Journal Article Review June 2018

June, 2018: “I’m now feeling much better after my wrist fracture, but am I eventually going get arthritis?”

Lalone E et al: Patient Reported Pain and Disability Following a Distal Radius Fracture: A Prospective Study. Open Orthop J. 2017 Jul 31;11:589-599.  Free PMC Article

You may have had patients express gratitude and concern as you discharged them from therapy after helping them recover motion and strength following a distal radius fracture. Here is some science to inform your answer.

Investigators from Canada prospectively followed 65 patients (17 men, 48 women, average age at injury 57 years) for an average of 11 years (range 2-20 years) after they had sustained a distal radius fracture. The participants were among 262 patients who had previously reported their results in a one-year follow-up study. Reasons for those choosing not to be part of the long-term study included time commitment, not recalling the injury, and doing well so not seeing any need for further analysis. Participants and non-participants in the long-term follow-up study did not differ significantly with respect to sex, age, or Patient Rated Wrist Evaluation (PRWE) scores at one year.  Original X-rays were available on 38 of the 65 long-term participants, so radiographic parameters of fracture pattern and bone alignment at healing could be analyzed. Continue reading:  

The long-term analysis consisted of each participant completing the 15-item PRWE outcome measure for the third time. The PRWE allows rating of wrist pain and disability during various daily living activities. A lower score indicates a better outcome. The investigators compared the recently obtained scores to those obtained at base-line and again 6-12 months after injury.

On average, PRWE scores were 70 at baseline and dropped to 17 at one year and to 12 at 2-20 years. Overall, 55/65 (85%) of participants reported having no change or less pain and disability at long-term follow-up, and this held steady from 2 and 10 years (84%) and from 10 and 20 years (85%).

The investigators were unable to identify any factors (sex, age, mechanism of injury, fracture pattern) that were predictive of outcome as long as 20 years after injury. The authors noted that, considering the common nature of distal radius fractures, 15% of those injured constitutes a large population burden of long-term pain and disability.

The investigators also addressed the possibility of selection bias because of the large number of participants in the one-year follow-up study who chose not to participate in the presently reported study. They also acknowledge that a much larger study would be required to identify specific patient and fracture characteristics that would be predictive of long-term outcome.

COMMENT: So according to the results of this study, we can tell patients that they will likely be doing well at a year after injury, and if so, they have an 85% chance of remaining the same or becoming even better over the ensuing years.

My experience suggests that we can be even more optimistic regarding long-term prognosis. An unknown percentage of people with scapho-lunate dissociations develop scapho-lunate advanced collapse pattern of osteoarthritis over decades following injury. This is well-known. It is certainly not common experience among hand surgeons nor is it reported in our literature, however, that patients initially doing well after distal radius fractures, even if the fracture is intra-articular and incompletely reduced, later become symptomatic. Consider that the current investigators analyzed long-term results in 65/262 patients who were studied at one year. That means that 197 were not taken into consideration for the long-term follow-up. I suspect that 95-99% of those 197 were asymptomatic or only minimally symptomatics. So 95% of 197 plus 85% of 65 equals 92%. And 99% of 197 plus 85% of 65 equals 95%.

My bottom-line response to the title question combines the results of this study with the literature and my experience: “You can expect to improve in comfort, motion, and strength for at least two years after injury and likely not give it another thought thereafter. Nothing is guaranteed, however, so save my phone number.”