), and carpal tunnel syndrome (p=0.003, Spearman rank correlation). Decreased pronation was associated with female sex (p<0.001, Kruskal-Wallis test) and malunion (p=0.007, Spearman rank correlation). The mean flexion of the injured wrists at follow-up was 62.2º, which was 85% that of the opposite wrist. Better flexion was associated with injury on the dominant side (p<0.001, Kruskal-Wallis test), whereas poorer flexion was associated with increasing dorsal angulation after healing (p<0.001, Spearman rank correlation), carpal malalignment (p=0.002, Kruskal-Wallis test), and greater positive ulnar variance (p=0.011, Spearman rank correlation). The mean extension of the injured wrists at follow-up was 55.1º, which was 94% that of the opposite wrist. Lower extension was associated with the injury side (p=0.015, Kruskal-Wallis test), volar comminution (p=0.021, Kruskal-Wallis test), and positive ulnar variance (p=0.031, Spearman rank correlation). The prediction was further improved by
Comparison Dominant vs. non-dominant Increase of 10 years Low-energy vs. high-energy Present vs. absent Present vs. absent Present vs. absent
complex regional pain syndrome or 6-week dorsal angulation (p<0.001, Spearman rank correlation) and again by one-year dorsal angulation (p<0.001, Spearman rank correlation). The flexion-extension arc of movement was associated with volar comminution, dorsal comminution, and positive ulnar variance (all p<0.001, Spearman rank correlation). According to equations to predict the probability of malunion and carpal malalignment,18 a higher probability of malunion correlated with a lower functional score (R= -0.12, p=0.002) and a worse grip strength (R=-0.16, p<0.001). A higher probability of carpal malalignment correlated with a lower functional score (R=-0.11, p=0.005) and a weaker grip strength (R= -0.13, p=0.001). The predicted malunion risk was added to the multiple regression model, but only improved the r2 by 0.001. Predicted malunion showed colinearity with age (r=0.657), dorsal comminution (r=0.694), and dorsal angulation (r=0.626). DISCUSSION There is conflicting evidence for the effect of residual dorsal angulation on function,19–27 possibly because of the difficulty in obtaining accurate measurements.7 Carpal malalignment is associated with poorer recovery of grip strength and range of movement,22 whereas a scapholunate angle of >25º is associated with poor outcome.28 In our study, both residual dorsal angulation and carpal alignment were independent risk factors for poor outcome. Positive ulnar variance is associated with pain,29 weak grip strength,30 increased risk of arthrosis in the long term,19 and poorer functional outcome.24,26,28,31 However, none of these studies adjusted for age. The equations to predict the probability of malunion of distal radial fractures were a surrogate
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Factors associated with one-year outcome after distal radial fracture treatment
measure for severity of an extra-articular or minimal articular fracture.18 A higher probability of malunion was associated with a lower functional score and weaker grip strength; the more severe the fracture the worse the outcome regardless of the final radiological outcome. This study had limitations. The Disabilities of the Arm, Shoulder and Hand Score was not measured, nor was psychological status, illness behaviour, socioeconomic status, or injury compensation; all
of which have been shown to affect outcome.10,31,32 Fractures with articular displacement occur in <5% of distal radius fractures,33 but in our study, only extraarticular fractures or undisplaced fractures were included. DISCLOSURE No conflicts of interest were declared by the authors
REFERENCES 1. Thompson PW, Taylor J, Dawson A. The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury 2004;35:462–6. 2. O’Neill TW, Cooper C, Finn JD, Lunt M, Purdie D, Reid DM, et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001;12:555–8. 3. Moore CM, Leonardi-Bee J. The prevalence of pain and disability one year post fracture of the distal radius in a UK population: a cross sectional survey. BMC Musculoskelet Disord 2008;9:129. 4. Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial fractures in young adults. J Hand Surg Br 2000;25:535–43. 5. Chung KC, Watt AJ, Kotsis SV, Margaliot Z, Haase SC, Kim HM. Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Joint Surg Am 2006;88:2687–94. 6. Fanuele J, Koval KJ, Lurie J, Zhou W, Tosteson A, Ring D. Distal radial fracture treatment: what you get may depend on your age and address. J Bone Joint Surg Am 2009;91:1313–9. 7. Ng CY, McQueen MM. What are the radiological predictors of functional outcome following fractures of the distal radius? J Bone Joint Surg Br 2011;93:145–50. 8. Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011;93:775–8. 9. Grewal R, MacDermid JC, Pope J, Chesworth BM. Baseline predictors of pain and disability one year following extraarticular distal radius fractures. Hand (N Y) 2007;2:104–11. 10. Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes after surgical treatment of distal radius fractures. J Hand Surg Am 2007;32:76–83. 11. AO classification of fractures. Available at: http:// www.aofoundation.org. Accessed on 7 March 2013. 12. van der Linden W, Ericson R. Colles’ fracture. How should its displacement be measured and how should it be immobilized? J Bone Joint Surg Am 1981;63:1285–8. 13. Melone CP Jr. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36. 14. American Association for Surgery of the Hand. Clinical assessment recommendations. The hand: examination and diagnosis. 2nd ed. New York: Churchill Livingstone; 1983:106–7. 15. American Society of Hand Therapists. Garner NC, editor. Clinical assessment recommendations. The Society; 1981:6–8. 16. Bechtol CO. Grip test; the use of a dynamometer with adjustable handle spacings. J Bone Joint Surg Am 1954;36:820–4. 17. Sheehan NJ, Sheldon F, Marks D. Grip strength and torquometry in the assessment of hand function in patients with rheumatoid arthritis. Br J Rheumatol 1983;22:158–64. 18. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am 2006;88:1944– 51. 19. Forward DP, Davis TR, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg Br 2008;90:629–37. 20. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am 1951;33:895–907. 21. Kopylov P, Johnell O, Redlund-Johnell I, Bengner U. Fractures of the distal end of the radius in young adults: a 30-year follow-up. J Hand Surg Br 1993;18:45–9. 22. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br 1988;70:649– 51. 23. Porter M, Stockley I. Fractures of the distal radius. Intermediate and end results in relation to radiologic parameters. Clin Orthop Relat Res 1987;220:241–52. 24. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19:325–40. 25. Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial fractures in young adults. J Hand Surg Br 2000;25:535–43. 26. Wilcke MK, Abbaszadegan H, Adolphson PY. Patient-perceived outcome after displaced distal radius fractures. A comparison between radiological parameters, objective physical variables, and the DASH score. J Hand Ther 2007;20:290–8. 27. Wakefield AE, McQueen MM. The role of physiotherapy and clinical predictors of outcome after fracture of the distal
J Cowie et al.
Journal of Orthopaedic Surgery
radius. J Bone Joint Surg Br 2000;82:972–6. 28. Batra S, Gupta A. The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures. Injury 2002;33:499–502. 29. Jenkins NH, Jones DG, Mintowt-Czyz WJ. External fixation and recovery of function following fractures of the distal radius in young adults. Injury 1988;19:235–8. 30. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. J Bone Joint Surg Br 1996;78:404–9. 31. MacDermid JC, Roth JH, Richards RS. Pain and disability reported in the year following a distal radius fracture: a cohort study. BMC Musculoskelet Disord 2003;4:24. 32. MacDermid JC, Donner A, Richards RS, Roth JH. Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture. J Clin Epidemiol 2002;55:849–54. 33. Hayes AJ, Duffy PJ, McQueen MM. Bridging and non-bridging external fixation in the treatment of unstable fractures of the distal radius: a retrospective study of 588 patients. Acta Orthop 2008;79:540–7.