Distal Radius Fracture
Distal Radius Fracture
Distal Radius Fracture
Robert S. Richards, MD
Surgeon and
Co-director, Clinical Research Laboratory
Hand and Upper Limb Centre
St. Joseph's Health Centre
London, Ontario
James H. Roth, MD
Medical Director, Surgeon, and
Co-director, Clinical Research Laboratory
Hand and Upper Limb Centre
St. Joseph's Health Centre
London, Ontario
Distal radius fractures are the most prevalent of all lifetime risk of distal radius fracture for white
fractures.' They occur in all age groups secondary to women at age 50 years is 15%.10,11 Among persons
trauma'< but have an increased incidence in post- under 40 years of age, men and boys are 1.4 times
menopausal women because of osteoporotic changes more likely to have a wrist fracture than women and
in the bones.3-6 Fractures of the distal radius com- girls. Thereafter, the rise in the incidence among
prise 74.5% of all forearm fractures? The incidence of women is nearly linear, with women 60 to 94 years of
distal radius fractures has recently been estimated as age being 6.2 times more likely to sustain a distal
27 (16 males, 37 females) per 10,000 population per radius fracture than men in the same age groupY
year.f Estimates from other studies indicate an over-
all rate between 23 and 67 per 10,000 population.' ETIOLOGY
Data from Rochester, Minnesota, suggest that inci-
dence rates may be higher in North American com- A fracture of the distal radius typically occurs as the
munities." This study, based on a 30-year population result of a fall on an outstretched hand. There is gener-
cohort, showed that the incidence of distal radius ally a sharp fracture on the palmar aspect of the radial
fractures among female residents of Rochester, metaphyseal area, and those that have a shear or com-
Minnesota, rose from 100 (per 100,000 person years) pression component produce intra-articular fractures
among those between 35 and 44 years of age to more that are more unstable. A Colles fracture involves the
than 500 for those aged 55 to 75 years. On the basis of distal metaphysis of the radius, which is dorsally dis-
the Minnesota data, it has been estimated that the placed and angulated. It occurs within 2cm from the
distal end of the radius but may extend into the radio-
carpal or ulnocarpal joint. Dorsal angulation, dorsal
Address correspondence and reprint requests to Joy C MacDerrnid, displacement, radial angulation, and radial shortening
BScPT, PhD, Co-director, Clinical Research Lab, Hand and Upper
Limb Centre, St. Joseph's Health Centre, PO Box 5777, London, are expected. There may be an accompanying fracture
Ontario, N6A 4L6; e-mail: <[email protected]>. of the ulnar styloid. A Smith fracture is a volar angu-
DASH~ 10 7 18 7 27 13 13 9 21 14 45 11 - 4 M 16 23 11
(7) (9) (10) (8) (28) (17) (13) (11) (12) (7) (13) (2) (16) (18) (13)
SF-36:
Physical function: 93 96 85 94 85 82 90 91 80 86 53 80 - 88 M 69 80 83
(16) (8) (7) (9) (21) (22) (14) (16) (17) (29) (26) (20) (25) (21) (22)
Bodily pain 77 78 52 80 70 68 71 80 41 64 38 77 95 M 67 59 74
(61 (23) (15) (16) (44) (24) (42) (24) (22) (15) (21) (9) (29) (25) (24)
General health 86 87 43 88 90 66 91 83 67 71 61 78 85 M 73 74 77
(15) (12) (2) (8) (10) (17) (13) (14) (25) (22) (17) (3) (22) (21) (18)
Vitality 87 64 43 80 75 60 83 65 65 65 48 70 82 M 66 67 66
(15) (22) (4) (16) (18) (18) (4) (20) (23) (7) (16) (7) (18) (20) (18)
SF-36 (cont):
Physical component 52 53 46 53 46 47 52 53 38 47 33 49 - 54 M 44 45 49
summary (4) (7) (3) (7) (7) (8) (9) (8) (9) (2) (11) (4) (2) (11) (0)
Mental component 61 53 33 55 57 50 58 57 51 51 47 55 - 58 M 53 52 53
summary (2) (6) (l) (3) (2) (9) (l) (1) (2) (2) (6) (3) (11) (11) (9)
Grip (kg):
Affected side 41 43 32 25 38 37 24 24 21 32 12 20 - 24 M 17 N/A N/A
(7) (2) (5) (8) (9) (5) (5) (0) (6) (5) (5) (4)
Flexion 64 63 58 57 42 51 62 58 43 44 36 51 - 58 M 52 50 53
(8) (14) (10) (22) (22) (l) (0) (4) (9) (4) (7) (13) (7) (5)
Extension 61 65 68 60 47 56 59 60 50 48 3 62 - 58 M 59 55 59
(4) (7) (4) (3) (0) (0) (12) (3) (11) (8) (2) (0) (2)
Pronation 82 78 76 78 77 77 85 83 81 77 76 80 - 74 M 79 79 79
(3) (1) (0) (9) (9) 0) (4) (0) (5) (9) (0) (9) (6) (9)
Supination 73 79 85 67 59 74 79 72 59 64 59 73 - 76 M 76 67 73
(11) (8) (7) (6) (7) (6) (9) (20) (5) (1) (7) (10) (13) (2)
Radial deviation 17 19 13 18 14 15 24 18 21 17 12 17 - 16 M 20 16 18
(8) (6) (4) (6) (5) (l) (6) (5) (3) (6) (1) (6) (6) (6)
» Ulnar deviation 31 29 28 27 20 25 22 29 22 21 20 25 - 25 M 23 24 25
"'C
:::l. (2) (9) (7) (4) (8) (4) (6) (7) (8) (7) (7) (7) (6) (7)
J:c:
:J NOTE: Data are subgrouped by age, sex, and secondary compensation (SC) subgroups. The SC subgroup included only those patients who had a legal or worker's compensation case related to the
l!)
wrist fracture; other patients are considered noncompensated (No SC) patients. Test scores and SDs are not shown if a subgroup was too small for SDs to be calculated.
t-.l
0 A blank H indicates missing data for the few patients (i.e., older compensated women) who did not complete the DASH or SF-36. Since age and sex did not affect PRWE, DASH, or ROM scores,
0
the most stable estimates of these parameters are the group results. The data for compensated and noncompensated patients are separated because of the strong effect compensation seems to have
on outcome. Scores on the physical health subscales of the SF-36 also tend to be age dependent; therefore, age-matched data comparisons are advisable.
0- Grip results for male and female subjects are not pooled because they are sex dependent, and comparisons should be made with the age- and sex-specific results; in other words, grouped data
for these results are not applicable (N / A).
Score
90
82
79 80
SF-36 PF
75 75
10
Baseline 8 weeks 3 months 6 months One year
Time
Score
70
____________________________________________________________ 59_
60 57
53
FIGURE 2. Scores (N = 250) for
50 flexion and extension active range
of motion at baseline, 8 weeks, 3
Extension 45 months,6 months,and 1 yearafter
distal radius fracture. Average
40 scores are notedabove the lines.
Flexion 36
30
Baseline 8 weeks 3 months 6 months One year
Time
Score
90
80 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -18- - - - - - - - - - - - .7_9_
76
73
Pronation 70
72
FIGURE 3. Scores (N = 250) for
70 pronation and supination active
range of motion at baseline, 8
weeks,3 months, 6 months, and 1
60 - - - -Supination 58 - - - year after distal radius fracture.
Averagescores are notedabove the
lines.
50 ----- --------- ---- -- ---- - - - -- - -- -- - -- -- - - - -- -- - - -- -- - -- -- -- ---
40
Baseline 8 weeks 3 months 6 months One year
Time
o
Baseline 8 weeks 3 months 6 months One year
Time
Score
35
Unaffected 30 30
30 - - - - - - - - - - - - - - 28 - - - - - - - - - - - - - -29- - - - - - - - - - -
25
25 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -23- - - - - - - - - - - --
o
Baseline 8 weeks 3 months 6 months One Year
Score
60
55
Mess 52 52
53
46_--------,
51
50
FIGURE 6. Scores (N=250) for 50 48 48
the SF-36 physical (PCSS) and
mental (MCSS) component sum- 45
maries at baseline, 8 weeks, 3
months, 6 months,and 1 yearafter
distal radius fracture. Average 40
scores arenotedabove the lines.
35
30
Baseline 8 weeks 3 months 6 months One year
Time
1. PAIN
Rate the average amount of pain in your wrist over the past week by circling the number that best describes your pain on a scale from
o to 10. A zero (0) means that you did not have any pain, and a ten (10) means that you had the worst pain you have ever experienced
or that you could not do the activity because of pain.
Sample scale: o1 2 3 4 5 6 7 8 9 10
No Pain Worst Ever
At rest o1 2 3 4 5 6 7 8 9 10
When doing a task with a repeated wrist movement o1 2 3 4 5 6 7 8 9 10
When lifting a heavy object o1 2 3 4 5 6 7 8 9 10
When it is at its worst o1 2 3 4 5 6 7 8 9 10
2. FUNCTION
A. Specific Activities
Rate the amount of difficulty you experienced performing each of the items listed below, over the past week, by circling the num-
ber that best describes your difficulty on a scale of 0 to 10. A zero (0) means you did not experience any difficulty, and a ten (10)
means it was so difficult you were unable to do it at all.
Sample scale o1 2 3 4 5 6 7 8 9 10
No Difficulty Unable to Do
B. Usual Activities
Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past
week, by circling the number that best describes your difficulty on a scale of 0 to 10. By "usual activities" we mean the activities that
you performed before you started having a problem with your wrist. A zero (0) means you did not experience any difficulty, and a
ten (10) means it was so difficult you were unable to do any of your usual activities.
Comment / interpretations:
PRWE 1 year PRWE = baseline PRWE (0.4) - 16 + 18 (if secondary compensation present) 0.22 Low
NOTES: ~F-36 PCSS.indic~t~s S.F-36 physical component summary score; DASH, Disabilities of the Arm, Shoulder and Hand' PRWE atient-
~te~~nst eval~ahon. R mdlca~es the p~rcent~ge of variance in the one-year outcome that can be predicted on the basis'of the ~:uation
ana es entere were the baseline questionnaire score, age, sex, and secondary compensation. .
Text continued from p. 159 cli~ical practice with an awareness of how typical
patients respond during this time provides therapists
are subdivided only into compensated and non-com-
with a more detailed and standardized means of
pensated groups.
assessing their patients.
Strength is known to be significantly affected by
In addition to determining how an individual
sex and, to a lesser extent, by age. Therefore, clinical
patient changes over time, it is now possible to com-
data for strength scores should be compared with
pare a patient's scores with average outcome scores
appropriate age- and sex-matched data. Similarly,
at different times. This study provides mean scores
this study and others have demonstrated that scores
and SDs for patients with wrist fractures. It would be
on the physical health subscale of the SF-36 are influ-
expected that 95% of the time, the average score for a
enced by age. Age-stratified SF-36 scores in this
patient would fall within the mean plus or minus the
cohort are appropriate for comparison with data
standard deviation times 2. This allows a score for a
obtained at other hand centers in patients with distal
specific pat~ent to be compared with a group average.
radius fractures.
On the baSIS of these data, the therapist can deter-
mine whether a patient's progress is following the
DISCUSSION
anticipated "pattern," or "slope," of recovery.
The one-year data were stratified according to a
This study provided data on a large cohort of dis-
number of potential predictors. Not all factors that
tal radius fracture patients, which may be useful to
affect outcome were considered. Thus, patients with
therapists who want to compare their outcomes with
a number of factors expected to adversely affect out-
results from other hand centers. An outcome study
come should be expected to fall below the group
can generally be conducted retrospectively, as a case
average when the group is based on age, sex, and
series, or prospectively, as a cohort study.
compensation stratifications. To predict outcomes,
Measurement of impairment, disability, and handi-
multivariate regression equations would be needed
cap in a prospective cohort provides data obtained in
to account for the relatively substantial number of
a standardized way, which are therefore more mean-
factors that could affect outcome. These data are use-
ingful than data from a case series, in which follow-
ful to "place" a patient's status, based on the score on
up time~ and patients available for study can vary.
a given questionnaire, against what is "average."
The SIze of an outcome study is also relevant to
Data in this study and our previous research sug-
ho~ valid the data are for comparative purposes.
gest that compensation is a powerful determinant of
This large cohort provides relatively stable estimates
PRWE scores. I30 For this reason we have presented
of patient outcomes, compared with smaller studies.
data for compensated and noncompensated patients
Finally, the validity of the data depends on the valid-
s~para~ely. The prediction equations (Table 3) quan-
ity of the measurements themselves, and only vali-
tify this effect mathematically, in that 18 (pain and
dated outcome measures were used in this study.
disability) points are added to the one-year PRWE
Data from patient questionnaires can be obtained
score if injury compensation is involved. This effect
from baseline to 8 weeks when impairments are not
wa~ n?t significant for the DASH or SF-36 , although
measurable. This allows a therapist to appreciate the
a similar trend for poorer scores in compensated
effects of interventions during this critical period of
patients was observed.
time. Incorporating one or more questionnaires into
The reasons for the more dramatic effect on the
PRWE is unclear. The effect was observed on all three
subscales of the PRWE, so it was not related to pain
FIGURE 7. The Patient-rated Wrist Evaluation. The scale con- perception alone. Because the PRWE clearly focuses
sists ~f three subscales. Pain is rated as 50% (summation of five on the wrist, it is possible that the effects of compen-
questions, each rated a to 10). Function is rated as 50% (sum-
matio~s of 10 questions rated a to 10, divided by 2). The total
sation for wrist injury are more distinct on this scale.
sco:e IS expressed as points out of 100, with a higher score indi- This would also explain why the observed effect was
eating morepainand disability. relatively larger for the DASH than for the SF-36.