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Commentary and Perspective

Distal Radial Fracture Malunion in Sweden: Is It the Same in Your Region?

Commentary on an article by Muhanned Ali, MD, et al.: “Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations. A Long-Term Follow-up”

Ochi, Kensuke MD, PhD*,a

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The Journal of Bone and Joint Surgery: April 18, 2018 - Volume 100 - Issue 8 - p e52
doi: 10.2106/JBJS.17.01559
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Commentary

A gold-standard treatment of a distal radial fracture is of great interest to orthopaedic surgeons, as there is currently no gold standard because of lack of sufficient evidence. Ali et al. are to be congratulated for their 12 to 14-year Swedish follow-up study of patient-reported outcome measures that provides a steady progression for the establishment of the gold-standard treatment. With a sample of 63 patients who responded to their questionnaires and underwent examinations (mean age, 53 years [range, 18 to 65 years]; 75% female patients), their study suggests that malunion of a distal radial fracture results in significantly greater activity limitations, with worse pain and lower satisfaction, and that the effect of malunion does not differ with age at the time of fracture. Mild radiocarpal osteoarthritis and styloid nonunion did not correlate with long-term outcome in the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores and the visual analog scale pain and satisfaction scores. This study adds more evidence that suggests we need to treat distal radial fracture to prevent malunion (dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°) for improved patient satisfaction.

Patient-reported outcome measures represent a recent trend for evaluating treatment results, and these measurements are excellent tools for evaluating treatment success from the patients’ perspective. Nevertheless, we should keep in mind that patient-reported results are based on a subjective, lay opinion. As the mean difference in the DASH questionnaire score between patients with malunion and those without malunion was close to the minimum clinically important difference, the results from Ali et al. might not hold true for different patient demographic characteristics (e.g., race, sex, age, mental outlook, customs, family living arrangements, work, daily activity). For example, when compared with the Western lifestyle populations (e.g., sleeping in beds and cleaning the floor with mops), the rural Japanese elderly population is more likely to use their hands to follow traditional Japanese customs (e.g., lifting heavy futons [Japanese sleeping mattresses] for daily sleeping routines and house cleaning with a “zokin” [a wet rug for floor cleaning]). However, >90% of the Japanese elderly patients with distal radial fracture malunion considered their treatment results as “excellent” to “acceptable” in our rural institute1. One of the reasons for this phenomenon seems to be the social perspective of the Japanese elderly population: many of them believe that patience is a great virtue. Furthermore, many Japanese patients with rheumatoid arthritis2 and distal radial fracture admitted to our institution forget their fracture history within several years, suggesting that this type of fracture may not greatly impact such patients after long follow-up periods. As this journal has a worldwide readership, it is important for the readers (especially in non-Western countries) to be aware of the demographic differences between the patients described in the study by Ali et al. and their own patients when interpreting and applying these results to their daily practice.

Two of the major risk factors for distal radial fracture are aging and high physical function3. As the world is rapidly aging and the elderly population is becoming more active than those in previous generations4, patients with distal radial fracture are expected to keep increasing. However, there are still many questions regarding proper treatment of this fracture. Do patient demographic characteristics have a strong influence on long-term outcome? If so, what demographic characteristics are the most important to consider during treatment? How should we decide between nonoperative and operative treatment options for widely varying patients? How should we customize surgical procedures and postoperative hand therapies to each patient? Accumulation of more data to establish the gold standard for treating distal radial fracture is an urgent task for both orthopaedic surgeons and hand surgeons alike. I eagerly hope that the readers of this journal will unravel these questions and accomplish this goal in the near future.

*Disclosure: There was no external funding for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/E670).

References

1. Yamabe E, Matsumura T, Aiba H, Yoshida H, Yashiro S, Shimizu K, Iwamoto T. Outcome following nonoperative treatment of distal radius fractures: correlation between the radiographic assessment and the disabilities in daily living. J East Jpn Orthop Traumatol. 2003;25:763-6.
2. Ochi K, Inoue E, Furuya T, Ikari K, Toyama Y, Taniguchi A, Yamanaka H, Momohara S. Ten-year incidences of self-reported non-vertebral fractures in Japanese patients with rheumatoid arthritis: discrepancy between disease activity control and the incidence of non-vertebral fracture. Osteoporos Int. 2015 Mar;26(3):961-8. Epub 2014 Oct 8.
3. Rikkonen T, Salovaara K, Sirola J, Kärkkäinen M, Tuppurainen M, Jurvelin J, Honkanen R, Alhava E, Kröger H. Physical activity slows femoral bone loss but promotes wrist fractures in postmenopausal women: a 15-year follow-up of the OSTPRE study. J Bone Miner Res. 2010 Nov;25(11):2332-40. Epub 2010 Jun 10.
4. Jupiter JB, Ring D, Weitzel PP. Surgical treatment of redisplaced fractures of the distal radius in patients older than 60 years. J Hand Surg Am. 2002 Jul;27(4):714-23.

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