Distal Radius Fractures are one of the most common upper limb injuries in adults population, and the second most common in the ageing population. Moreover, the numbers of radial fractures are not likely to stay there, but are expected to increase progressively due to the ageing of the population.
One of the most important points in order to provide an adequate treatment for DRFs and promote early recovery is a correct evaluation and follow-up of the clinical outcomes. Objective information enable healthcare professionals to deliver the proper intervention or change the current one if a complication arises.
Thus, today we summarise the synthesis work done by the team of M. Hall et al (2021) published in Hand Clinics, entitled “Outcome measurement for Distal Radius Fractures”.
1. Pain Assessment in Distal Radius Fracture
Pain is the most frequent symptom in a distal radius fracture, being very predominant in the early weeks after injury. Although there are scales that include subsections where the painful state of the wrist is evaluated (DASH Scale, QuickDASH, PRWE or Michigan Hand Outcome Questionnare among others), the fact of using these results in an aggregate manner to the rest of the scale, can reduce the importance of the impact of pain on the patient.
This is why the authors recommend the use of the Visual Analogue or Numerical Scale (VAS or NRS) to objectively assess severity. In addition to this scale, it is recommended to obtain related data such as frequency, qualitative description or aggravating or triggering factors, for which the scales mentioned above can help.
These results should always be evaluated within each patient´s context, as different situations (compensation process after injury, baseline pain, socioeconomic level and culture or the fracture itself) can condition the final evolution of the patient.
Learn how to treat Distal Radius Fractures using a sensorimotor system approach 🤯
2. Patient-Reported Outcomes Measures for Distal Radius Fracture
The potential of PROMS is the ability to translate a patient’s subjective experience of an injury in a numerical and objective response for the professional in charge. Characteristics such as severity, impact on activities of daily living or work are some of the items they assess. In addition, these questionnaires do not require any equipment and can be answered without assistance, making them easy to implement.
Several questionnaires are recommended to assess the status of a distal radius fracture:
|PRWE||A 15-item questionnaire that assesses the patient’s pain and disability. It has been developed specifically for wrist injuries.|
There is a minimum clinically relevant difference (MCID) of 11.5 points for distal radius fractures.
It is a valid, reliable and resposive questionnaire for distal radius fractures.
It has good correlation with DASH or VAS.
|DASH||A 30-item questionnaire that assesses pain, function, and the impact of the injury on work, activities of daily living or art activities.|
It is a valid, reliable scale that is responsive to change. Although MCID data is available (from 5-15 depending on the injury), it is not specific to this fracture.
|QuickDASH: Shortened version of 11 items, with additional modules on Work, Sport and Arts.|
|MHQ||37-item scale divided into 6 subdomains for both hands: Pain, General Hand Function, ADL, Work Performance, Aesthetics and Satisfaction.|
It is the only scale that assesses both hands separately, and the only one that includes a section on hand aesthetics.
Although MCID figures are available (8-23), there are limitations in obtaining them for radius fractures.
|bMHQ: shortened version with 12 items and the same 6 domains, and with similar psychometric data.|
Does not distinguish between both hands.
|SF-36||36-item questionnaire measuring 8 domains: physical function, physical roles, pain, general health, vitality, social functioning, emotional health and mental health.|
Unlike the others, this one assesses the impact of the fracture on general health, which makes it easier to obtain an overall view of quality of life.
Although it is not as sensitive to change, it does have validity and reliability studies.
|SF-12: shortened version with good correlation data with SF-36, and effective for distal radius fractures.|
|PROMIS-CAT-UE||Health status assessment instrument including 3 domains: physical, mental and social health.|
Due to certain limitations, the PROMIS-CAT-UE was developed for the upper limb with 16 items.
Good correlation with QuickDASH and MHQ.
Further studies are needed to refine the scale, given its many limitations such as ceiling effect or non-parametric distribution.
Despite advances in the field of PROMs, questionnaires have limitations, sometimes lacking specific MCIDs, which makes it difficult to extrapolate results. It is always interesting to combine these tools with other types of assessment.
3. Radiographic Findings in Distal Radius Fracture
Imaging tests play an important role in determining the status of the injury, fracture alignment, healing and position. Traditionally, normal values for bone alignment of the distal radius have been determined to be:
-Radius inclination of 22 degrees (Image A).
-Volar tilt of 11 degrees (Image B).
-Radial length of 12.3 mm (Image C).
-Ulnar variance of 0.4 mm (Image D).
Some authors have proposed figures for nonunion or impaired bone healing: radial inclination less than 10°, volar tilt greater than 20° or dorsal tilt greater than 20°, radial lenght less than 10 mm, ulnar variance greater than 2 mm and intra-articular space greater than 2 mm.
Although radiographs are useful, they do NOT correlate with perceived pain or functional status, so they should always be interpreted with caution.
The authors recommend that radiographs NOT be followed up periodically by imaging as the primary measurement.
4. Performance Measures in DRF
Some of the most commonly used measurements in the follow-up of distal radius fractures are grip and pinch strength, and finger, wrist and forearm ROM. Impairment of these variables has been directly related to functional limitations of the upper limb.
Importantly, grip strength should be assessed bilaterally in order to control for inter-patient variability.
If you are interested in a more in-depth assessment of the wrist, you MUST read this post on the “Principles for a successful diagnosis of wrist pain“.
5. Complications in Distal Radius Fractures
Another important point when evaluating the evolution after a radius fracture is to know the possible associated complications. Although there is no standardised model for reporting these findings, there are proposals such as that of McKay et al (2001), where complications are distributed according to tissue and severity.
I leave you here the Link to the article. Here is the standarized proposal:
6. Factors that modify the outcomes
Another important point is to know the characteristics and qualities of the patient and the injury that can determine a favourable or unfavourable evolution. These factors have been defined as socio-demographic, physiological, psychological, procedural and injury factors.
|Sociodemographic||Age, Sex, Race, Work status, Education, Occupation, Hobbies, etc.|
|Physiologic||Medical comorbidities, Preinjury functional level, Prior injury, Preexisting arthritis|
|Psychological||Depression, Catastrophic thinking, Baseline pain level, Coping strategies|
|Injury||Fracture classification, Open fracture, Nerve injury, Ipsilateral extremity fracture|
|Treatment||Surgical fixation vs closed reduction, time to treatment, fixations, rehabilitation programme, etc.|
7. Temporalization for evaluation
There is also a need to standardise the proper measurement moments after a distal radius fracture. Of particular importance is the baseline assessment, where outcome modifying factors or PROMS will be analysed.
In distal radius fracture, measurements are recommended at 2, 6 and 12 weeks after injury, and at 1 year follow-up. The 12-week measurement is the most relevant, as this is the point at which patients usually report the greatest functional improvement. However, improvement may continue over the long term.
Final recommentations of the Authors
Finally, the authors propose a series of standard measurements and their timing, as shown in this table:
ReHand as a Monitoring System in Distal Radius Fractures
Given the importance of being able to obtain reliable and objective data on the evolution of our patients after a wrist fracture such as a distal radius fracture, we, as health professionals, need tools to facilitate this process. Sometimes, the use of scales and questionnaires can be very time-consuming in the consultation room, where it is usually limited.
Thus, the ReHand digital tool incorporates a Prescription, Treatment and Monitoring System for hand-wrist-fingers patients through a tablet. This allows our patient to complete their treatment telematically at home, while we can know the patient’s condition thanks to the sending of validated scales or PROMS such as the QuickDASH Scale, the Michigan (MHQ) or the EVA Scale.
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Hall MJ, Ostergaard PJ, Rozental TD. Outcome Measurement for Distal Radius Fractures. Hand Clin [Internet]. 2021;37(2):215–27. Available from: https://doi.org/10.1016/j.hcl.2021.02.004
Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | Hand Therapy, PT and eHealth Researcher