If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Corresponding author: Marjolein A. M. Mulders, MD, PhD, Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
To evaluate the association between alignment, as determined by plain radiographs, and patient-reported outcome in adults with a displaced distal radius fracture. We also determined which specific radiological parameters are associated with patient-reported outcomes.
Methods
We performed a systematic literature search to identify studies that evaluated the association between radiological and patient-reported outcome in adults with a displaced distal radius fracture and who had an average follow-up of at least 12 months. Radiological outcome was determined as acceptable or unacceptable reduction, defined by radiological parameters. Patient-reported outcome was assessed with the Disability of the Arm, Shoulder, and Hand, the Quick–Disability of the Arm, Shoulder, and Hand, and the Patient-Rated Wrist Evaluation questionnaires.
Results
Sixteen articles were included, comprising 1,961 patients with a distal radius fracture. A significant mean difference of 4.15 points in patient-reported outcomes (95% confidence interval [CI], 0.26–8.04) was found in favor of an acceptable radiological reduction. Moreover, a significant mean difference of 5.38 points in patient-reported outcomes (95% CI, 1.69–9.07) was found in favor of an acceptable dorsal angulation, and 6.72 points (95% CI, 2.16–11.29) in favor of an acceptable ulnar variance.
Conclusions
An unacceptable radiological reduction is significantly associated with worse patient-reported outcomes in adults with a displaced distal radius fracture. Dorsal angulation and ulnar variance are the most important radiological parameters. Despite the statistical significance, the mean difference of each association did not meet the threshold of the minimally clinically important difference and therefore were unlikely to be clinically important.
The Journal of Hand Surgery will contain at least 2 clinically relevant articles selected by the editor to be offered for CME in each issue. For CME credit, the participant must read the articles in print or online and correctly answer all related questions through an online examination. The questions on the test are designed to make the reader think and will occasionally require the reader to go back and scrutinize the article for details.
The JHS CME Activity fee of $15.00 includes the exam questions/answers only and does not include access to the JHS articles referenced.
Statement of Need: This CME activity was developed by the JHS editors as a convenient education tool to help increase or affirm reader’s knowledge. The overall goal of the activity is for participants to evaluate the appropriateness of clinical data and apply it to their practice and the provision of patient care.
Accreditation: The ASSH is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
AMA PRA Credit Designation: The American Society for Surgery of the Hand designates this Journal-Based CME activity for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH for educational purposes only. This material is not intended to represent the only methods or the best procedures appropriate for the medical situation(s) discussed, but rather it is intended to present an approach, view, statement, or opinion of the authors that may be helpful, or of interest, to other practitioners. Examinees agree to participate in this medical education activity, sponsored by the ASSH, with full knowledge and awareness that they waive any claim they may have against the ASSH for reliance on any information presented. The approval of the US Food and Drug Administration is required for procedures and drugs that are considered experimental. Instrumentation systems discussed or reviewed during this educational activity may not yet have received FDA approval.
ASSH Disclosure Policy: As a provider accredited by the ACCME, the ASSH must ensure balance, independence, objectivity, and scientific rigor in all its activities.
Disclosures for this Article
Editors
Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose.
Authors
All authors of this journal-based CME activity have no relevant conflicts of interest to disclose. In the printed or PDF version of this article, author affiliations can be found at the bottom of the first page.
Planners
Jennifer Moriatis Wolf, MD, has no relevant conflicts of interest to disclose. The editorial and education staff involved with this journal-based CME activity has no relevant conflicts of interest to disclose.
Learning Objectives
Upon completion of this CME activity, the learner should achieve an understanding of:
•
How radiological parameters are used to grade radiological outcomes of distal radius fractures
•
What patient-reported outcomes are used by a cross-section of studies
•
The correlation between radiographic and patient-reported outcomes after fracture of the distal radius.
Deadline: Each examination purchased in 2018 must be completed by January 31, 2019, to be eligible for CME. A certificate will be issued upon completion of the activity. Estimated time to complete each JHS CME activity is up to one hour.
Outcome after distal radius fracture treatment has traditionally been assessed radiologically using radiological parameters, and functionally using range of motion and grip strength. Nowadays, patient-reported outcome measures are commonly used, in particular the Disability of the Arm, Shoulder, and Hand (DASH) and the Patient-Rated Wrist Evaluation (PRWE) questionnaire.
There is no definite clinical evidence for the superiority of one particular treatment over another in patients with a displaced distal radius fracture.
Although surgeon’s preference and fracture characteristics still influence therapeutic decision making, in most cases surgical treatment is guided by radiological reduction criteria.
In displaced distal radius fractures with an unacceptable closed reduction or in fracture redisplacement, open reduction and internal fixation is increasingly being carried out owing to the general belief that an anatomic reduction is positively related to functional outcome. However, evidence of an association between radiological reduction criteria and functional outcome is still inconclusive, particularly in elderly patients. Some studies have shown that radiological outcome correlates with patient-reported outcome,
The aim of this meta-analysis was to evaluate the association between alignment, as determined by plain radiographs, and patient-reported outcome in adults with a displaced distal radius fracture. We also aimed to determine which specific radiological parameters correlate with patient-reported outcomes.
Materials and Methods
This systematic review and meta-analysis was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.
All of the following steps were performed by 2 independent reviewers (M.A.M.M. and R.D.). Disagreement between the 2 reviewers was addressed by discussion until agreement was reached.
Literature search and study selection
A systematic literature search was performed in MEDLINE (PubMed), EMBASE (Ovid), and the Cochrane Central Register of Controlled Trials on October 31, 2016, to identify studies describing the association between radiologic and patient-reported outcome in adults with displaced distal radius fractures. The search strategy was constructed with the assistance of a clinical librarian (Appendix A, available on the Journal’s Web site at www.jhandsurg.org). To ensure proper interpretation of the results, publication language was restricted to English, German, French, and Dutch. No restrictions were applied regarding the publication date.
Studies based on original data that evaluated the association between radiological outcome and patient-reported outcome measures (PROMs) in adults with a nonsurgically or surgically treated displaced distal radius fracture with an average follow-up of at least 12 months were eligible for inclusion. Only studies that used the following upper extremity–specific PROMs were included: the DASH, the QuickDASH, and the PRWE questionnaire. After abstract screening, full-text articles were retrieved and read. In addition, a cross-reference check was performed. If full texts could not be retrieved, authors were contacted. When no full text could be obtained, articles were excluded.
Outcome measures
Radiological outcome was determined as either an acceptable or unacceptable reduction, defined by radiological parameters including dorsal and volar (palmar) angulation, ulnar variance, radial inclination, radial length or height, and radial shortening. The definition of an acceptable reduction depended on the one used in the included articles. If the definition of an acceptable reduction was not provided, we applied that of an acceptable reduction in accordance with the Dutch guidelines for treatment of distal radius fractures.
This includes a radial inclination of 15° or greater, a dorsal angulation less than 15°, a volar angulation less than 20°, radial shortening less than 5 mm, and positive ulnar variance less than 2 mm.
Only the DASH, QuickDASH, and PRWE questionnaire were included, because they have been shown to be valid, reliable, and highly responsive in the distal radius fracture patient population.
Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture.
The DASH questionnaire focuses on disability and symptoms of the upper extremity and consists of 30 questions rendering a score from 0 (no disability) to 100 (severe disability).
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
The QuickDASH is a modified version of the DASH questionnaire, with 11 questions instead of 30. Subsequently, the score is transformed to a scale of 0 to 100 for easy comparison, with higher score indicating greater disability.
The score ranges from 0 (no pain and functional impairment) to 100 (severe pain and functional impairment).
The minimal clinically important difference (MCID) is the minimal change that the patient perceives to be important. For the DASH and QuickDASH this is 10 and 14, respectively, and for the PRWE it is 11.5.
Data were extracted using a predefined data collection form. The extracted data included study characteristics (ie, first author, year of publication, and study design), patient characteristics (ie, number of patients, sex, age), fracture classification and treatment, duration of follow-up, radiological parameters, the definition of an acceptable reduction, and PROMs. Means and standard deviations (SD) of the DASH, QuickDASH, and PRWE were extracted. When a median and interquartile range were reported, these values were transferred to a mean and SD using the formula of Wan et al.
If the standard error of the mean was provided, the SD was obtained by multiplying the standard error of the mean by the square root of the sample size, in accordance with the Cochrane Handbook.
Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. London: The Cochrane Collaboration; 2011. Available from http://www.handbook.cochrane.org. Accessed May 23, 2018.
The articles were independently assessed for methodological quality by 2 reviewers (M.A.M.M. and R.D.). Studies with scores of 8 or 9 were considered to have a low risk of bias, 5 to 7 a moderate risk of bias, and below 5 a high risk of bias. Oxford Level of Evidence criteria were used to assess the level of evidence. The reviewers discussed disagreements until agreement was reached.
Statistical analysis
We used descriptive outcome analysis to compare the results, data, and outcomes of the individual studies. The mean differences of DASH, QuickDASH, and PRWE scores between patients with and without an acceptable reduction were calculated using a 95% confidence interval (CI). The scores from the PROMs were pooled, because these questionnaires scored disability on a 100-point scale. If more than one PROM was used, the average was calculated and used for analysis. This method of pooling individual PROMs was described by Buijze et al
Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.
The mean difference for the separate radiological parameters was calculated in the same manner. We applied an inverse variance method and random effect model to all outcomes. If radiographic parameters were reported using multiple categories of continuous values based on different cutoff values, these data were pooled and categorized into acceptable and unacceptable reduction using a weighted mean and SD, in accordance with the Cochrane Handbook.
Differences in outcome between acceptable and unacceptable reduction were considered statistically significant at P < .05. Heterogeneity was determined using I2 statistics.
The I2 is a statistic that indicates the percentage of variance and is established as follows: 0% to 40%, might not be important; 30% to 60%, may represent moderate heterogeneity; 50% to 90%, may represent substantial heterogeneity; and 75% to 100%, may represent considerable heterogeneity. Meta-analyses were conducted using Review Manager (version 5.3, Cochrane Collaboration, London, UK, 2014).
Results
Literature search and study selection
Figure 1 shows the study selection process. After excluding duplicates, the initial search yielded 1,223 studies. After titles and abstracts screening, 84 articles were considered for inclusion in the systematic review. A total of 69 articles were excluded because the average follow-up was less than 12 months, the studies had an inadequate study design (eg, reviews or case series) or comparison (ie, no comparison between radiological and patient-reported outcome), or no patient-reported outcomes were used. In addition, we excluded one article because it used the same cohort of patients as a previous article by the same author.
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Characteristics of the included studies are outlined in Appendix B (available on the Journal’s Web site at www.jhandsurg.org). Nine cross-sectional studies, 6 prospective cohort studies, and 1 retrospective cohort study were included. A total of 1,961 patients with a distal radius fracture were included. The age of included patients ranged from 18 to 95 years; mean reported age was 46.1 to 78 years. The methodological quality of the studies was variable (Appendix C, available on the Journal’s Web site at www.jhandsurg.org).
Table 1 presents an overview of the reported association of each study. Ten studies found a significant association between poor patient-reported outcomes and unacceptable radiological reduction.
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
showed that this was applicable only to patients aged less than 65 and 60 years, respectively. The remaining 6 studies found no significant association between poor patient-reported outcomes and unacceptable radiological reduction.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
Significant correlation between PRWE and QuickDASH scores and unacceptable radiological parameters (radial inclination, radial length, dorsal angulation, and ulnar variance)
PRWE: Radial inclination: P < .05 Radial length: P < .001 Dorsal angulation: P < .01 Ulnar variance: P < .01 QuickDASH: Radial inclination: P < 0.01 Radial length: P < .001 Dorsal angulation: P < .01 Ulnar variance: P < .01
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
For patients aged <65 y: PRWE and DASH scores of unacceptable alignment (PRWE = 29.3; DASH = 23.2) were significantly worse compared with acceptable alignment (PRWE = 13.1; DASH = 9.2) Significant association between PRWE and DASH scores and unacceptable radiological parameters (radial inclination [PRWE = 46.2 vs 15.9) and ulnar variance (PRWE = 29.0 vs 16.1; DASH = 24.6 vs 11.5]) For patients aged ≥65 y: No differences in DASH and PRWE scores of unacceptable alignment compared with acceptable alignment
DASH: Alignment: P < .001 Ulnar variance: P = .002 PRWE: Alignment: P = .001 Radial inclination: P = .04 Ulnar variance: P = .02 NS
For patients aged <60 y: Significant association between DASH score and unacceptable radiological parameters (volar angulation) For patients aged ≥60 y: No correlation between DASH score and acceptable and unacceptable radiological parameters
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Significant association between DASH score and unacceptable radiological parameters: radial inclination (DASH score of 24 vs 11), dorsal angulation (DASH score of 18 vs 8) and ulnar variance (DASH score of 16 vs 6)
Radial inclination: P = .03 Dorsal angulation: P < .001 Ulnar variance: P = .001
In total, 9 articles relevant to acceptable versus unacceptable reduction and separate radiological parameters were included in the meta-analysis.
Six studies concerning acceptable versus unacceptable reduction, composed of a total of 582 patients (mean age, 46–72 years) were included in the meta-analysis.
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
A statistically significant mean difference in patient-reported outcome of 4.15 points (P < .05; 95% CI, 0.26–8.04) was found in favor of an acceptable radiological reduction (Fig. 2). This difference was not clinically relevant because it was smaller than the MCID. The heterogeneity was 50%.
Figure 2Forest plot comparing acceptable and unacceptable radiological reductions.
Five studies concerning separate radiological parameters were included in the meta-analysis, composed of 569 patients (mean age, 46–78 years). Four studies on the radiological parameters of dorsal angulation and ulnar variance
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
We found a significant mean difference of 5.38 points in patient-reported outcome (P < .05; 95% CI, 1.69–9.07) in favor of an acceptable dorsal angulation and of 6.72 points (P < .05; 95% CI, 2.16–11.29) in favor of an acceptable ulnar variance. The mean differences of each association were smaller than the MCID and therefore were not clinically relevant. No significant differences were found for radial inclination (Table 2).
Table 2Results of Meta-Analysis for Radiological Parameters
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
The available literature shows that when results were pooled, unacceptable radiological reduction was significantly associated with worse patient-reported outcomes. Moreover, significantly worse patient-reported outcomes were specifically found for unacceptable dorsal angulation and ulnar variance. Despite the statistical significance, the mean difference of each association did not meet the threshold of the MCID and were therefore considered unlikely to be clinically important.
This meta-analysis provides a comprehensive and systematic overview of the current available literature, including 16 studies with a total of 1,961 patients who had a distal radius fracture. The results of this study correspond to those of a previously published review from Reynolds,
who looked at the association of radiographic outcome and functional outcome only in elderly patients. Reynolds stated that in most studies looking at this patient group, no significant association was found between functional and radiological outcome. In addition, Arora et al
A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating.
A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.
conducted 2 studies, one retrospective cohort study and one randomized controlled trial, comparing surgical with nonsurgical treatment in patients aged over 70 and 65 years, respectively, with a displaced distal radius fracture. In both studies, radiological parameters improved significantly in operatively treated patients; however, there were no significant differences in functional outcome between groups. However, the studies from Reynolds et al and Arora et al focused only on elderly patients, whereas most articles reviewed in this study did not investigate the role of age in patient-reported outcome. Only Grewal and MacDermid
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
categorized their cohort based on age; they both found a higher risk of poor patient-reported outcome with unacceptable reduction in patients aged less than 65 and 60 years, respectively. Moreover, Brennan et al,
who included only patients aged less than 65 years, found that worse PRWE and DASH scores were associated with unacceptable radiological parameters. These results may indicate that the radiological outcome may be relevant only to younger patients. This was also suggested by Reynolds, who stated that studies including younger patients were more likely to show some association between patient-reported outcomes and radiologic results, and that radial shortening and dorsal and volar angulation have the greatest impact on patient-reported outcomes. If unacceptable reduction were better tolerated in elderly patients, this might have diminished the overall effect of alignment on patient-reported outcome, because we included patients of all ages. Unfortunately, we were unable to investigate this hypothesis since we were not able to perform a separate meta-analysis based on age because there were insufficient data even after contacting the authors.
Although after pooling the results we found a statistically significant difference between patient-reported outcomes and radiological reduction, the difference was smaller than the MCID of all 3 of the patient-reported outcome measures and therefore not clinically important. However, 2 of the included studies found both a statistically and clinically important difference. Brogren et al
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
reported a significant difference of 16.2 points in PRWE score and 14 points in DASH score between both groups. These reported differences between an unacceptable and acceptable reduction are above the MCID of the DASH and the PRWE scores.
Of all radiological parameters, unacceptable ulnar variance and dorsal angulation seem to have had the most important negative impact on patient-reported outcomes. Besides the studies included in the meta-analysis, 6 other studies determined the association between ulnar variance or dorsal angulation and patient-reported outcome.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
reported no association between the DASH score and unacceptable dorsal angulation. Unfortunately, those studies could not be included in the meta-analysis of the separate radiological parameters owing to incomplete data. In a review article, Ng and McQueen
outlined radiological parameters that predict functional outcome. Although they did not systematically evaluate all of the available literature, they stated that an ulnar-plus deformity predicts worse functional outcomes in patients with high functional demands.
Some limitations of this study should be addressed. One limitation regarding the meta-analysis is the variation in fracture types and different treatment modalities encountered in the included articles. It is unclear to what extent these differing characteristics influenced the patient-reported outcome.
Second, studies with a higher methodological quality were not more heavily weighted in the meta-analysis. However, the risk of bias and the level of evidence of each included study were assessed independently by 2 reviewers.
Of particular note is the variation in the criteria applied for an acceptable radiological outcome. All articles applied a variety of acceptable radiological criteria. For example, cutoff values for dorsal angulation ranged from 10° to 20°. If no criteria were mentioned, we chose to apply the criteria for an acceptable reduction in accordance with the Dutch guidelines,
A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures.
Further research may be beneficial to determine these specific cutoff values, in particular dorsal angulation and ulnar variance, aiming to define which values affect patient-reported outcome. Nevertheless, all articles included in this study met the description of an acceptable radiological outcome, defined as dorsal angulation less than 20°, volar (palmar) angulation (tilt) less than 25°, ulnar variance less than 5 mm, radial inclination 15° or greater, and radial shortening less than 5 mm.
Moreover, the studies reviewed a variety of terms for the radiological parameters. Some could be interchangeable: for example, radial shortening and ulnar variance. The use of equal definitions would allow a more generalizable evaluation of the results. Furthermore, not all of the included studies applied the same methods to measure the different radiological parameters.
Finally, we chose to report the results of a minimal average follow-up of 12 months. However, the range of follow-up varied among the included studies, which means that patients with a both a shorter and longer follow-up were included in this review.
An unacceptable radiological reduction is significantly associated with worse patient-reported outcomes in adults with a displaced distal radius fracture. Dorsal angulation and ulnar variance are the most important radiological parameters. However, the differences were small and unlikely to be clinically important. Nonetheless, because radiological reduction is not the only factor influencing patient-reported outcome, future studies should focus on finding specific predictors of patient-reported outcomes.
Acknowledgments
We thank F.S. van Etten-Jamaludin, clinical librarian, for her assistance in compiling the search strategy.
Appendix A. Search Strategy
MEDLINE
Filters: English; Dutch; German; French
(“Radius Fractures”[Mesh] OR radius fracture*[tiab] OR radial fracture*[tiab] OR colles fracture*[tiab] OR smith fracture*[tiab] OR barton fracture*[tiab] OR wrist fracture*[tiab]) AND (“Wrist Injuries”[MeSH] OR “Wrist Joint”[MeSH] OR wrist*[tiab] OR distal[tiab]) AND (dislocat*[tiab] OR displac*[tiab] OR distal[tiab] OR undisplac*[tiab] OR redisplac*[tiab] OR un-displac*[tiab] OR re-displac*[tiab]) AND (“radiography” [Subheading] OR (radiograph*[tiab] OR radiologic*[tiab] OR radiology[tiab]) AND (parameter*[tiab] OR reduction*[tiab] OR examin*[tiab] OR assessment*[tiab] OR outcome*[tiab] OR report*[tiab]) OR radiogram*[tiab] OR radial slope[tiab]) AND (“Treatment Outcome”[Mesh] OR “Disability Evaluation”[Mesh] OR “Patient Satisfaction”[Mesh] OR “Range of Motion, Articular”[Mesh] OR (functional*[tiab]) AND (outcome*[tiab] OR result*[tiab]) OR patient-perceived outcome*[tiab] OR patient-reported outcome*[tiab] OR clinical outcome*[tiab] OR clinical parameter*[tiab] OR disability evaluation*[tiab] OR satisf*[tiab] OR range of motion*[tiab] OR performance measure*[tiab]) NOT (“Animals”[Mesh] NOT “Humans”[Mesh]) NOT (“Editorial” [Publication Type] OR “Letter” [Publication Type] OR “News” [Publication Type] OR “Comment” [Publication Type] OR “Historical Article” [Publication Type] OR “Anecdotes as Topic”[Mesh] OR letter*[ti] OR comment*[ti] OR abstracts[ti] OR “Child”[Mesh] OR “Pediatrics”[Mesh] OR pediatric*[ti] OR paediatric*[ti])
EMBASE
((radius fracture/ or (radius fracture* or radial fracture* or colles fracture* or smith fracture* or barton fracture* or wrist fracture*).ti,ab,kw.) and (wrist/ or (wrist* or distal).ti,ab,kw.) and (dislocat* or displac* or distal or undisplac* or redisplac* or un-displac* or re-displac*).ti,ab,kw. and (radiography/ or wrist radiography/ or ((radiograph* or radiologic* or radiology) and (parameter* or reduction* or examin* or assessment* or outcome* or report*)).ti,ab,kw. or (radiogram* or radial slope).ti,ab,kw.) and (exp treatment outcome/ or disability/ or patient satisfaction/ or “range of motion”/ or patient rated wrist evaluation/ or “disabilities of the arm, shoulder and hand (score)”/ or functional assessment/ or (functional* and (outcome* or result*)).ti,ab,kw. or (patient-perceived outcome* or patient-reported outcome* or clinical outcome* or clinical parameter* or disability evaluation* or satisf* or range of motion* or performance measure*).ti,ab,kw.)) not (animal/ not human/) not (editorial/ or letter/ or news/ or Comment/ or Anecdotes as Topic/ or child/ or pediatrics/ or (letter* or comment* or abstracts or pediatric* or paediatric*).ti.)
limit to (Dutch or English or French or German)
Cochrane Central Register of Controlled Trials
MeSH descriptor: [Radius Fractures] explode all trees or radius fracture* or radial fracture* or colles fracture* or smith fracture* or barton fracture* or wrist fracture*:ti,ab,kw (Word variations have been searched) and MeSH descriptor: [Wrist Injuries] explode all trees or MeSH descriptor: [Wrist Joint] explode all trees or wrist* or distal:ti,ab,kw (Word variations have been searched) and dislocat* or displac* or distal or undisplac* or redisplac* or un-displac* or re-displac*:ti,ab,kw (Word variations have been searched) and MeSH descriptor: [Radiography] explode all trees or ((radiograph* or radiologic* or radiology) and (parameter* or reduction* or examin* or assessment* or outcome* or report*)) or radiogram* or radial slope:ti,ab,kw (Word variations have been searched) and MeSH descriptor: [Treatment Outcome] explode all trees or MeSH descriptor: [Disability Evaluation] explode all trees or MeSH descriptor: [Patient Satisfaction] explode all trees or MeSH descriptor: [Range of Motion, Articular] explode all trees or (functional*) and (outcome* or result*):ti,ab,kw (Word variations have been searched) or patient-perceived outcome* or patient-reported outcome* or clinical outcome* or clinical parameter* or disability evaluation* or satisf* or range of motion* or performance measure*:ti,ab,kw (Word variations have been searched)
Appendix BCharacteristics of Included Studies (n = 16)
Author (Year of Publication)
Study design
Oxford Level of Evidence
Patients, n (M/W)
Age, y (mean [range])
Fracture Classification
Treatment
Duration of Follow-Up, mo (mean [range])
Radiological Parameters
Acceptable Radiological Parameters
Patient-Reported Outcome Measure
Amorosa et al (2011)
Cross-sectional study
4
58 (7/51)
78 (70–94)
AO types A, B, and C
Closed reduction and casting vs closed reduction and percutaneous pinning vs external fixation vs open reduction internal fixation
33 (13–65)
DA, UV, articular stepoff
DA <20° UV neutral or negative Articular stepoff <2 mm
DASH
Barton et al (2007)
Cross-sectional study
4
60 (10/50)
69.2 (57–70)
Frykman types I-II, III-IV, V-VI, and VII-VIII
Closed reduction and K-wire fixation
29 (10–46)
DA, RI, RS
Not defined
PRWE
Bentohami et al (2013)
Cross-sectional study
4
257 (59/198)
65 (48–76)
AO types A2 and A3
Closed reduction and casting
36 (range not defined)
DA, VA, RI, UV
DA <15° VA <20° RI >15° UV <5 mm
QuickDASH
Brennan et al (2016)
Cross-sectional study
4
318 (112/206)
46.9 (20–65)
AO types A, B, and C
K-wire fixation vs open reduction and internal volar plate fixation
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
Nonsurgical (nonspecific) and operative (nonspecific)
12 (range not defined)
DA, RI, UV, articular stepoff and articular gap
DA <20° RI ≥15° UV <4 mm Articular gap or stepoff <4 mm
QuickDASH
Synn et al (2009)
Cross-sectional study
4
53 (7/46)
69 (55–90)
Extra-articular and intra-articular
Closed reduction and casting vs closed reduction and percutaneous pinning vs open reduction internal fixation vs open reduction internal/external fixation
17 (6–45)
DA, VA, RS, articular stepoff and articular gap
DA <10° VA <25° RS <5mm Articular stepoff and gap <2 mm
DASH, PRWE
Wilcke et al (2007)
Cross-sectional study
4
78 (21/57)
59 (22–95)
Frykman types I-II, III-IV, V-VI, and VII-VIII
Closed reduction and casting vs closed reduction external fixation
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture.
Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. London: The Cochrane Collaboration; 2011. Available from http://www.handbook.cochrane.org. Accessed May 23, 2018.
Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.
Fractures of the distal radius in women aged 50 to 75 years: natural course of patient-reported outcome, wrist motion and grip strength between 1 year and 2-4 years after fracture.
The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients.
Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating.
A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.
A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures.
30613-0&id=gr1.jpg){kind=link}
30613-0&id=gr2.jpg){kind=link}