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Fractures of the distal radius: radiological measurements and clinical outcome
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Ortopedi.ORCID-id: 0000-0002-8727-9555
2024 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)Alternativ titel
Distala radiusfrakturer : radiologiska mätningar och kliniskt utfall (Svenska)
Abstract [en]

The most common fracture is the distal radius fracture (DRF). Wrist function is of importance for the ability to perform activities of daily living, work-related tasks and leisure activities. Treatment generally focuses on restoring anatomical alignment and providing adequate rehabilitation.

To improve our knowledge of DRFs, this thesis explores factors affecting clinical and radiological outcomes in the short- and long-term after a DRF.

Paper I analysed the magnitude of radiographic malalignment leading to deterioration in clinical outcomes. Some 366 patients with prospective data were analysed 1 year after fracture. A nonlinear association between radiographic and clinical outcome was found for dorsal tilt. Larger malalignment resulted in increasingly worse outcomes, starting from about 5 degrees of dorsal tilt and progressing with increasing malalignment.

In Paper II, a novel predictor of instability was assessed, namely marginal secondary displacement. The study included 165 patients with prospective data treated non-operatively with complete radiological follow-up and acceptable alignment 10-14 days after injury. Marginal secondary displacement was an important predictor of late displacement with malunion in DRFs. Clinicians should not unequivocally accept general guidelines for alignment. They should also assess the deterioration in fracture alignment at radiographic follow-up and be aware of the potential need for surgery to avoid malunion, even if radiographic measures are within acceptable limits.

Paper III investigated the long-term effects of DRFs in a large prospective study 11 to 13 years post-injury and found that clinical outcomes improve with time. A decade after the fracture, patient-reported function, health-related quality of life, grip strength and range of motion were restored at the group level. Neither osteoarthritis nor pseudoarthrosis of the ulnar styloid affected the outcomes. Dorsal tilt, radial inclination and ulnar variance did not affect long-term clinical outcomes or the risk of osteoarthritis. Recovery after a DRF is an ongoing process lasting years. A decade after injury, recovery was achieved regardless of radiological outcomes.

Paper IV evaluated the potential consequences of the fast-tracks introduced in the Swedish National Guidelines in a retrospective study. Some 1,609 patients with DRFs 4-7 years before the introduction of the national guidelines were studied. The patients' treatment was compared to how they would have been treated had the guidelines been followed. The results suggest that the fast-track treatment pathway will probably i) identify unstable fractures, ii) lead to more patients being treated with early primary surgery and iii) result in delayed primary surgery being avoided in most cases.

To conclude, clinical outcomes are affected by the degree of radiological alignment 1 year after a DRF. However, patients continue to recover over a long period. After a decade, normal function is restored at the group level, irrespective of the radiological outcome. Clinical outcomes at 1 year can most likely be ameliorated by identifying unstable fractures and following protocols promoting early surgery for these fractures.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University, 2024. , s. 112
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2279
Nyckelord [en]
Radius, distal radius fracture, fracture, orthopedics, radiology, outcome, clinical outcome
Nyckelord [sv]
Radius, distal radius fraktur, fraktur, ortopedi, radiologi, utfall, kliniskt utfall
Nationell ämneskategori
Ortopedi Kirurgi
Forskningsämne
ortopedi
Identifikatorer
URN: urn:nbn:se:umu:diva-222962ISBN: 978-91-8070-249-2 (tryckt)ISBN: 978-91-8070-250-8 (digital)OAI: oai:DiVA.org:umu-222962DiVA, id: diva2:1848577
Disputation
2024-05-08, Aulan, Sundsvalls sjukhus, Sundsvall, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2024-04-17 Skapad: 2024-04-03 Senast uppdaterad: 2024-04-09Bibliografiskt granskad
Delarbeten
1. Association between radiographic and clinical outcomes following distal radial fractures: a prospective cohort study with 1-year follow-up in 366 patients
Öppna denna publikation i ny flik eller fönster >>Association between radiographic and clinical outcomes following distal radial fractures: a prospective cohort study with 1-year follow-up in 366 patients
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2023 (Engelska)Ingår i: Journal of Bone and Joint Surgery. American volume, ISSN 0021-9355, E-ISSN 1535-1386, Vol. 105, nr 15, s. 1156-1167Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Several studies of distal radial fractures have investigated final displacement and its association with clinical outcomes. There is still no consensus on the importance of radiographic outcomes, and published studies have not used the same criteria for acceptable alignment. Previous reports have involved the use of linear or dichotomized analyses.

METHODS: The present study included 438 patients who were managed with either reduction and cast immobilization or surgery for the treatment of distal radial fractures. Radiographic outcomes were determined on the basis of radiographs that were made 3 months after the injury. Clinical outcome was determined on the basis of the QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) score, range of motion, and grip strength at 1 year after the injury. Nonlinear relations were analyzed with cubic splines.

RESULTS: Three hundred and sixty-six patients (84%) had both radiographic and clinical follow-up. Seventy patients were lost to follow-up. The mean age was 57 years (range, 18 to 75 years), and 79% of the patients were female. Dorsal tilt was the radiographic parameter that was most strongly associated with the QuickDASH score, grip strength, and range of motion. We found nonlinear relations. Clinical outcomes were found to worsen with increasing dorsal tilt, with the cutoff value being approximately 5°.

CONCLUSIONS: We found that clinical outcomes following distal radial fractures have a nonlinear relationship with dorsal tilt, with worse outcomes being associated with increasing dorsal tilt. The decline in clinical outcome starts at 5°, but there is unlikely to be a noticeable difference in capability as measured with the QuickDASH until 20° of dorsal tilt (based on the minimum clinically important difference) in a population up to 75 years old.

LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Ort, förlag, år, upplaga, sidor
Wolters Kluwer, 2023
Nationell ämneskategori
Ortopedi
Identifikatorer
urn:nbn:se:umu:diva-208252 (URN)10.2106/JBJS.22.01096 (DOI)001041574300005 ()37172109 (PubMedID)2-s2.0-85166396145 (Scopus ID)
Tillgänglig från: 2023-05-15 Skapad: 2023-05-15 Senast uppdaterad: 2024-04-08Bibliografiskt granskad
2. Marginal secondary displacement in fractures of the distal radius at follow-up - an important predictor for late displacement and malunion
Öppna denna publikation i ny flik eller fönster >>Marginal secondary displacement in fractures of the distal radius at follow-up - an important predictor for late displacement and malunion
2023 (Engelska)Ingår i: Journal of Hand Surgery, European Volume, ISSN 1753-1934, E-ISSN 2043-6289, Vol. 48, nr 6, s. 524-531Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Treatment recommendations in fractures of the distal radius are often based on the degree of displacement and functional demands. The fracture may be within an acceptable radiological range, but a marginal deterioration in alignment then occurs between the initial visit and follow-up. This may pose a risk for late displacement that may require further treatment. We secondarily analysed prospectively collected data and included 165 patients. We found that marginal secondary displacement (odds ratio (OR) 9.7), anterior comminution (OR 8.8), loss of anterior apposition (OR 6.8) and dorsal comminution (OR 2.6) were predictors of late displacement. Marginal secondary displacement is an important predictor of late displacement and malunion in fractures of the distal radius. Clinicians should not unequivocally accept general guidelines on alignment but also assess a deterioration in fracture alignment on radiographic follow-up and be aware of the potential need for surgery to avoid malunion in cases that show early secondary displacement, even when radiographic measures are within acceptable limits.Level of evidence: III.

Ort, förlag, år, upplaga, sidor
Sage Publications, 2023
Nyckelord
Distal radius fracture, instability, late displacement, malunion, marginal secondary displacement
Nationell ämneskategori
Ortopedi
Identifikatorer
urn:nbn:se:umu:diva-202710 (URN)10.1177/17531934221146063 (DOI)000911377300001 ()36624929 (PubMedID)2-s2.0-85146164839 (Scopus ID)
Tillgänglig från: 2023-01-13 Skapad: 2023-01-13 Senast uppdaterad: 2024-04-03Bibliografiskt granskad
3. Functional outcomes are restored a decade after a distal radius fracture: a prospective long-term follow-up study
Öppna denna publikation i ny flik eller fönster >>Functional outcomes are restored a decade after a distal radius fracture: a prospective long-term follow-up study
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2024 (Engelska)Ingår i: Journal of Hand Surgery, European Volume, ISSN 1753-1934, E-ISSN 2043-6289, Vol. 49, nr 3, s. 322-328Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

We performed an 11-13-year prospective follow-up of patients after a distal radial fracture (DRF) to investigate the association between fracture malunion, radiocarpal osteoarthritis and clinical outcome. In total, 292 patients responded to patient-reported outcome measures; of them, 242 underwent clinical examination. Clinical outcomes improved with time. A decade after fracture, median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 5, EuroQol Five-dimensions score was 1.0, and range of motion and grip strength were 96% of the contralateral side. Neither osteoarthritis (6%) nor pseudoarthrosis of the ulnar styloid (30%) affected the outcomes. Dorsal tilt, radial inclination, ulnar variance and intra-articular extension did not affect long-term clinical outcomes or the risk of osteoarthritis. Recovery after a DRF is an ongoing process that lasts years. A decade after the injury event, range of motion, grip strength and QuickDASH were recovered to population normal, regardless of radiological outcomes.

Level of evidence: II.

Ort, förlag, år, upplaga, sidor
Sage Publications, 2024
Nyckelord
Distal radius fracture, functional outcomes, grip strength, long-term results, outcomes, patient-reported outcome measure, range of motion
Nationell ämneskategori
Ortopedi
Identifikatorer
urn:nbn:se:umu:diva-214296 (URN)10.1177/17531934231194682 (DOI)001061922700001 ()37684021 (PubMedID)2-s2.0-85170554329 (Scopus ID)
Tillgänglig från: 2023-09-11 Skapad: 2023-09-11 Senast uppdaterad: 2024-04-08Bibliografiskt granskad
4. Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures
Öppna denna publikation i ny flik eller fönster >>Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures
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2022 (Engelska)Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 17, nr 2, artikel-id e0260296Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND AND PURPOSE: National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions.

PATIENTS AND METHODS: In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines.

RESULTS: On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery.

INTERPRETATION: The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

Ort, förlag, år, upplaga, sidor
Public Library of Science, 2022
Nationell ämneskategori
Ortopedi
Identifikatorer
urn:nbn:se:umu:diva-192459 (URN)10.1371/journal.pone.0260296 (DOI)000797657800004 ()35143508 (PubMedID)2-s2.0-85124387217 (Scopus ID)
Forskningsfinansiär
Region Västernorrland, LVNFOU921951
Tillgänglig från: 2022-02-14 Skapad: 2022-02-14 Senast uppdaterad: 2024-04-03Bibliografiskt granskad

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