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Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations

A Long-Term Follow-up

Ali, Muhanned, MD*,1,a; Brogren, Elisabeth, MD, PhD*,2; Wagner, Philippe, PhD3; Atroshi, Isam, MD, PhD1,4

doi: 10.2106/JBJS.17.00107
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Background: The long-term effect of distal radial fracture malunion on activity limitations is unknown. Between 2001 and 2002, we conducted a prospective cohort study of all patients with distal radial fracture treated with casting or percutaneous fixation in northeast Scania in Sweden. In that original study, the patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at baseline and at 2 years. We performed a long-term follow-up study of patients who were 18 to 65 years of age at the time of the fracture to investigate the association between fracture malunion and activity limitations.

Methods: In this long-term follow-up, patients who had participated in the original study completed the DASH questionnaire and a visual analog scale (VAS) for pain and for satisfaction (scored, 0 [best] to 100) and underwent radiographic and physical examinations at 12 to 14 years after the fracture. We defined malunion as dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°. We also assessed the presence of radiocarpal osteoarthritis and ulnar styloid nonunion. The primary outcome was the change in DASH score from baseline. Secondary outcomes were DASH, pain, and satisfaction scores, wrist range of motion, and grip strength at the time of the follow-up.

Results: Of 85 eligible patients, 63 (74%) responded to the questionnaires and underwent examinations. Malunion was found in 25 patients, osteoarthritis was found in 38 patients, and styloid nonunion was found in 9 patients. Compared with patients without malunion, those with malunion had significantly worse DASH scores from baseline to 12 to 14 years (p = 0.002); the adjusted mean difference was 11 points (95% confidence interval [CI], 4 to 17 points). Similarly, follow-up scores were significantly worse among patients with malunion; the adjusted mean difference was 14 points (95% CI, 7 to 22 points; p < 0.001) for DASH scores, 10 points (95% CI, 0 to 20 points; p = 0.049) for VAS pain scores, and 26 points (95% CI, 11 to 41 points; p = 0.001) for VAS satisfaction scores. No differences were found in range of motion or grip strength. Osteoarthritis (mostly mild) and styloid nonunion had no significant association (p > 0.05) with DASH scores, VAS pain or satisfaction scores, or grip strength.

Conclusions: Patients who sustain a distal radial fracture at the age of 18 to 65 years and develop malunion are more likely to have worse long-term outcomes including activity limitations and pain.

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

1Department of Orthopedics, Kristianstad and Hässleholm Hospitals, Hässleholm, Sweden

2Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden

3Centre for Clinical Research, Uppsala University, Västmanland County Hospital, Västerås, Sweden

4Department of Clinical Sciences - Orthopedics, Lund University, Lund, Sweden

aE-mail address for M. Ali: muhanned.ali@skane.se

*Muhanned Ali, MD, and Elisabeth Brogren, MD, PhD, contributed equally to the writing of this article.

Copyright © 2018 by The Journal of Bone and Joint Surgery, Incorporated
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