Journal Article Review November 2017

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

Studies that assess outcomes greater than two years after distal radius fracture are sparse. Investigators in London, Ontario, recently evaluated 65 patients at an average of 11 years (range 2-20 years) following treatment for distal radius fractures. These were among 262 patients who had participated in a previous prospective study and all had Patient-rated Wrist Evaluation (PRWE) scores from one-year follow-up.

The investigators sought to answer these questions: Do symptoms worsen over many years? What factors (cause of injury, age, sex, length of follow-up) will predict which patients will do poorly over the long term?

All participants in the previous study were contacted by mail, and 65 returned their completed PRWE questionnaires. Baseline characteristics (sex, age at fracture, baseline PRWE, and one-year PRWE) did not differ significantly between those who participated and those who did not participate in the long-term study.

One-year PRWE scores averaged 17.4 and long-term PRWE scores averaged 11.8 (lower is better). Overall, 55 patients (85%) had no change or had less pain and disability at long-term follow-up compared to one-year follow-up. This percentage did not differ between those followed 2-10 years and those followed 10-20 years.

Neither current patient age, sex, nor injury mechanism had a significant influence on the long-term follow-up PRWE scores. The ten patients who worsened over the long-term interval reported having hypertension, diabetes, depression, osteoarthritis, rheumatoid arthritis, osteoporosis, and other medical conditions, but such comorbidities were also present in the 85% of patients who did not have worse PRWE scores at long-term follow-up.

Study strengths include its prospective design and use of the validated PRWE at the beginning and end of the study, which eliminated the risk of recall bias. A weakness was that some of the original 262 patients who did not recall having a fracture or who had no long-term sequelae were less likely to complete the PRWE.

COMMENT: Patients will naturally ask if their distal radius fracture is going to be chronically painful, if they are going to develop early arthritis, and if their function will improve or deteriorate over the long term. This study approaches answers to these questions by using the objective PRWE, and the study results indicate that overall, patients have at least an 85% chance of being better 2-20 years after fracture than they were at one year. The good results are likely higher than this since patients with no recall or no symptoms were less likely to respond to the questionnaire than those with residual symptoms.

 To answer the questions more accurately, it would be helpful to know if the original fracture (degree of comminution, degree of displacement, method of treatment, and final alignment) had an effect on the long-term outcome. My general impression (level V evidence) is that once the fracture heals, even if it is moderately malunited, symptoms resolve. It would be great to have level I evidence to support or refute general impressions.

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