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The Association Between Psychological Factors and Outcomes After Distal Radius Fracture

      Purpose

      The aim of this study was to identify psychological factors associated with pain intensity and disability following distal radius fracture.

      Methods

      We prospectively followed 216 adult patients with distal radius fracture for 9 months. Demographics, injury and treatment details, and psychological measures (Hospital Anxiety and Depression Score [HADS], Pain Catastrophizing Scale, Posttraumatic Stress Disorder Checklist–Civilian, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire Brief [IPQB], General Self-Efficacy Scale, and Recovery Locus of Control [RLOC]) were collected at enrollment. Multivariable linear regression was used to identify factors associated with Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and Likert pain scores.

      Results

      Higher 10-week DASH scores were associated with increased age, the presence of a nerve pathology, increased HADS Depression subscale scores, increased IPQB scores, and lower RLOC scores. Higher 9-month DASH scores were associated with increased age, increased deprivation scores, increased numbers of medical comorbidities, a greater degree of radial shortening, increased HADS Depression subscale scores, and lower RLOC scores. A higher 10-week pain score was associated with increased deprivation and IPQB scores. A higher pain score at 9 months was associated with an increased number of medical comorbidities.

      Conclusions

      Psychosocial factors measured early after fracture are associated with pain and disability up to 9 months after distal radius fracture. Illness perception is a potentially modifiable psychological construct not previously studied in hand conditions. It may provide a suitable target for psychological interventions that could enhance recovery.

      Type of study/level of evidence

      Prognostic II.

      Key words

      Distal radius fracture is a common injury. The majority of people recover well, but a proportion have ongoing pain, stiffness, deformity, and functional limitations. Associations between these outcomes, injury characteristics, and treatment methods are unpredictable. For example, a deformed wrist is not always painful, stiff, and functionally limiting.
      It is recommended that radiocarpal alignment and radial length be restored and an articular gap of less than 2 mm be achieved to optimize outcomes after distal radius fracture.
      • Ng C.Y.
      • McQueen M.M.
      What are the radiological predictors of functional outcome following fractures of the distal radius?.
      • Jupiter J.B.
      • Knirk J.L.
      Intra-articular fractures of the distal end of the radius in young adults.
      • Batra S.
      • Gupta A.
      The effect of fracture-related factors on the functional outcome at 1 year in distal radius fractures.
      • Trumble T.E.
      • Schmitt S.R.
      • Vedder N.B.
      Factors affecting functional outcome of displaced intra-articular distal radius fractures.
      • McQueen M.M.
      • Hajducka C.
      • Court-Brown C.M.
      Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment.
      • McQueen M.
      • Caspers J.
      Colles fracture: does the anatomical result affect the final function?.
      However, the associations between these radiographic parameters and patient-reported outcomes (symptom intensity and disability) are inconsistent.
      • Ng C.Y.
      • McQueen M.M.
      What are the radiological predictors of functional outcome following fractures of the distal radius?.
      ,
      • Wilcke M.K.T.
      • 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.
      • Cowie J.
      • Anakwe R.
      • McQueen M.
      Factors associated with one-year outcome after distal radial fracture treatment.
      • Souer J.S.
      • Lozano-Calderon S.A.
      • Ring D.
      Predictors of wrist function and health status after operative treatment of fractures of the distal radius.
      • Rockwood C.A.
      • Green D.P.
      • Bucholz R.W.
      • Court-Brown C.
      • McQueen M.
      • Tornetta P.
      Rockwood and Green’s Fractures in Adults.
      The World Health Organization (WHO) recognizes the impact of psychological, social, and environmental factors in the translation of a pathophysiological (biomedical) process to disability, symptom intensity, and ultimately health.
      World Health Organization (WHO)
      Preamble to the Constitution of the World Health Organization as Adopted by the International Health Conference, New York, 19–22 June, 1946; Signed on 22 July 1946 by the Representatives of 61 States.
      It has been demonstrated that psychosocial factors are associated with patient-reported outcomes and pain responses in a number of conditions affecting the hand.
      • Souer J.S.
      • Lozano-Calderon S.A.
      • Ring D.
      Predictors of wrist function and health status after operative treatment of fractures of the distal radius.
      ,
      • London D.A.
      • Stepan J.G.
      • Boyer M.I.
      • Calfee R.P.
      The impact of depression and pain catastrophization on the initial presentation and treatment outcomes for atraumatic hand conditions.
      ,
      • Sacks H.A.
      • Stepan J.G.
      • Wessels L.E.
      • Fufa D.T.
      The relationship between pain-related psychological factors and postoperative opioid use after ambulatory hand surgery.
      The psychological response to fracture and the specific role that individual psychological factors play in recovery remain poorly understood. The identification of potentially modifiable psychological factors that can be measured quantitatively at an early stage following injury and are associated with longer-term outcomes may help target additional psychological interventions aimed at enhancing recovery.
      The aim of this prospective cohort study was to identify psychological factors, measured within 4 weeks of injury, that are associated with disability and pain intensity at 10 weeks and 9 months after distal radius fracture.

      Materials and Methods

      All patients with distal radius fractures presenting within 4 weeks of injury to a single orthopedic trauma department at the Royal Infirmary Edinburgh, Edinburgh, UK, between August 2015 and February 2016, were assessed for eligibility for recruitment into the study. This department is the sole provider of orthopedic trauma care to patients over age 13 for a population of approximately 560,000.

      National Records of Scotland. Scotland Census 2011. Crown; 2011. Accessed May 12, 2015. Available at: http://www.scotlandscensus.gov.uk/

      All skeletally mature patients age 16 and over were included, regardless of treatment type. Patients were offered 1 of either: open reduction and internal fixation with a volar plate, closed reduction and cast, or cast immobilization alone. Treatment decisions were made by the consultant orthopedic surgeon in charge of care following a discussion of treatment options with the patient. Patients were excluded if they declined involvement, did not speak English, lacked the cognitive capacity to understand and complete questionnaires, were undertaking injury compensation proceedings, were using illicit drugs, or had a psychiatric diagnosis resulting in psychosis. The study was approved by the South East Scotland Research Ethics Service.
      Details of demographics, the level of social deprivation (The Scottish Index of Multiple Deprivation
      The Scottish Government
      Scottish Index of Multiple Deprivation 2009: General Report.
      ), medical history, radiographic parameters; Orthopaedic Trauma Association (AO-OTA) fracture classification,
      • Marsh J.
      • Slongo T.
      • Agel J.
      Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee.
      radiocarpal alignment, radial shortening, and dorsal tilt, injury and treatment characteristics, and psychological assessment questionnaires were collected prospectively at enrollment. Outcome questionnaires were completed at a mean of 10 weeks and 9 months. Psychological measures were the Hospital Anxiety and Depression Score (HADS) Depression subscale, HADS Anxiety subscale, Pain Catastrophizing Scale (PCS), Tampa Scale for Kinesiophobia (TSK), Posttraumatic Stress Disorder Civilian Checklist (PCL-C), Illness Perception Questionnaire Brief (IPQB), General Self-Efficacy Scale (GSES) and Recovery Locus of Control (RLOC) scores. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) score and Numerical Rating Scale (NRS) pain score.

      Psychological measures

      The HADS is a 14-item scoring system used to screen patients for symptoms of anxiety and depression.
      • Zigmond A.S.
      • Snaith R.P.
      The Hospital Anxiety and Depression scale.
      It has both Anxiety and Depression subscales, each with 7 items scored between 0–3, giving a score of between 0 and 21 for each. The PCS is a 13-question scoring system of catastrophic thinking, scored between 0 and 52.
      • Sullivan M.J.L.
      • Bishop S.R.
      • Pivik J.
      The Pain Catastrophizing Scale: development and validation.
      Higher scores reflect higher levels of catastrophic thinking. The TSK measures fear of movement related to pain or fear of reinjury.
      • Kori S.H.
      • Miller R.P.
      • Todd D.D.
      Kinesiophobia: a new view of chronic pain behavior.
      It is scored between 17 and 68, with higher scores representing greater fear avoidance behavior. The PCL-C assesses symptoms of posttraumatic stress disorder. It is scored between 17 (low) and 85 (high).
      • Conybeare D.
      • Behar E.
      • Solomon A.
      • Newman M.G.
      • Borkovec T.D.
      The PTSD Checklist–Civilian Version: reliability, validity, and factor structure in a nonclinical sample.
      ,
      • Hoge C.W.
      • Castro C.A.
      • Messer S.C.
      • McGurk D.
      • Cotting D.I.
      • Koffman R.L.
      Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
      The IPQB is a 9-item measure in which each question represents 1 dimension of illness perception (consequence, timeline acute/chronic, timeline cyclical, personal control, treatment control, identity, coherence, emotional representation, and cause). An overall score is calculated, which represents the degree to which an illness or injury is perceived to be threatening (high) or benign (low).
      • Broadbent E.
      • Petrie K.J.
      • Main J.
      • Weinman J.
      The brief illness perception questionnaire.
      The GSES assesses beliefs about the personal ability to cope with difficult situations: perceived self-efficacy.
      • Jerusalem M.
      • Schwarzer R.
      Self-efficacy as a resource factor in stress appraisal processes.
      ,
      • Weinman J.
      • Wright S.
      • Johnston M.
      Generalized self-efficacy scale.
      It is scored from 10 (low) to 40 (high). The RLOC is used to evaluate an individual’s beliefs about the control they have over their recovery from a traumatic event.
      • Partridge C.
      • Johnston M.
      Perceived control of recovery from physical disability: measurement and prediction.
      It is scored from 9 (high external locus) to 45 (high internal locus). “High external locus” refers to a patient’s belief that their recovery is dependent on external factors that they have no control over, in contrast to a “high internal locus,” which refers to a mindset where patients believe they have control over the recovery from and outcome of their injury.

      Outcome measures

      The DASH score is a patient-reported scoring system used in the assessment of upper extremity conditions. It is scored between 0 and 100, with a higher score representing greater 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).
      ,
      • Changulani M.
      • Okonkwo U.
      • Keswani T.
      • Kalairajah Y.
      Outcome evaluation measures for wrist and hand:which one to choose?.
      It contains items that assess all 3 aspects of the WHO’s International Classification of Functioning, Disability and Health (ICF) framework: impairment, activity limitation, and participation restriction.
      • Dixon D.
      • Johnston M.
      • McQueen M.
      • Court-Brown C.
      The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF).
      The NRS pain score assesses average pain over the preceding week, measured on an 11-point Likert scale from 0 (no pain) to 10 (worst pain imaginable).
      Posteroanterior and lateral radiographs of the wrist were taken in a standard manner. All radiographic assessments were carried out by a single Trauma and Orthopaedic Specialty Trainee Registrar using a picture-archiving and communication system (Carestream, Version 11.40.1253).

      Cohort

      Of the 288 patients with complete outcome data at both 10 weeks and 9 months, 216 formed the final study cohort (Fig. 1). Details of the study cohort and a comparison with those lost to follow-up are seen in Appendix E1 (available online on the Journal’s website at www.jhandsurg.org).

      Statistical methods

      Descriptive statistics were used to present demographic, comorbidity, injury, treatment, radiographic, and psychological characteristics. Patients who did not complete follow-up are compared to the study cohort in Appendix E1. The Wilcoxon signed rank test and Freidman’s test were used to assess changes in outcome variables over time.
      The response variables were DASH scores and pain intensity at 10 weeks and 9 months. The explanatory variables were age; sex; social deprivation quintile; number of medical comorbidities; AO-OTA fracture classification (grouped as A, B, or C); nerve pathology; multiple fractures; radiographic alignment at T2: radiocarpal alignment, radial shortening, and dorsal tilt; surgical or nonoperative management; time to presentation and follow-up; and psychological measures (HADS Anxiety, HADS Depression, PCS, TSK, PCL-C, IPQB, GSES, and RLOC scores). Spearman correlations, Mann-Whitney U tests, and Kruskal-Wallis tests were used for nonparametric data and Pearson correlations, Student t tests, and analyses of variance were used for parametric data. Factors with P values < .1 in a bivariate analysis were entered into multivariable linear regression models. Where there was a correlation of >0.7 between factors in any regression analysis, 1 factor was dropped from the model. For the study cohort of 216 patients, outcome data were 100% complete and data for each explanatory variable were over 90% complete. Missing explanatory variable data were completed with mean imputation.

      Results

      Enrollment psychological scores are shown and compared to normative and chronic pain cohorts in Table 1. The enrollment psychological scores of the study cohort were better than those of both chronic pain and normative populations. Radiographic outcomes following treatment are seen in Table 2.
      Table 1Comparison of Mean Cohort Enrollment Psychological Scores with Reference Populations
      Psychological FactorDistal Radius Fracture Study Cohort, Mean (Range, SD, 95% CI)Reference Normative Population ScoresReference Chronic Pain Population Scores
      PCS6.9 (0–47, 9.1, 6–8)12 (0–52, 9.1)
      • Mounce C.
      • Keogh E.
      • Eccleston C.
      A principal components analysis of negative affect-related constructs relevant to pain: evidence for a three component structure.
      20.9 (0–50, 12.5)

      Sullivan MJL. The pain catastrophising scale user manual. Accessed January 16, 2017. http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf

      HADS Depression3.1 (0–15, 3.2, 2.7–3.6)Female 4.1 (3.8)
      • Hoge C.W.
      • Castro C.A.
      • Messer S.C.
      • McGurk D.
      • Cotting D.I.
      • Koffman R.L.
      Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.


      Male 3.8 (3.7)
      • Breeman S.
      • Cotton S.
      • Fielding S.
      • Jones G.T.
      Normative data for the Hospital Anxiety and Depression Scale.
      8.1
      • Pallant J.F.
      • Bailey C.M.
      Assessment of the structure of the Hospital Anxiety and Depression Scale in musculoskeletal patients.
      HADS Anxiety4.6 (0–16, 3.5, 4.1–5.1)Female 6.8 (4.2)
      • Breeman S.
      • Cotton S.
      • Fielding S.
      • Jones G.T.
      Normative data for the Hospital Anxiety and Depression Scale.


      Male 5.5 (4)
      • Breeman S.
      • Cotton S.
      • Fielding S.
      • Jones G.T.
      Normative data for the Hospital Anxiety and Depression Scale.
      9.3
      • Pallant J.F.
      • Bailey C.M.
      Assessment of the structure of the Hospital Anxiety and Depression Scale in musculoskeletal patients.
      TSK37.9 (22–55, 6, 37–39)n/a41.2 (9.4)
      • Nicholas M.K.
      • Asghari A.
      • Blyth F.M.
      What do the numbers mean? Normative data in chronic pain measures.
      PCL-C (PTSD)23.6 (17–71, 9.5, 22–25)Gunshot wound 30 (22–48)
      • Alarcon L.H.
      • Germain A.
      • Clontz A.S.
      • et al.
      Predictors of acute posttraumatic stress disorder symptoms following civilian trauma: highest incidence and severity of symptoms after assault.


      Assault 30 (23–53)
      • Alarcon L.H.
      • Germain A.
      • Clontz A.S.
      • et al.
      Predictors of acute posttraumatic stress disorder symptoms following civilian trauma: highest incidence and severity of symptoms after assault.


      Fall 21 (18–28)
      • Alarcon L.H.
      • Germain A.
      • Clontz A.S.
      • et al.
      Predictors of acute posttraumatic stress disorder symptoms following civilian trauma: highest incidence and severity of symptoms after assault.
      35 (13)
      • Pagé G.M.
      • Kleiman V.
      • Asmundson G.J.G.
      • Katz J.
      Structure of posttraumatic stress disorder symptoms in pain and pain-free patients scheduled for major surgery.
      IPQB33 (0–61, 12, 31–34)n/an/a
      GSES31.9 (12–40, 5.3, 31–33)n/a29 (6)
      • Barlow J.H.
      • Williams B.
      • Wright C.
      The Generalized Self-Efficacy Scale in people with arthritis.
      RLOC35.6 (20–45, 4.9, 35–36)n/an/a
      CI, confidence interval; n/a, not available; PTSD, posttraumatic stress disorder.
      Table 2Radiographic Outcomes Following Treatment
      Data provide a comparison of participants in the study cohort to those lost to follow-up.
      Radiographic Parameters at 10 Weeksn (%)
      Study CohortIncomplete Follow-Up
      n = 216n = 72
      Radiocarpal alignment maintained
       Yes151 (70)55 (76)
       No65 (30)17 (24)
      Dorsal tilt degrees

      Mean (range, SD, 95% CI)
      0 (−39 to 43, 14, −2 to 2)−2 (−12 to 31, 11, −5 to 1)
      Ulnar variance, mm

      Mean (range, SD, 95% CI)
      1 (−4 to 11, 3, 1–2)1 (−7 to 10, 2, 0–1)
      CI, confidence interval.
      Data provide a comparison of participants in the study cohort to those lost to follow-up.

      Disability and pain

      The median DASH and NRS pain scores improved with time. DASH returned to near the quoted normal population value of 10 (Table 3).
      • Caughlin B.
      • Hunsaker F.G.
      • Cioffi D.A.
      • Amadio P.C.
      • Wright J.G.
      The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population.
      Table 3Change in Outcome Variables Over Time
      Enrollment (<3 Weeks)10 Weeks9 MonthsP Value
      Median DASH (IQR)n/a28 (14–45)13 (4–29)<.05
      Wilcoxon signed rank test.
      Median NRS pain score (IQR)5 (2–6)4 (2–6)2 (1–4)<.05
      Friedman’s test.
      IQR, interquartile range; n/a, not available.
      Wilcoxon signed rank test.
      Friedman’s test.

      Multivariable regression analysis

      Those factors associated with outcomes at each time point on bivariate analysis (P < .1) were entered into the multivariable regression analysis.
      Table 4 shows the factors included in the multivariable regression models that predicted worse DASH scores at 10 weeks (P < .05; adjusted [adj] R2 = 0.4) and 9 months (P < .05; adj R2 = 0.3). Increasing age, level of social deprivation, HADS Depression subscale score, IPQB score, an external locus of control (RLOC), and nerve pathology were associated with an increased DASH score at 10 weeks. Increasing age, level of social deprivation, HADS Depression subscale score, an external locus of control (RLOC), an increased number of medical comorbidities, and increased radial shortening were associated with an increased DASH score at 9 months.
      Table 4Factors From Multivariable Linear Regression Models That Predict DASH Scores at 10 Weeks and 9 Months Following Distal Radius Fracture
      VariableRegression Coefficient (Unstandardized)Standardized Coefficient95% Confidence LimitsP Value
      DASH score at 10 weeks
       Age (increased age with higher DASH)0.40.30.2 to 0.5<.05
       SIMD quintile 1 (most deprived)9.70.22.0 to 17.4<.05
       HADS Depression1.50.20.4 to 2.6<.05
       IPQB0.40.20.2 to 0.7<.05
       Nerve pathology16.00.13.3 to 28.6<.05
       RLOC−0.6−0.1−1.1 to −0.1<.05
       Sex (female with higher DASH score)1.70.0−3.9 to 7.4.548
       Number of medical comorbidities0.60.0−0.8 to 2.1.396
       Fracture at multiple site in body2.00.0−6.1 to 10.1.627
       Dorsal tilt0.10.1−0.1 to 0.2.581
       Radial shortening0.80.5−0.2 to 1.2.107
       Radiocarpal alignment0.42.7−4.8 to 5.6.886
       PCS0.00.2−0.3 to 0.4.787
       HADS Anxiety−0.60.4−1.4 to 0.3.186
       PTSD0.10.2−0.3 to 0.5.739
       TSK−0.10.2−0.6 to 0.4.785
       GSES0.10.3−0.4 to 0.7.581
       Time to follow-up−1.00.6−2.1 to 0.2.091
      DASH score at 9 months
       SIMD quintile 1 (most deprived)10.10.22.1 to 18.1<.05
       HADS Depression1.40.20.3 to 2.5<.05
       Age (increased age with higher DASH score)0.20.10 to 0.3<.05
       Number of medical comorbidities1.60.10.1 to 3.2<.05
       Radial shortening1.10.10.1 to 2.1<.05
       RLOC−0.6−0.1−1.2 to −0.1<.05
       Sex (female with higher DASH score)4.93.0−1.1 to 10.8.109
       Dorsal tilt0.00.1−0.2 to 0.3.683
       Radiocarpal alignment0.42.7−5.0 to 5.8.887
       AO-OTA Group B−3.43.3−9.9 to 3.0.295
       Nerve pathology12.26.7−1.0 to 25.4.070
       PCS−0.10.2−0.4 to 0.2.454
       HADS Anxiety−0.20.4−1.1 to 0.7.646
       PTSD0.30.2−0.1 to 0.7.134
       TSK−0.10.3−0.6 to 0.4.676
       IPQB0.10.1−0.1 to 0.4.365
       GSES0.00.3−0.5 to 0.5.972
       Time to follow-up−0.30.4−1.1 to 0.5.429
      PTSD, posttraumatic stress disorder; SIMD, The Scottish Index of Multiple Deprivation.
      Table 5 shows the factors included in the multivariable regression models that predicted increased pain scores at 10 weeks (P < .05; adj R2 = 0.3) and 9 months (P < .05; adj R2 = 0.2). Increasing levels of social deprivation and IPQB scores were associated with increased pain scores at 10 weeks. An increasing number of medical comorbidities was associated with an increased pain score at 9 months.
      Table 5Factors From Multivariable Linear Regression Models That Predict Pain Scores 10 Weeks and 9 Months Following Distal Radius Fracture
      VariableRegression CoefficientStandardized Coefficient95% Confidence LimitsP Value
      NRS pain score at 10 weeks
       IPQB0.10.30 to 0.1<.05
       SIMD quintile 1 (most deprived)1.00.10 to 2.0<.05
       Sex (female with higher score)0.10.4−0.6 to 0.8.756
       Number of medical comorbidities−0.00.1−0.2 to 0.2.875
       Nerve pathology0.70.8−1.0 to 2.3.415
       Radiocarpal alignment−0.10.3−0.7 to 0.6.881
       Radial shortening0.10.10.0 to 0.2.157
       Dorsal angulation0.00.00.0 to 0.0.102
       PCS0.00.00.0 to 0.1.245
       HADS Depression0.00.1−0.1 to 0.1.974
       HADS Anxiety0.10.1−0.1 to 0.2.340
       PTSD0.00.00.0 to 0.1.847
       TSK0.00.0−0.1 to 0.1.774
       GSES0.00.0−0.1 to 0.1.688
       RLOC0.00.0−0.1 to 0.0.219
       Time to follow-up−0.10.1−0.3 to 0.0.050
      NRS pain score at 9 months
       Number of medical comorbidities0.20.10 to 0.4<.05
       Sex (female with higher score)0.10.4−0.7 to 0.9.814
       Radial shortening0.10.1−0.1 to 0.2.329
       Dorsal angulation0.00.00.0 to 0.0.354
       PCS0.00.00.0 to 0.0.894
       HADS Depression0.00.1−0.1 to 0.2.627
       HADS Anxiety0.00.1−0.1 to 0.1.650
       PTSD0.00.00.0 to 0.1.330
       IPQB0.00.00.0 to 0.1.166
       GSES0.00.0−0.1 to 0.1.923
       RLOC0.00.0−0. to 0.0.450
       AO-OTA Group C0.40.4−0.4 to 1.1.361
      PTSD, posttraumatic stress disorder; SIMD, The Scottish Index of Multiple Deprivation.

      Discussion

      This study identifies a number of demographic, psychosocial, and injury characteristics associated with outcomes after distal radius fracture. It confirms the association with psychosocial factors, as previously demonstrated in other conditions of the upper limb. It identifies illness perception, RLOC, and depressive symptoms as specific psychological factors that can be measured within 4 weeks of injury and are associated with longer-term DASH scores. These may provide potential targets for psychological interventions to enhance recovery from this common injury.
      Increased age was associated with an increased DASH score at 9 months and was the factor most strongly associated with an increased DASH score 10 weeks after injury. This is unsurprising given the reduced functional level that comes with increasing age, and likely reflects the higher baseline levels of disability seen as patients get older.
      • Aasheim T.
      • Finsen V.
      The DASH and the QuickDASH instruments. Normative values in the general population in Norway.
      An increased level of social deprivation was associated with worse DASH scores at 10 weeks and 9 months and a higher pain score at 10 weeks. Similar trends are seen in pediatric upper extremity fracture
      • Okoroafor U.C.
      • Gerull W.
      • Wright M.
      • Guattery J.
      • Sandvall B.
      • Calfee R.P.
      The impact of social deprivation on pediatric PROMIS health scores after upper extremity fracture.
      and carpal tunnel syndrome.
      • Wright M.A.
      • Beleckas C.M.
      • Calfee R.P.
      Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation.
      The association is less profound when measures that more specifically assess impairments are used. A prospective study of 3,893 patients with distal radius fracture found that increased social deprivation was not associated with a decreased range of motion, grip strength, or the Moberg Pick-Up Test. These measures are more specific to wrist impairment than the DASH score, which measures the broader concept of patient-reported disability in the upper extremity.
      • Dixon D.
      • Johnston M.
      • McQueen M.
      • Court-Brown C.
      The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF).
      The number of medical comorbidities a patient had at the time of injury was associated with longer-term outcomes, pain, and disability at 9 months. This may be due to a slower functional recovery from fracture in more frail populations, as well as the incidental influence of comorbid conditions.
      • Chen X.
      • Mao G.
      • Leng S.X.
      Frailty syndrome: an overview.
      ,
      • Fried L.P.
      • Tangen C.
      • Walston J.
      • et al.
      Frailty in older adults: evidence for a phenotype.
      The association between these demographic factors and patient reported outcome measures (PROMs) is strong but these factors are not modifiable in the context of treatment of distal radius fracture. The potentially modifiable factors most strongly associated with outcomes are psychological, and therefore these are of interest.
      Increased levels of depressive symptoms and a belief in an external locus of control (belief that the outcome is dependent on others rather than oneself) were associated with increased disability at 10 weeks and 9 months. An increased perception that injury posed a threat to health (IPQB score) was associated with increased disability and pain at the 10-week follow-up.
      The measured psychological score after injury is likely to reflect both an individual’s preinjury condition and their response to injury. It was not possible to make a distinction between the 2 with our data because patients were recruited after injury. A better understanding of this association would help target interventions, because acute psychological responses to injury may be more amenable to modification with interventions than long-standing psychological traits.
      These findings are in keeping with work in the wider orthopedic literature. In cross-sectional studies of patients with mixed upper limb conditions, depressive symptoms have been associated with poorer grip strength, patient-reported functional outcomes, and pain.
      • Vrahas M.S.
      • Crichlow R.J.
      • Andres P.L.
      • Morrison S.M.
      • Haley S.M.
      Depression in orthopaedic trauma patients. prevalence and severity.
      • Watson J.
      • Ring D.
      Influence of psychological factors on grip strength.
      • Oflazoglu K.
      • Mellema J.J.
      • Menendez M.E.
      • Mudgal C.S.
      • Ring D.
      • Chen N.C.
      Prevalence of and factors associated with major depression in patients with upper extremity conditions.
      In a cross-sectional study of 594 patients with acute hand and wrist fractures, Ross et al
      • Ross C.
      • Juraskova I.
      • Lee H.
      • et al.
      Psychological distress mediates the relationship between pain and disability in hand or wrist fractures.
      found that depression affected the relationship between pain and disability. Nota et al
      • Nota S.P.F.T.
      • Bot A.G.J.
      • Ring D.
      • Kloen P.
      Disability and depression after orthopaedic trauma.
      found that increased depressive symptoms at enrollment were associated with poorer functional scores 8 months following injury in a longitudinal study of a mixed cohort of orthopedic trauma patients. A longitudinal study of patients admitted to hospital with injuries (Injury Severity Score ≥ 9) found an association between illness perceptions at 3 months and functional outcomes at 6 months following injury.
      • Chaboyer W.
      • Lee B.O.
      • Wallis M.
      • Gillespie B.
      • Jones C.
      Illness representations predict health-related quality of life 6 months after hospital discharge in individuals with injury: a predictive survey.
      Baseline psychological scores in the study cohort were better than established normative scores. Catastrophic thinking is thought to have a dose-dependent association with outcomes.
      • Wertli M.M.
      • Eugster R.
      • Held U.
      • Steurer J.
      • Kofmehl R.
      • Weiser S.
      Catastrophizing–a prognostic factor for outcome in patients with low back pain: a systematic review.
      This may explain the failure of this study to corroborate the previously demonstrated association between catastrophic thinking and outcomes.
      Injury, radiographic, and treatment factors were associated with outcomes to a lesser degree than demographic and psychological factors. The presence of symptoms or signs of nerve pathology was associated with increased disability at 10 weeks and the degree of radial shortening was associated with the severity of disability at 9 months. No other associations were found between biomedical factors and outcomes in this study.
      Radial shortening has been associated with outcomes following distal radius fracture in a number of other studies but, in general, the associations between radiographic measures and patient-reported outcomes are inconsistent.
      • Ng C.Y.
      • McQueen M.M.
      What are the radiological predictors of functional outcome following fractures of the distal radius?.
      ,
      • Wilcke M.K.T.
      • 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.
      • Cowie J.
      • Anakwe R.
      • McQueen M.
      Factors associated with one-year outcome after distal radial fracture treatment.
      • Souer J.S.
      • Lozano-Calderon S.A.
      • Ring D.
      Predictors of wrist function and health status after operative treatment of fractures of the distal radius.
      • Rockwood C.A.
      • Green D.P.
      • Bucholz R.W.
      • Court-Brown C.
      • McQueen M.
      • Tornetta P.
      Rockwood and Green’s Fractures in Adults.
      It should be noted that in the cohort of patients studied, the majority of the injuries were low energy, and good radiographic outcomes were achieved. This may have reduced the influence of these factors on the outcomes.
      Although the cohort is from a well-defined population, those lost to follow-up were younger and had radiographically less severe injuries. Patients with a cognitive impairment or psychosis were excluded. Baseline psychological scores in the study cohort were better than recognized normative values. Variation in baseline scores would be expected in different populations, but the reasons for better scores in this cohort are unclear. These points must be considered when generalizing the results. The results do not establish causality.
      The average time to a final follow-up was 9 months. The majority of recovery should have occurred within this period, and in the study cohort the mean DASH score had returned to near population normative levels.
      • Roh Y.H.
      • Lee B.K.
      • Noh J.H.
      • Oh J.H.
      • Gong H.S.
      • Baek G.H.
      Effect of anxiety and catastrophic pain ideation on early recovery after surgery for distal radius fractures.
      ,
      • Egol K.A.
      • Walsh M.
      • Romo-Cardoso S.
      • Dorsky S.
      • Paksima N.
      Distal radial fractures in the elderly: operative compared with nonoperative treatment.
      However, outcomes can still be expected to improve beyond this point. The R2 value in the multivariable regression models indicates that a proportion of the variance in outcome scores remains unexplained.
      Of the psychological factors identified, more were associated with variance in disability than variance in pain. The DASH score contains items that measure pain, activity limitations, and restrictions in social participation.
      • Dixon D.
      • Johnston M.
      • McQueen M.
      • Court-Brown C.
      The Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH) can measure the impairment, activity limitations and participation restriction constructs from the International Classification of Functioning, Disability and Health (ICF).
      Thus, the larger number of predictive factors for this measure might simply reflect the fact that disability is a broader concept than pain and, as such, has more variability.
      There may be unrecognized collinearity between factors used as entry variables. This was addressed by dropping 1 entry variable in the event of a correlation coefficient > 0.7 between entry variables on bivariate analysis. There were no such correlations between any of the psychological variables.
      The psychological questionnaires used were large in number and often in length; this can create questionnaire fatigue. Multiplicity and resultant type I errors must be considered in the type of bivariate analysis used, particularly with the number of entry variables and outcome measures considered. Attempts to limit this were made by rationalizing the entry factors used and focusing on the primary outcome measure. In order to develop a psychological intervention that can supplement current best-practice management of distal radius fracture, an association between the psychological construct upon which the intervention acts and the outcome after fracture must be demonstrated. In an attempt to find such a construct, multiple psychological scoring systems were included in the analysis. Each system used was distinct and represents a different, potentially modifiable psychological construct that can be quantitatively measured. Of all the psychological constructs used, illness perception (IPQB) may be the best focus for future work. It is associated with both pain and disability and is potentially modifiable following fracture.
      • Lee B.O.
      • Chien C.S.
      • Hung C.C.
      • Chou P.L.
      Effects of an in-hospital nursing intervention on changing illness perceptions in patients with injury.
      The scoring system is also quick and easy to administer.
      The associations between depressive symptoms, illness perceptions, perceived locus of control, and outcomes in this cohort of patients with distal radius fracture are significant but small. Psychological factors are potentially modifiable after injury.
      • Lee B.O.
      • Chien C.S.
      • Hung C.C.
      • Chou P.L.
      Effects of an in-hospital nursing intervention on changing illness perceptions in patients with injury.
      Measuring these factors at baseline may identify those subgroups of patients at risk of poor outcomes and allow referrals to specialized services designed to improve psychological responses to injury, and ultimately PROMs. Future work should focus on how best to identify these patients and how best to intervene, with the aim of treatment being to optimize both the physical and psychological conditions for recovery from fracture.

      Supplementary Data

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