Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

Long-term Outcomes of the Treatment of Distal Radial Fractures: a Narrative Review

BACKGROUND

Distal radius fractures are the second most common type of fractures encountered in the emergency room, with an incidence of 16 to 32 fractures per 10,000 person/year (the most common being hand bone fractures). The objective of this study was to review the literature on the long-term (a minimum of 3 years' follow-up) functional outcomes of treating distal radial fractures with different methods and get insight into the possible superiority of certain treatment methods (operative vs conservative) over other methods.

MATERIAL AND METHODS

Randomized clinical trials and observational studies reporting on functional and radiological outcomes of distal radial fractures treated conservatively vs operatively in adult patients found in the PubMed and Medline databases were reviewed. Published papers from the PubMed and Medline databases were included.

RESULTS

Nine studies were found that met the inclusion criteria for the analysis. The range of follow-up duration varied from 3 to 14 years, the size of the study groups ranged from 32 to 342 individuals and age of the patients ranged from 18 to 76 years. All the papers reported no significant differences between long-term functional outcomes after surgical vs conservative treatment. All studies reported better radiological outcomes after surgical treatment and worse outcomes for plaster cast immobilization, the latter combined with a high rate of re-dislocations and frequent malunions. This, however, did not translate into worse clinical outcomes. We noticed some significant bias in the studies analysed that significantly affects the reliability and validity of conclusions drawn from these studies.

CONCLUSIONS

1. Our review shows that treatment outcomes of distal radial fractures are generally good regardless of the method used. 2. Current literature does not provide uniform evidence to prove the superiority of a particular treatment method when long-term functional outcomes are compared. 3. Conservative treatment by closed reduction and plaster cast immobilization still appears to be a good option for treatment of these fractures, particularly in older patients. 4. There is still a need for research conducted according to trustworthy and credible scientific criteria, to obtain reliable data and improve the treatment guidelines.

Distal Radius Fracture Rehabilitation

Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.

Performance of Fracture Risk Assessment Tools by Race and Ethnicity: A Systematic Review for the ASBMR Task Force on Clinical Algorithms for Fracture Risk

The American Society of Bone and Mineral Research (ASBMR) Professional Practice Committee charged an ASBMR Task Force on Clinical Algorithms for Fracture Risk to review the evidence on whether current approaches for differentiating fracture risk based on race and ethnicity are necessary and valid. To help address these charges, we performed a systematic literature review investigating performance of calculators for predicting incident fractures within and across race and ethnicity groups in middle-aged and older US adults. We included English-language, controlled or prospective cohort studies that enrolled US adults aged >40 years and reported tool performance predicting incident fractures within individual race and ethnicity groups for up to 10 years. From 4838 identified references, six reports met eligibility criteria, all in women. Just three, all from one study, included results in non-white individuals. In these three reports, non-white women experienced relatively few major osteoporotic fractures (MOFs), especially hip fractures, and risk thresholds for predicting fractures in non-white women were derived from risks in the overall, predominantly white study population. One report suggested the Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) overestimated hip fracture similarly across race and ethnicity groups (black, Hispanic, American Indian, Asian, white) but overestimated MOF more in non-white than White women. However, these three reports were inconclusive regarding whether discrimination of FRAX or the Garvan calculator without BMD or of FRAX with BMD for MOF or hip fracture differed between white versus black women. This uncertainty was at least partly due to imprecise hip fracture estimates in black women. No reports examined whether ratios of observed to predicted hip fracture risks within each race or ethnicity group varied across levels of predicted hip fracture risk. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Self-Efficacy for Managing Injury After Distal Radius Fracture: A Mixed Methods Exploration

Self-efficacy for managing injury may contribute to variation in clients' support needs after distal radius fracture (DRF). This study aimed to (a) explore associations between self-efficacy for managing injury and self-reported health and (b) compare qualitative descriptions of the self-management process and outcome between high and low self-efficacy groups. In this cross-sectional convergent mixed methods study, 31 adults aged 45 to 72 with a unilateral DRF completed patient-reported outcome measures and a semi-structured interview 2 to 4 weeks after discontinuing full-time wrist immobilization. Higher self-efficacy was moderately associated with better physical, mental, and social health. The High-Self-Efficacy group described self-directed behaviors to manage injury sequelae and more confidence in their ability to use their injured hand. They also described less disruptive physical and emotional symptoms and fewer participation restrictions compared with the Low-Self-Efficacy group. Findings suggest that occupational therapy practitioners should assess and address self-efficacy for managing DRF sequelae to support recovery.

Prognostic factors for persistent pain after a distal radius fracture: a systematic review

Introduction

The aim of this systematic review was to synthesize the evidence regarding prognostic factors for persistent pain, including Complex Regional Pain Syndrome (CRPS), after a distal radius fracture (DRF), a common condition after which persistent pain can develop.

Methods

Medline, Pubmed, Embase, Psychinfo, CINAHL, BNI, AMED and the Cochrane Register of Clinical Trials were searched from inception to May 2021 for prospective longitudinal prognostic factor studies investigating persistent pain in adults who had sustained a DRF. The Quality in Prognostic Studies (QUIPS) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework were used to assess the strength of evidence.

Results

A search yielded 440 studies of which 7 studies met full eligibility criteria. From five studies we found low evidence for high baseline pain or an ulnar styloid fracture as prognostic factors for persistent pain, and very low evidence for diabetes or older age. From two studies, investigating an outcome of CRPS, there was low evidence for high baseline pain, slow reaction time, dysynchiria, swelling and catastrophising as prognostic factors, and very low evidence for depression. Sex was found not to be a prognostic factor for CRPS or persistent pain.

Conclusions

The associations between prognostic factors and persistent pain following a DRF are unclear. The small number of factors investigated in more than one study, along with poor reporting and methodological limitations contributed to an assessment of low to very low strength of evidence. Further prospective studies, investigating psychosocial factors as candidate predictors of multidimensional pain outcomes are recommended.