Association Between Radiological and Patient-Reported Outcome in Adults With a Displaced Distal Radius Fracture: A Systematic Review and Meta-Analysis

      Purpose

      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.

      Type of study/level of evidence

      Prognostic IV.

      Key words

      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.
      Provider Information can be found at https://www.assh.org/About-ASSH/Contact-Us.
      Technical Requirements for the Online Examination can be found at https://www.jhandsurg.org/cme/home.
      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.
      Copyright © 2018 by the American Society for Surgery of the Hand. All rights reserved.
      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.
      • Calfee R.P.
      • Adams A.A.
      Clinical research and patient-rated outcome measures in hand surgery.
      • Hoang-Kim A.
      • Pegreffi F.
      • Moroni A.
      • Ladd A.
      Measuring wrist and hand function: common scales and checklists.
      There is no definite clinical evidence for the superiority of one particular treatment over another in patients with a displaced distal radius fracture.
      • Chung K.C.
      • Shauver M.J.
      • Yin H.
      • Kim H.M.
      • Baser O.
      • Birkmeyer J.D.
      Variations in the use of internal fixation for distal radial fracture in the United States medicare population.
      Although surgeon’s preference and fracture characteristics still influence therapeutic decision making, in most cases surgical treatment is guided by radiological reduction criteria.
      • Walenkamp M.M.
      • Mulders M.A.
      • Goslings J.C.
      • Westert G.P.
      • Schep N.W.
      Analysis of variation in the surgical treatment of patients with distal radial fractures in the Netherlands.
      • Waljee J.F.
      • Zhong L.
      • Shauver M.J.
      • Chung K.C.
      The influence of surgeon age on distal radius fracture treatment in the United States: a population-based study.
      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,
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      • Brogren E.
      • Wagner P.
      • Petranek M.
      • Atroshi I.
      Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      whereas others have reported contradictory results.
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      • Barton T.
      • Chambers C.
      • Bannister G.
      A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      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.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      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.

      Brink PRG, Bransz N, Deijkers RLM, et al. Guideline for distal radius fractures: diagnosis and treatment. http://www.heelkunde.nl/uploads/h8/VM/h8VMOlRX83oW2NSR_5rTWw/Richtlijn_Distale_radius_fracturen_definitieve_versie_0511.pdf. Accessed June 26, 2017.

      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.
      • MacDermid J.C.
      • Richards R.S.
      • Donner A.
      • Bellamy N.
      • Roth J.H.
      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).
      • Hudak P.L.
      • Amadio P.C.
      • Bombardier C.
      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.
      • Beaton D.E.
      • Wright J.G.
      • Katz J.N.
      Development of the QuickDASH: comparison of three item-reduction approaches.
      The PRWE is a 15-item questionnaire designed to measure wrist pain and disability in activities of daily living.
      • MacDermid J.C.
      Development of a scale for patient rating of wrist pain and 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.
      • Sorensen A.A.
      • Howard D.
      • Tan W.H.
      • Ketchersid J.
      • Calfee R.P.
      Minimal clinically important differences of 3 patient-rated outcomes instruments.
      • Walenkamp M.M.
      • de Muinck Keizer R.J.
      • Goslings J.C.
      • Vos L.M.
      • Rosenwasser M.P.
      • Schep N.W.
      The minimum clinically important difference of the Patient-Rated Wrist Evaluation score for patients with distal radius fractures.

      Data extraction

      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.
      • Wan X.
      • Wang W.
      • Liu J.
      • Tong T.
      Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
      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.

      If multiple points in time were used, only the follow-up closest to 12 months was used for the meta-analysis.

      Methodological quality assessment

      The methodological quality of all included articles was assessed using the Newcastle–Ottawa Scale for nonrandomized studies.

      The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed May 21, 2017.

      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
      • Buijze G.A.
      • Doornberg J.N.
      • Ham J.S.
      • Ring D.
      • Bhandari M.
      • Poolman R.W.
      Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.
      and Wijffels et al.
      • Wijffels M.M.
      • Keizer J.
      • Buijze G.A.
      • et al.
      Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical 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.
      • Higgins J.P.
      • Thompson S.G.
      Quantifying heterogeneity in a meta-analysis.
      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.
      • Brogren E.
      • Wagner P.
      • Petranek M.
      • Atroshi I.
      Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.
      In all, 16 articles were included in this systematic review.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      • Barton T.
      • Chambers C.
      • Bannister G.
      A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      • Grewal R.
      • MacDermid J.C.
      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.
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      • Nelson G.N.
      • Stepan J.G.
      • Osei D.A.
      • Calfee R.P.
      The impact of patient activity level on wrist disability after distal radius malunion in older adults.
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      Figure thumbnail gr1
      Figure 1Flowchart showing study selection process.

      Systematic review

      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.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      • Grewal R.
      • MacDermid J.C.
      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.
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      The studies of Grewal and MacDermid
      • Grewal R.
      • MacDermid J.C.
      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.
      and Kumar et al
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      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.
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      • Barton T.
      • Chambers C.
      • Bannister G.
      A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      • Grewal R.
      • MacDermid J.C.
      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.
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      • Nelson G.N.
      • Stepan J.G.
      • Osei D.A.
      • Calfee R.P.
      The impact of patient activity level on wrist disability after distal radius malunion in older adults.
      However, they did not stratify results based on age.
      Table 1Correlation Between Functional Outcomes and Radiological Alignment
      AuthorReported ResultsP ValueCorrelation Coefficient, r (in Case of Significance)
      Amorosa et al
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      No correlation between DASH score and acceptable and unacceptable alignmentNS
      Barton et al
      • Barton T.
      • Chambers C.
      • Bannister G.
      A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
      No correlation between PRWE score and acceptable and unacceptable alignmentNS
      Bentohami et al
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      No correlation between QuickDASH score and acceptable and unacceptable radiological parametersNS
      Brennan et al
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      PRWE and DASH scores were negatively correlated with radial inclination, radial length and volar tilt and positively correlated with ulnar varianceNot mentionedNot mentioned
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      DASH scores of unacceptable alignment (21.8 [SD, 20]) were significantly worse compared with acceptable alignment (11.5 [SD, 17])P = .012Not mentioned
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      DASH scores of unacceptable alignment (20 [interquartile range, 12–48]) were significantly worse compared with acceptable alignment (not reported)P = .009Not mentioned
      Finsen et al
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) 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
      PRWE:

      Radial inclination:

      –0.134

      Radial length: –0.224

      Dorsal angulation: 0.189

      Ulnar variance: 0.192

      QuickDASH:

      Radial inclination:

      –0.160

      Radial length: –0.237

      Dorsal angulation: 0.184

      Ulnar variance: 0.194
      Grewal and MacDermid
      • Grewal R.
      • MacDermid J.C.
      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
      Not mentioned
      Karnezis et al
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      Significant correlation between PRWE score and unacceptable radiological parameters (radial shortening)P < .010.53
      Kumar et al
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      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
      P < .05

      NS
      Not mentioned
      Larouche et al
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      Significant association between positive ulnar variance and DASH scores and an articular gap or stepoff > 2 mm and worse DASH and PRWE scoresDASH:

      Ulnar variance: P = .03

      Gap and stepoff > 2 mm: P = .021

      PRWE:

      Gap and stepoff > 2 mm: P = .045
      Not mentioned
      Lee et al
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      Significant correlation between ulnar variance and DASH scoresP = .0421.423
      Regression coefficient.
      Machado et al
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      No correlation between DASH score and acceptable and unacceptable radiological parameters (radial inclination, radial length, and volar angulation)NS
      Nelson et al
      • Nelson G.N.
      • Stepan J.G.
      • Osei D.A.
      • Calfee R.P.
      The impact of patient activity level on wrist disability after distal radius malunion in older adults.
      No correlation between QuickDASH score and unacceptable alignmentNS
      Synn et al
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      No differences in DASH and PRWE scores of unacceptable alignment compared with acceptable alignmentNS
      Wilcke et al
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      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
      Not mentioned
      NS, not significant.
      Data are shown as means (SD).
      Regression coefficient.

      Meta-analysis

      Of the 16 articles included, 7 reported insufficient data to be included in the meta-analysis. One study provided raw data for this study.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      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.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      • Nelson G.N.
      • Stepan J.G.
      • Osei D.A.
      • Calfee R.P.
      The impact of patient activity level on wrist disability after distal radius malunion in older adults.
      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 thumbnail gr2
      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
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      and 3 on radial inclination were included in the meta-analysis.
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      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
      Radiological parameterIncluded StudiesUnacceptable Alignment, nAcceptable Alignment, nI2 (%)Mean Difference (95% CI)P Value
      Dorsal angulationAmoroso et al,
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      Brogren et al,
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      Finsen et al,
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      Wilcke et al
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      15331705.38 (1.69 to 9.07)< .05
      Radial inclinationFinsen et al,
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      Karnezis et al,
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      Wilcke et al
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      12022560–2.24 (–9.16 to 4.68).53
      Ulnar varianceAmoroso et al,
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      Brogren et al,
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      Finsen et al,
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      Wilcke et al
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      237234296.72 (2.16 to 11.29)< .05
      Bolded values are statistically significant.

      Discussion

      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,
      • Reynolds P.
      The correlation of radiographic outcome to functional outcome following fracture of the distal radius in elderly patients: a literature review.
      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
      • Arora R.
      • Gabl M.
      • Gschwentner M.
      • Deml C.
      • Krappinger D.
      • Lutz M.
      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.
      • Arora R.
      • Lutz M.
      • Deml C.
      • Krappinger D.
      • Haug L.
      • Gabl M.
      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
      • Grewal R.
      • MacDermid J.C.
      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.
      and Kumar et al
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      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,
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      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
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      reported a mean difference in DASH score between an unacceptable and acceptable reduction of 10.3 points. Moreover, Grewal and MacDermid
      • Grewal R.
      • MacDermid J.C.
      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.
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      • Grewal R.
      • MacDermid J.C.
      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.
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      Five of the 6 studies found a significant effect of ulnar variance or dorsal angulation on DASH and PRWE scores.
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      • Grewal R.
      • MacDermid J.C.
      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.
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      Grewal and MacDermid
      • Grewal R.
      • MacDermid J.C.
      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.
      also reported a clinically significant difference for ulnar variance of 12.9 and 13.1 points on the PRWE and DASH scores, respectively. Machado et al
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      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
      • Ng C.Y.
      • McQueen M.M.
      What are the radiological predictors of functional outcome following fractures of the distal radius?.
      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,

      Brink PRG, Bransz N, Deijkers RLM, et al. Guideline for distal radius fractures: diagnosis and treatment. http://www.heelkunde.nl/uploads/h8/VM/h8VMOlRX83oW2NSR_5rTWw/Richtlijn_Distale_radius_fracturen_definitieve_versie_0511.pdf. Accessed June 26, 2017.

      because these criteria are less stringent than other guidelines. This was only applied to one study included in the meta-analysis.
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      Nonetheless, a lack of consensus remains regarding what the parameters should be for an acceptable radiologic result.
      • Mulders M.A.
      • Rikli D.
      • Goslings J.C.
      • Schep N.W.
      Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and residents.
      • Lalone E.A.
      • Grewal R.
      • King G.J.
      • MacDermid J.C.
      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 designOxford Level of EvidencePatients, n (M/W)Age, y (mean [range])Fracture ClassificationTreatmentDuration of Follow-Up, mo (mean [range])Radiological ParametersAcceptable Radiological ParametersPatient-Reported Outcome Measure
      Amorosa et al (2011)Cross-sectional study458 (7/51)78 (70–94)AO types A, B, and CClosed reduction and casting vs closed reduction and percutaneous pinning vs external fixation vs open reduction internal fixation33 (13–65)DA, UV, articular stepoffDA <20°

      UV neutral or negative

      Articular stepoff <2 mm
      DASH
      Barton et al (2007)Cross-sectional study460 (10/50)69.2 (57–70)Frykman types I-II, III-IV, V-VI, and VII-VIIIClosed reduction and K-wire fixation29 (10–46)DA, RI, RSNot definedPRWE
      Bentohami et al (2013)Cross-sectional study4257 (59/198)65 (48–76)AO types A2 and A3Closed reduction and casting36 (range not defined)DA, VA, RI, UVDA <15°

      VA <20°

      RI >15°

      UV <5 mm
      QuickDASH
      Brennan et al (2016)Cross-sectional study4318 (112/206)46.9 (20–65)AO types A, B, and CK-wire fixation vs open reduction and internal volar plate fixation32.2 (12–60)VA, RI, RL, UVVA <10°

      RI >16°

      RL <7 mm

      UV >5 mm or > –4 mm
      DASH, PRWE
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      (2011)
      Prospective cohort study3143 (33/110)(65 (19–95)AO types A, B, and CClosed reduction and casting vs closed reduction and external or percutaneous pinning12 (range not defined)DA, UV, RI, articular stepoffDA ≤10°

      UV ≤0 mm
      DASH
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      (2011)
      Prospective cohort study349 (0/49)(65 (50–75)AO type ACasting vs closed reduction and casting vs closed reduction external fixation39 (25–55)DA, UVDA <15° UV <3 mmDASH
      Finsen et al (2013)Cross-sectional study4260 (32/228)62 (30–84)AO type A2, A3, C1, and C2Casting vs closed reduction and casting75.6 (30–152.4)DA, VA, UV, RI, RL, articular stepoff and articular gapNot definedQuickDASH, PRWE
      Grewal and MacDermid (2007)Prospective cohort study3216 (38/168)55.2 (18–89)Extra-articularCasting vs closed reduction and casting vs intrafocal pinning and external fixation vs open reduction external fixation12 (range not defined)DA, RI, UVDA ≤10°

      RI ≥15°

      UV <3 mm
      DASH, PRWE
      Karnezis et al (2005)Prospective cohort study330 (11/19)46.1 (18–76)AO types A2, A3, C1, and C2Closed reduction K-wire fixation12 (range not defined)VA, RI, RS, articular stepoff and articular gapNot definedPRWE
      Kumar et al (2008)Cross-sectional study495 (16/79)67 (22–94)Extra-articularClosed reduction and casting14 (range 7–34)VA, RI, RLDA <15°

      VA <20°

      RS <5mm

      RI ≥15°
      DASH
      Larouche et al (2016)Prospective cohort study3129 (12/117)64.6 (55–90)Not mentionedClosed reduction and casting vs open reduction internal fixation12 moVA, RI, RL, UV, articular stepoff and articular gapNot definedDASH, PRWE
      Lee et al (2016)Prospective cohort study389 (19/70)57.6 (28–78)AO types A and COpen reduction and internal volar locking plate fixation12 moVA, RI, RL, UVNot definedDASH
      Machado et al (2012)Retrospective study430 (16/14)51 (20–84)Intra-articularOpen reduction internal fixation17.5 (12–26)VA, RI, RLAccording to Lidström
      • Lidstrom A.
      Fractures of the distal end of the radius. A clinical and statistical study of end results.
      DASH
      Nelson et al (2015)Cross-sectional study496 (21/75)72 (not defined)AO type A, B, and CNonsurgical (nonspecific) and operative (nonspecific)12 (range not defined)DA, RI, UV, articular stepoff and articular gapDA <20°

      RI ≥15°

      UV <4 mm

      Articular gap or stepoff <4 mm
      QuickDASH
      Synn et al (2009)Cross-sectional study453 (7/46)69 (55–90)Extra-articular and intra-articularClosed reduction and casting vs closed reduction and percutaneous pinning vs open reduction internal fixation vs open reduction internal/external fixation17 (6–45)DA, VA, RS, articular stepoff and articular gapDA <10°

      VA <25°

      RS <5mm

      Articular stepoff and gap <2 mm
      DASH, PRWE
      Wilcke et al (2007)Cross-sectional study478 (21/57)59 (22–95)Frykman types I-II, III-IV, V-VI, and VII-VIIIClosed reduction and casting vs closed reduction external fixation22 (10–31)DA, VA, UVDA ≤15°

      VA ≤10°

      UV <2 mm
      DASH
      DA, dorsal angulation (tilt); RI, radial Inclination (angle); RL, radial length (height); RS, radial shortening; UV, ulnar variance (height); VA, volar (palmar/radial) angulation (tilt).
      Appendix CNewcastle–Ottawa Scale for Risk of Bias Assessment of Studies Included in Systematic Review
      StudySelectionComparabilityOutcomeOverall
      Representative Exposed CohortSelection of NonexposedAscertainment of ExposureOutcome Not Present at StartAssessment of OutcomeAdequate Follow-Up LengthAdequacy of Follow-Up
      Amorosa et al
      • Amorosa L.F.
      • Vitale M.A.
      • Brown S.
      • Kaufmann R.A.
      A functional outcomes survey of elderly patients who sustained distal radius fractures.
      ★★9
      Barton et al
      • Barton T.
      • Chambers C.
      • Bannister G.
      A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
      ★★7
      Bentohami et al
      • Bentohami A.
      • Bijlsma T.S.
      • Goslings J.C.
      • de Reuver P.
      • Kaufmann L.
      • Schep N.W.
      Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
      ★★9
      Brennan et al
      • Brennan S.A.
      • Kiernan C.
      • Beecher S.
      • et al.
      Volar plate versus k-wire fixation of distal radius fractures.
      8
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Wagner P.
      • Dahlin L.B.
      • Atroshi I.
      Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
      ★★9
      Brogren et al
      • Brogren E.
      • Hofer M.
      • Petranek M.
      • Dahlin L.B.
      • Atroshi I.
      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.
      7
      Finsen et al
      • Finsen V.
      • Rod O.
      • Rod K.
      • Rajabi B.
      • Alm-Paulsen P.S.
      • Russwurm H.
      The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
      7
      Grewal and MacDermid
      • Grewal R.
      • MacDermid J.C.
      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.
      ★★9
      Karnezis et al
      • Karnezis I.A.
      • Panagiotopoulos E.
      • Tyllianakis M.
      • Megas P.
      • Lambiris E.
      Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
      8
      Kumar et al
      • Kumar S.
      • Penematsa S.
      • Sadri M.
      • Deshmukh S.C.
      Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
      ★★8
      Larouche et al
      • Larouche J.
      • Pike J.
      • Slobogean G.P.
      • et al.
      Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
      ★★9
      Lee et al
      • Lee S.J.
      • Park J.W.
      • Kang B.J.
      • Lee J.I.
      Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
      ★★8
      Machado et al
      • Machado D.G.
      • da Cruz Cerqueira S.A.
      • Rodarte R.R.
      • de Souza Araújo Netto C.A.
      • de Mathias M.B.
      Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
      ★★8
      Nelson et al
      • Nelson G.N.
      • Stepan J.G.
      • Osei D.A.
      • Calfee R.P.
      The impact of patient activity level on wrist disability after distal radius malunion in older adults.
      ★★8
      Synn et al
      • Synn A.J.
      • Makhni E.C.
      • Makhni M.C.
      • Rozental T.D.
      • Day C.S.
      Distal radius fractures in older patients: is anatomic reduction necessary?.
      ★★9
      Wilcke et al
      • Wilcke M.K.
      • Abbaszadegan H.
      • Adolphson P.Y.
      Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
      ★★9
      Good quality: 8–9 stars total; fair quality: 5–7 stars total; poor quality: 4 or fewer stars total.

      References

        • Calfee R.P.
        • Adams A.A.
        Clinical research and patient-rated outcome measures in hand surgery.
        J Hand Surg Am. 2012; 37: 851-855
        • Hoang-Kim A.
        • Pegreffi F.
        • Moroni A.
        • Ladd A.
        Measuring wrist and hand function: common scales and checklists.
        Injury. 2011; 42: 253-258
        • Chung K.C.
        • Shauver M.J.
        • Yin H.
        • Kim H.M.
        • Baser O.
        • Birkmeyer J.D.
        Variations in the use of internal fixation for distal radial fracture in the United States medicare population.
        J Bone Joint Surg Am. 2011; 93: 2154-2162
        • Walenkamp M.M.
        • Mulders M.A.
        • Goslings J.C.
        • Westert G.P.
        • Schep N.W.
        Analysis of variation in the surgical treatment of patients with distal radial fractures in the Netherlands.
        J Hand Surg Eur Vol. 2017; 42: 39-44
        • Waljee J.F.
        • Zhong L.
        • Shauver M.J.
        • Chung K.C.
        The influence of surgeon age on distal radius fracture treatment in the United States: a population-based study.
        J Hand Surg Am. 2014; 39: 844-851
        • Brogren E.
        • Hofer M.
        • Petranek M.
        • Wagner P.
        • Dahlin L.B.
        • Atroshi I.
        Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.
        BMC Musculoskelet Disord. 2011; 12: 9
        • Brogren E.
        • Wagner P.
        • Petranek M.
        • Atroshi I.
        Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study.
        Clin Orthop Relat Res. 2013; 471: 1691-1697
        • Finsen V.
        • Rod O.
        • Rod K.
        • Rajabi B.
        • Alm-Paulsen P.S.
        • Russwurm H.
        The relationship between displacement and clinical outcome after distal radius (Colles’) fracture.
        J Hand Surg Eur Vol. 2013; 38: 116-126
        • Karnezis I.A.
        • Panagiotopoulos E.
        • Tyllianakis M.
        • Megas P.
        • Lambiris E.
        Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius.
        Injury. 2005; 36: 1435-1439
        • Amorosa L.F.
        • Vitale M.A.
        • Brown S.
        • Kaufmann R.A.
        A functional outcomes survey of elderly patients who sustained distal radius fractures.
        Hand (N Y). 2011; 6: 260-267
        • Barton T.
        • Chambers C.
        • Bannister G.
        A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years.
        J Hand Surg Eur Vol. 2007; 32: 165-169
        • Bentohami A.
        • Bijlsma T.S.
        • Goslings J.C.
        • de Reuver P.
        • Kaufmann L.
        • Schep N.W.
        Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome.
        J Hand Surg Eur Vol. 2013; 38: 524-529
        • Synn A.J.
        • Makhni E.C.
        • Makhni M.C.
        • Rozental T.D.
        • Day C.S.
        Distal radius fractures in older patients: is anatomic reduction necessary?.
        Clin Orthop Relat Res. 2009; 467: 1612-1620
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
      1. Brink PRG, Bransz N, Deijkers RLM, et al. Guideline for distal radius fractures: diagnosis and treatment. http://www.heelkunde.nl/uploads/h8/VM/h8VMOlRX83oW2NSR_5rTWw/Richtlijn_Distale_radius_fracturen_definitieve_versie_0511.pdf. Accessed June 26, 2017.

        • MacDermid J.C.
        • Richards R.S.
        • Donner A.
        • Bellamy N.
        • Roth J.H.
        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.
        J Hand Surg Am. 2000; 25: 330-340
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
        Am J Ind Med. 1996; 29: 602-608
        • Beaton D.E.
        • Wright J.G.
        • Katz J.N.
        Development of the QuickDASH: comparison of three item-reduction approaches.
        J Bone Joint Surg Am. 2005; 87: 1038-1046
        • MacDermid J.C.
        Development of a scale for patient rating of wrist pain and disability.
        J Hand Ther. 1996; 9: 178-183
        • Sorensen A.A.
        • Howard D.
        • Tan W.H.
        • Ketchersid J.
        • Calfee R.P.
        Minimal clinically important differences of 3 patient-rated outcomes instruments.
        J Hand Surg Am. 2013; 38: 641-649
        • Walenkamp M.M.
        • de Muinck Keizer R.J.
        • Goslings J.C.
        • Vos L.M.
        • Rosenwasser M.P.
        • Schep N.W.
        The minimum clinically important difference of the Patient-Rated Wrist Evaluation score for patients with distal radius fractures.
        Clin Orthop Relat Res. 2015; 473: 3235-3241
        • Wan X.
        • Wang W.
        • Liu J.
        • Tong T.
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodol. 2014; 14: 135
      2. 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.

      3. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed May 21, 2017.

        • Buijze G.A.
        • Doornberg J.N.
        • Ham J.S.
        • Ring D.
        • Bhandari M.
        • Poolman R.W.
        Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials.
        J Bone Joint Surg Am. 2010; 92: 1534-1544
        • Wijffels M.M.
        • Keizer J.
        • Buijze G.A.
        • et al.
        Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical trials.
        Injury. 2014; 45: 1889-1895
        • Higgins J.P.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Brennan S.A.
        • Kiernan C.
        • Beecher S.
        • et al.
        Volar plate versus k-wire fixation of distal radius fractures.
        Injury. 2016; 47: 372-376
        • Brogren E.
        • Hofer M.
        • Petranek M.
        • Dahlin L.B.
        • Atroshi I.
        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.
        J Hand Surg Eur Vol. 2011; 36: 568-576
        • Grewal R.
        • MacDermid J.C.
        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.
        J Hand Surg Am. 2007; 32: 962-970
        • Kumar S.
        • Penematsa S.
        • Sadri M.
        • Deshmukh S.C.
        Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?.
        Int Orthop. 2008; 32: 505-509
        • Larouche J.
        • Pike J.
        • Slobogean G.P.
        • et al.
        Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years.
        J Orthop Trauma. 2016; 30: 445-449
        • Machado D.G.
        • da Cruz Cerqueira S.A.
        • Rodarte R.R.
        • de Souza Araújo Netto C.A.
        • de Mathias M.B.
        Statistical analysis on functional and radiographic results after use of locked volar plate for fractures of the distal radius.
        Rev Bras Orthop. 2012; 47: 297-303
        • Nelson G.N.
        • Stepan J.G.
        • Osei D.A.
        • Calfee R.P.
        The impact of patient activity level on wrist disability after distal radius malunion in older adults.
        J Orthop Trauma. 2015; 29: 195-200
        • Wilcke M.K.
        • Abbaszadegan H.
        • Adolphson P.Y.
        Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score.
        J Hand Ther. 2007; 20 (quiz 299): 290-298
        • Lee S.J.
        • Park J.W.
        • Kang B.J.
        • Lee J.I.
        Clinical and radiologic factors affecting functional outcomes after volar locking plate fixation of dorsal angulated distal radius fractures.
        J Orthop Sci. 2016; 21: 619-624
        • Reynolds P.
        The correlation of radiographic outcome to functional outcome following fracture of the distal radius in elderly patients: a literature review.
        Hand Ther. 2014; 19: 31-39
        • Arora R.
        • Gabl M.
        • Gschwentner M.
        • Deml C.
        • Krappinger D.
        • Lutz M.
        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.
        J Orthop Trauma. 2009; 23: 237-242
        • Arora R.
        • Lutz M.
        • Deml C.
        • Krappinger D.
        • Haug L.
        • Gabl M.
        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.
        J Bone Joint Surg Am. 2011; 93: 2146-2153
        • Ng C.Y.
        • McQueen M.M.
        What are the radiological predictors of functional outcome following fractures of the distal radius?.
        J Bone Joint Surg Br. 2011; 93: 145-150
        • Mulders M.A.
        • Rikli D.
        • Goslings J.C.
        • Schep N.W.
        Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and residents.
        Eur J Trauma Emerg Surg. 2017; 43: 239-248
        • Lalone E.A.
        • Grewal R.
        • King G.J.
        • MacDermid J.C.
        A structured review addressing the use of radiographic measures of alignment and the definition of acceptability in patients with distal radius fractures.
        Hand (N Y). 2015; 10: 621-638

      Linked Article