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Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius
Injury, Int. J. Care Injured (2005) 36, 1435—1439
www.elsevier.com/locate/injury
Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius I.A. Karnezis a,c,*, E. Panagiotopoulos b, M. Tyllianakis b, P. Megas b, E. Lambiris b a
Department of Orthopaedic Surgery, University of Bristol, UK Department of Orthopaedic Surgery, University of Patras, Greece c Athens Medical Centre (Psychiko Clinic), Orthopaedics, Andersen 1, 115 25 Athens, Greece b
Accepted 5 September 2005
KEYWORDS Distal radius fractures; Wrist radiography; Wrist function; Wrist pain
Summary The present study investigates the correlation between radiological parameters of wrist fractures and the clinical outcome expressed by objective clinical parameters and the level of patient-rated wrist dysfunction. Thirty consecutive cases of unstable distal radial fractures treated with closed reduction and percutaneous fixation were prospectively studied for a period of one year. The outcome parameters included objective clinical and radiological parameters and the previously described and validated patient-rated wrist evaluation (PRWE) score. Analysis showed that for unstable (AO classification types 23-A2, -A3, -C1 and -C2) fractures the fracture type affects the range of wrist palmarflexion ( p = 0.04) and that the presence of postoperative articular ‘step-off’ affects the range of wrist dorsiflexion and the patientrated wrist function at the final time of the study ( p < 0.01 and p = 0.02, respectively). It is also shown that permanent radial shortening and loss of the palmar angle were associated with prolonged wrist pain ( p < 0.01 and p = 0.03, respectively). Our finding that residual articular incongruity correlates with persisting loss of wrist dorsiflexion and wrist dysfunction contradicts the view that loss of articular congruity is associated with late development of articular degeneration but not with early wrist dysfunction. Additionally, this study failed to show any association between the fracture type and the functional outcome as rated by the patients. # 2005 Published by Elsevier Ltd.
Introduction * Corresponding author. Present address: Kyprou 29, 154 62 Athens, Greece. Tel.: +30 210 8011622; fax: +30 210 8087746. E-mail address: [email protected] (I.A. Karnezis). 0020–1383/$ — see front matter # 2005 Published by Elsevier Ltd. doi:10.1016/j.injury.2005.09.005
It is generally accepted that the clinical outcome following fractures of the distal radius is associated with the radiological parameters of the fractures.
1436
I.A. Karnezis et al.
However, there is disagreement regarding the degree to which specific radiological parameters of the fracture influence the final clinical outcome. Furthermore, despite the undoubted role of fracture classifications in treatment decision-making there are doubts about the prognostic value of classifications for the functional outcome.1,10,17,19,21 The aim of the present study was to investigate the correlation between specific radiological fracture parameters and the clinical outcome as expressed by objective parameters of wrist function in a group of patients with distal radial fractures managed with closed reduction and percutaneous wire fixation. In addition, this study investigates for the first time the association between specific radiological parameters of the fracture and the functional outcome as expressed by a patient-rated wrist dysfunction score.
Patients and methods Thirty-five patients with unstable fractures of the distal radius were studied prospectively. The inclusion criteria were acutely presenting (within 24 h from the injury) unstable (AO classification types 23A2, -A3, -C1 and -C2) fractures of the distal radius in skeletally mature patients amenable to treatment by closed reduction and percutaneous wire fixation. Exclusion criteria included fractures in skeletally immature patients (unfused epiphyses), minor (undisplaced) and severely comminuted intraarticular multifragmentary (AO classification type 23-C3) fractures, open fractures, presence of multiple injuries, fractures necessitating treatment by open reduction and internal fixation as well as redisplaced fractures necessitating secondary treatment (re-manipulation or delayed open reduction and internal fixation). All patients were managed by closed reduction under general anaesthesia, percutaneous fixation using Kirschner-wires (cross-wire fixation using two or three wires inserted from the radial styloid and the dorso-ulnar corner of the distal radius) and postoperative immobilisation in a below-elbow plaster cast. All surgical procedures were performed by a consultant or a senior
trainee (specialist registrar) grade surgeon. The wires were removed four weeks following fracture fixation and full mobilisation of the joint commenced at the sixth postoperative week. Clinical assessment and patient self-assessment of the outcome took place at 12 months post-injury. The clinical parameters considered were the range of movement of the wrist (palmarflexion and dorsiflexion) and forearm (pronation and supination) and the grip strength using the Jamar dynamometer (Therapeutic Equipment Corporation, Clinton, NJ). Measurements were made bilaterally and the results were expressed as an affected over non-affected side ratio. Additionally, the grip strength ratio was corrected using a factor of 1.07 as the effect of the side dominance.14 Furthermore, the patient-rated wrist evaluation (PRWE) score13 was used by patients filling in the relevant form. The radiographic study was based on antero-posterior and lateral wrist radiographs taken at the time of initial presentation, immediately postoperatively and 12 months post-injury. The radiological parameters of the study at initial presentation were the fracture type according to Frykman5 and AO15 classifications, the presence or not of intra-articular extension of the fracture and the degree of radial shortening. In addition, the palmar angle, the radial angle (inclination), the degree of radial shortening and the presence of a postoperative intra-articular ‘step’ of 1 mm or more were estimated from radiographs taken immediately following the operation and at the final time of the study (12 months postinjury). Thirty patients (19 women, 11 men, mean age: 46.1 years, range: 18—76 years) were available for assessment throughout the entire period of the study. According to the Frykman classification there were seven type VIII, seven type II, five type V, four type VII, four type I, two type VI and one type III fractures. According to the AO classification there were 12 type 23-C2, 9 type 23-A3, 5 type 23-A2 and 4 type 23-C1 fractures. Statistical analysis of the results used the Mann— Whitney test and the Kruskal—Wallis (non-parametric) analysis of variance for comparisons between groups and statistical correlation (Spearman rank correlation coefficient) for description of
Table 1 Overview of the results of the radiographic measurements of the study
Mean S.D. Range
Initial radial shortening (mm)
Postoperative radial shortening (mm)
Postoperative palmar angle (8)
Postoperative radial angle (8)
Final radial shortening (mm)
Final palmar angle (8)
Final radial angle (8)
4.7 5.4 0—20
0.4 0.8 0—2
7.7 7.9 24 to 15
19.8 6.1 1—26
2.0 1.7 0—5
4.5 9.5 25 to 23
15.9 7.9 0—27
Correlation between radiological parameters and patient-rated wrist dysfunction
1437
Figure 1 Comparisons of the range of wrist palmarflexion between intra-articular and extra-articular fractures.
Figure 3 Comparisons of the total PRWE score between fractures with and without intra-articular ‘step-off’ (dots represent outliers).
the association between parameters. All statistical analyses were performed with the Minitab 12.1 software (Minitab Inc.). A p-value of less than 0.05 was considered significant.
also found between the four investigated (23-A2, A3, -C1 or -C2) AO classification fracture types ( p = 0.04, Kruskal—Wallis analysis of variance). More specifically, the range of wrist palmarflexion varied between median value of 92% of normal for type A2 fractures and a median value of 84% for type C2 fractures ( p = 0.04). No statistically significant differences in the objective or patient-rated functional outcome parameters were found between the fracture types of the Frykman classification. Furthermore, no statistically significant correlation between the postoperative radiographic parameters of radial shortening, palmar angle and radial angle and the final clinical parameters was found. However, there was a statistically significant correlation between the postoperative presence of radiographic intra-articular ‘step-off’ and the final range of wrist dorsiflexion ( p < 0.01, Mann—Whitney test, Fig. 2) and the PRWE score ( p = 0.01, Mann—Whitney test, Fig. 3). Regarding the radiological parameters at the final follow-up, statistically significant correlation between the degree of radial shortening and the PRWE score ‘pain’ sub-score ( p < 0.01, rs = 0.58) and total PRWE score ( p < 0.01, rs = 0.53, Fig. 4)
Results An overview of the results of the radiographic measurements used for the statistical analysis of the study is shown in Table 1. No statistically significant correlation between the initial radiographic parameters of the fracture and the final outcome as expressed by the PRWE score and its ‘function’ and ‘pain’ sub-scores was found. Regarding the correlation between the initial radiographic parameters of the fracture and the objective measurements of the final outcome, statistically significant difference in the range of wrist palmarflexion at final follow-up was found between extra- and intraarticular fractures ( p = 0.02, Mann—Whitney test) (Fig. 1). In addition, significant differences in the range of wrist palmarflexion at final follow-up were
Figure 2 Comparisons of the range of wrist dorsiflexion between fractures with and without intra-articular ‘stepoff’ (dot represents outlier).
Figure 4 Correlation between the degree of radial shortening and the total PRWE score.
1438
I.A. Karnezis et al. as ‘acceptable’ this ranges from as low as 1089—1581 to as high as 308.10 The results of the present study suggest that permanent loss of palmar angle is associated with persisting wrist pain as measured by the ‘pain’ PRWE sub-score that includes patientrated level of pain at rest, various activities as well as the intensity and frequency of pain.13 However, statistical analysis failed to show significant correlation between loss of palmar angle and the ‘function’ PRWE sub-score.
Figure 5 Correlation between the palmar angle and the total PRWE score.
was found. Furthermore, there was statistically significant correlation between the palmar angle and the ‘pain’ PRWE sub-score ( p = 0.03, rs = 0.40, Fig. 5). No statistically significant correlation was found between the considered final radiographic parameters and the objective measurements of the final outcome (range of wrist movement and grip strength).
Discussion Radiological parameters of the fracture and functional outcome It is generally accepted that the functional outcome following distal radius fractures is directly associated with the radiological appearance of the fracture. The known effects of specific radiological parameters on the final clinical outcome are discussed below. Loss of palmar angle Classic studies in the literature support the view that loss of the palmar angle of the distal radius does not significantly affect the clinical outcome6 with the possible exception of a small increase in the probability for non-satisfactory final outcome.5 More recently,21 it has also been concluded that dorsal angulation of the distal radial articular surface is not an important factor leading to unsatisfactory clinical results. However, early7,12 and more recent8,17,18 clinical studies have concluded that dorsal angulation (loss of palmar angle) of the distal radius leads to significant deterioration of the final outcome. In addition, biomechanical studies using pressure-sensitive film16 also showed that angulations of more than 208 result in a measurable shift of the radio-carpal pressure areas and local concentration of loads. Regarding the degree of dorsal angulation of the distal radius generally considered
Loss of radial angle (inclination) It has been supported that an abnormal radial angle does not affect the final functional outcome following distal radial fractures.6,21 However, Rubinovich and Rennie18 concluded that a radial angle of less than 108 results in reduced grip strength while Altissimi et al.1 reported 100% unsatisfactory results when the radial angle was less than 58. The present study did not show significant correlation between loss of radial angle and the PRWE score. However, this finding must be interpreted with caution as our studied group did not include a large number of cases with significant permanent loss radial angle (mean radial angle at the final time of the study: 15.98, range: 08—278). Radial shortening Classic5,12 and more recent2 studies concluded that a degree of radial shortening results in unsatisfactory clinical results, more evidently a significant reduction of grip strength.11,21 Generally, up to 3 mm of radial shortening is considered as ‘acceptable’2 although up to 5 mm of radial shortening has be accepted in older patients.10 The results of the present study show that permanent radial shortening is strongly associated with persistent wrist pain (deterioration of the ‘pain’ PRWE sub-score) although our results did not show significant correlation between the degree of radial shortening and the ‘function’ PRWE sub-score. Articular incongruity Studies of distal radial fractures in young individuals showed that radiological secondary degenerative changes develop in all cases of fractures uniting with an articular ‘step-off’ of more than 2 mm11 and that restoration of the articular surface and maintenance of joint congruity was more important in predicting the final clinical outcome than the nature of the initial injury. No development of secondary degenerative changes was observed when fractures united with an articular ‘step-off’ of 1 mm or less.4 Furthermore, the view that the presence of a residual intra-articular ‘step-off’ is associated with late development of secondary degenerative
Correlation between radiological parameters and patient-rated wrist dysfunction changes but not with early or intermediate joint dysfunction has been supported.3,20 However, the latter is contradicted by our findings which showed that the presence of postoperative articular incongruity of 1 mm or more is associated with persisting loss of wrist dorsiflexion and wrist joint dysfunction (‘function’ PRWE sub-score) persisting at one year following injury.
Fracture type and functional outcome Although the role of fracture classifications in decision-making and treatment is indisputable it is believed that the functional outcome following fractures of the distal radius depends on the severity of the initial fracture displacement but is not directly associated with the precise fracture type.1,19 The latter is supported by the results of the present study which did not show significant correlation between the fracture type (AO and Frykman classifications) and the functional outcome as rated by the patients.
Conclusions From the analysis of the results of the present study it is concluded that: permanent loss of the palmar angle and radial shortening of the distal radius are associated with persisting wrist pain; the presence of postoperative radio-carpal articular incongruity with a ‘step-off’ of 1 mm or more is associated with loss of wrist dorsiflexion and persisting wrist dysfunction; there is no obvious correlation between the AO and Frykman fracture type and the functional outcome although, for the types of unstable fractures investigated (23-A2, -A3, -C1 and -C2), the AO fracture type correlates with persisting loss of wrist palmarflexion; the results of the present study must be interpreted in the context of the studied age group, type of injury and the applied treatment method.
References 1. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the distal radius. Clin Orthop 1986;206:202—10.
1439
2. Camelot C, Ramare ´ S, Lemoine J, Saillant G. Conservative treatment for displaced fractures of the distal end of the radius according to Judet: anatomical and functional results of 280 cases. J Bone Joint Surg [Br] 1999;81B(Suppl. 3): 363. 3. Catalano LW, Cole RJ, Gelberman RH, et al. Displaced intraarticular fractures of the distal aspect of the radius. Longterm results in young adults after open reduction and internal fixation. J Bone Joint Surg [Am] 1997;79A:1290—302. 4. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg [Am] 1991;16A: 375—84. 5. Frykman G. Fracture of the distal radius including sequelae: shoulder hand finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop Scand Suppl 1967;108:1—155. 6. Gartland JJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg [Am] 1951;33A:895—907. 7. Green JT, Gay FH. Colles’ fracture–—residual disability. Am J Surg 1956;91:636—42. 8. Hollingsworth R, Morris J. The importance of the ulnar side of the wrist in fractures of the distal end of the radius. Injury 1976;7:263—6. 9. Kazuki K, Kusunoki M, Yamada J, et al. Cineradiographic study of wrist motion after fractures of the distal radius. J Hand Surg [Am] 1993;18A:41—6. 10. Kelly AJ, Warwick D, Crichlow TP, Bannister GC. Is manipulation of moderately displaced Colles’ fracture worthwhile? A prospective randomized trial. Injury 1997;28:283—7. 11. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg [Am] 1986;68A:647—59. 12. Lidstro ¨m A. Fractures of the distal radius: a clinical and statistical study of end results. Acta Orthop Scand 1959;41:1—118. 13. MacDermid JC, Turgeon T, Richards RS, et al. Patient rating of wrist pain and dysfunction. A reliable and valid measurement tool. J Orthop Trauma 1998;12:577—86. 14. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg [Am] 1984;9A:222—6. 15. Mu ¨ller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Heidelberg: Springer-Verlag, 1990. 16. Pogue DJ. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg [Am] 1990;15A:721—7. 17. Porter ML, Stockley I. Fracture of the distal radius: intermediate and end results in relation to radiological parameters. J Bone Joint Surg [Br] 1986;68B:666. 18. Rubinovich RM, Rennie WR. Colles’ fracture: end results in relation to radiologic parameters. Can J Surg 1983;26:361—3. 19. Stewart HD, Innes AR, Burke FD. Functional cast-bracing for Colles’ fractures: a comparison between cast-bracing and conventional plaster casts. J Bone Joint Surg [Br] 1984;66B:749—53. 20. Strange-Vognsen HH. Intra-articular fractures of the distal end of the radius in young adults. Acta Orthop Scand 1991;62:527—30. 21. Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles’ fracture. A prospective review. J Bone Joint Surg [Br] 1987;69B:635—8.
www.elsevier.com/locate/injury
Correlation between radiological parameters and patient-rated wrist dysfunction following fractures of the distal radius I.A. Karnezis a,c,*, E. Panagiotopoulos b, M. Tyllianakis b, P. Megas b, E. Lambiris b a
Department of Orthopaedic Surgery, University of Bristol, UK Department of Orthopaedic Surgery, University of Patras, Greece c Athens Medical Centre (Psychiko Clinic), Orthopaedics, Andersen 1, 115 25 Athens, Greece b
Accepted 5 September 2005
KEYWORDS Distal radius fractures; Wrist radiography; Wrist function; Wrist pain
Summary The present study investigates the correlation between radiological parameters of wrist fractures and the clinical outcome expressed by objective clinical parameters and the level of patient-rated wrist dysfunction. Thirty consecutive cases of unstable distal radial fractures treated with closed reduction and percutaneous fixation were prospectively studied for a period of one year. The outcome parameters included objective clinical and radiological parameters and the previously described and validated patient-rated wrist evaluation (PRWE) score. Analysis showed that for unstable (AO classification types 23-A2, -A3, -C1 and -C2) fractures the fracture type affects the range of wrist palmarflexion ( p = 0.04) and that the presence of postoperative articular ‘step-off’ affects the range of wrist dorsiflexion and the patientrated wrist function at the final time of the study ( p < 0.01 and p = 0.02, respectively). It is also shown that permanent radial shortening and loss of the palmar angle were associated with prolonged wrist pain ( p < 0.01 and p = 0.03, respectively). Our finding that residual articular incongruity correlates with persisting loss of wrist dorsiflexion and wrist dysfunction contradicts the view that loss of articular congruity is associated with late development of articular degeneration but not with early wrist dysfunction. Additionally, this study failed to show any association between the fracture type and the functional outcome as rated by the patients. # 2005 Published by Elsevier Ltd.
Introduction * Corresponding author. Present address: Kyprou 29, 154 62 Athens, Greece. Tel.: +30 210 8011622; fax: +30 210 8087746. E-mail address: [email protected] (I.A. Karnezis). 0020–1383/$ — see front matter # 2005 Published by Elsevier Ltd. doi:10.1016/j.injury.2005.09.005
It is generally accepted that the clinical outcome following fractures of the distal radius is associated with the radiological parameters of the fractures.
1436
I.A. Karnezis et al.
However, there is disagreement regarding the degree to which specific radiological parameters of the fracture influence the final clinical outcome. Furthermore, despite the undoubted role of fracture classifications in treatment decision-making there are doubts about the prognostic value of classifications for the functional outcome.1,10,17,19,21 The aim of the present study was to investigate the correlation between specific radiological fracture parameters and the clinical outcome as expressed by objective parameters of wrist function in a group of patients with distal radial fractures managed with closed reduction and percutaneous wire fixation. In addition, this study investigates for the first time the association between specific radiological parameters of the fracture and the functional outcome as expressed by a patient-rated wrist dysfunction score.
Patients and methods Thirty-five patients with unstable fractures of the distal radius were studied prospectively. The inclusion criteria were acutely presenting (within 24 h from the injury) unstable (AO classification types 23A2, -A3, -C1 and -C2) fractures of the distal radius in skeletally mature patients amenable to treatment by closed reduction and percutaneous wire fixation. Exclusion criteria included fractures in skeletally immature patients (unfused epiphyses), minor (undisplaced) and severely comminuted intraarticular multifragmentary (AO classification type 23-C3) fractures, open fractures, presence of multiple injuries, fractures necessitating treatment by open reduction and internal fixation as well as redisplaced fractures necessitating secondary treatment (re-manipulation or delayed open reduction and internal fixation). All patients were managed by closed reduction under general anaesthesia, percutaneous fixation using Kirschner-wires (cross-wire fixation using two or three wires inserted from the radial styloid and the dorso-ulnar corner of the distal radius) and postoperative immobilisation in a below-elbow plaster cast. All surgical procedures were performed by a consultant or a senior
trainee (specialist registrar) grade surgeon. The wires were removed four weeks following fracture fixation and full mobilisation of the joint commenced at the sixth postoperative week. Clinical assessment and patient self-assessment of the outcome took place at 12 months post-injury. The clinical parameters considered were the range of movement of the wrist (palmarflexion and dorsiflexion) and forearm (pronation and supination) and the grip strength using the Jamar dynamometer (Therapeutic Equipment Corporation, Clinton, NJ). Measurements were made bilaterally and the results were expressed as an affected over non-affected side ratio. Additionally, the grip strength ratio was corrected using a factor of 1.07 as the effect of the side dominance.14 Furthermore, the patient-rated wrist evaluation (PRWE) score13 was used by patients filling in the relevant form. The radiographic study was based on antero-posterior and lateral wrist radiographs taken at the time of initial presentation, immediately postoperatively and 12 months post-injury. The radiological parameters of the study at initial presentation were the fracture type according to Frykman5 and AO15 classifications, the presence or not of intra-articular extension of the fracture and the degree of radial shortening. In addition, the palmar angle, the radial angle (inclination), the degree of radial shortening and the presence of a postoperative intra-articular ‘step’ of 1 mm or more were estimated from radiographs taken immediately following the operation and at the final time of the study (12 months postinjury). Thirty patients (19 women, 11 men, mean age: 46.1 years, range: 18—76 years) were available for assessment throughout the entire period of the study. According to the Frykman classification there were seven type VIII, seven type II, five type V, four type VII, four type I, two type VI and one type III fractures. According to the AO classification there were 12 type 23-C2, 9 type 23-A3, 5 type 23-A2 and 4 type 23-C1 fractures. Statistical analysis of the results used the Mann— Whitney test and the Kruskal—Wallis (non-parametric) analysis of variance for comparisons between groups and statistical correlation (Spearman rank correlation coefficient) for description of
Table 1 Overview of the results of the radiographic measurements of the study
Mean S.D. Range
Initial radial shortening (mm)
Postoperative radial shortening (mm)
Postoperative palmar angle (8)
Postoperative radial angle (8)
Final radial shortening (mm)
Final palmar angle (8)
Final radial angle (8)
4.7 5.4 0—20
0.4 0.8 0—2
7.7 7.9 24 to 15
19.8 6.1 1—26
2.0 1.7 0—5
4.5 9.5 25 to 23
15.9 7.9 0—27
Correlation between radiological parameters and patient-rated wrist dysfunction
1437
Figure 1 Comparisons of the range of wrist palmarflexion between intra-articular and extra-articular fractures.
Figure 3 Comparisons of the total PRWE score between fractures with and without intra-articular ‘step-off’ (dots represent outliers).
the association between parameters. All statistical analyses were performed with the Minitab 12.1 software (Minitab Inc.). A p-value of less than 0.05 was considered significant.
also found between the four investigated (23-A2, A3, -C1 or -C2) AO classification fracture types ( p = 0.04, Kruskal—Wallis analysis of variance). More specifically, the range of wrist palmarflexion varied between median value of 92% of normal for type A2 fractures and a median value of 84% for type C2 fractures ( p = 0.04). No statistically significant differences in the objective or patient-rated functional outcome parameters were found between the fracture types of the Frykman classification. Furthermore, no statistically significant correlation between the postoperative radiographic parameters of radial shortening, palmar angle and radial angle and the final clinical parameters was found. However, there was a statistically significant correlation between the postoperative presence of radiographic intra-articular ‘step-off’ and the final range of wrist dorsiflexion ( p < 0.01, Mann—Whitney test, Fig. 2) and the PRWE score ( p = 0.01, Mann—Whitney test, Fig. 3). Regarding the radiological parameters at the final follow-up, statistically significant correlation between the degree of radial shortening and the PRWE score ‘pain’ sub-score ( p < 0.01, rs = 0.58) and total PRWE score ( p < 0.01, rs = 0.53, Fig. 4)
Results An overview of the results of the radiographic measurements used for the statistical analysis of the study is shown in Table 1. No statistically significant correlation between the initial radiographic parameters of the fracture and the final outcome as expressed by the PRWE score and its ‘function’ and ‘pain’ sub-scores was found. Regarding the correlation between the initial radiographic parameters of the fracture and the objective measurements of the final outcome, statistically significant difference in the range of wrist palmarflexion at final follow-up was found between extra- and intraarticular fractures ( p = 0.02, Mann—Whitney test) (Fig. 1). In addition, significant differences in the range of wrist palmarflexion at final follow-up were
Figure 2 Comparisons of the range of wrist dorsiflexion between fractures with and without intra-articular ‘stepoff’ (dot represents outlier).
Figure 4 Correlation between the degree of radial shortening and the total PRWE score.
1438
I.A. Karnezis et al. as ‘acceptable’ this ranges from as low as 1089—1581 to as high as 308.10 The results of the present study suggest that permanent loss of palmar angle is associated with persisting wrist pain as measured by the ‘pain’ PRWE sub-score that includes patientrated level of pain at rest, various activities as well as the intensity and frequency of pain.13 However, statistical analysis failed to show significant correlation between loss of palmar angle and the ‘function’ PRWE sub-score.
Figure 5 Correlation between the palmar angle and the total PRWE score.
was found. Furthermore, there was statistically significant correlation between the palmar angle and the ‘pain’ PRWE sub-score ( p = 0.03, rs = 0.40, Fig. 5). No statistically significant correlation was found between the considered final radiographic parameters and the objective measurements of the final outcome (range of wrist movement and grip strength).
Discussion Radiological parameters of the fracture and functional outcome It is generally accepted that the functional outcome following distal radius fractures is directly associated with the radiological appearance of the fracture. The known effects of specific radiological parameters on the final clinical outcome are discussed below. Loss of palmar angle Classic studies in the literature support the view that loss of the palmar angle of the distal radius does not significantly affect the clinical outcome6 with the possible exception of a small increase in the probability for non-satisfactory final outcome.5 More recently,21 it has also been concluded that dorsal angulation of the distal radial articular surface is not an important factor leading to unsatisfactory clinical results. However, early7,12 and more recent8,17,18 clinical studies have concluded that dorsal angulation (loss of palmar angle) of the distal radius leads to significant deterioration of the final outcome. In addition, biomechanical studies using pressure-sensitive film16 also showed that angulations of more than 208 result in a measurable shift of the radio-carpal pressure areas and local concentration of loads. Regarding the degree of dorsal angulation of the distal radius generally considered
Loss of radial angle (inclination) It has been supported that an abnormal radial angle does not affect the final functional outcome following distal radial fractures.6,21 However, Rubinovich and Rennie18 concluded that a radial angle of less than 108 results in reduced grip strength while Altissimi et al.1 reported 100% unsatisfactory results when the radial angle was less than 58. The present study did not show significant correlation between loss of radial angle and the PRWE score. However, this finding must be interpreted with caution as our studied group did not include a large number of cases with significant permanent loss radial angle (mean radial angle at the final time of the study: 15.98, range: 08—278). Radial shortening Classic5,12 and more recent2 studies concluded that a degree of radial shortening results in unsatisfactory clinical results, more evidently a significant reduction of grip strength.11,21 Generally, up to 3 mm of radial shortening is considered as ‘acceptable’2 although up to 5 mm of radial shortening has be accepted in older patients.10 The results of the present study show that permanent radial shortening is strongly associated with persistent wrist pain (deterioration of the ‘pain’ PRWE sub-score) although our results did not show significant correlation between the degree of radial shortening and the ‘function’ PRWE sub-score. Articular incongruity Studies of distal radial fractures in young individuals showed that radiological secondary degenerative changes develop in all cases of fractures uniting with an articular ‘step-off’ of more than 2 mm11 and that restoration of the articular surface and maintenance of joint congruity was more important in predicting the final clinical outcome than the nature of the initial injury. No development of secondary degenerative changes was observed when fractures united with an articular ‘step-off’ of 1 mm or less.4 Furthermore, the view that the presence of a residual intra-articular ‘step-off’ is associated with late development of secondary degenerative
Correlation between radiological parameters and patient-rated wrist dysfunction changes but not with early or intermediate joint dysfunction has been supported.3,20 However, the latter is contradicted by our findings which showed that the presence of postoperative articular incongruity of 1 mm or more is associated with persisting loss of wrist dorsiflexion and wrist joint dysfunction (‘function’ PRWE sub-score) persisting at one year following injury.
Fracture type and functional outcome Although the role of fracture classifications in decision-making and treatment is indisputable it is believed that the functional outcome following fractures of the distal radius depends on the severity of the initial fracture displacement but is not directly associated with the precise fracture type.1,19 The latter is supported by the results of the present study which did not show significant correlation between the fracture type (AO and Frykman classifications) and the functional outcome as rated by the patients.
Conclusions From the analysis of the results of the present study it is concluded that: permanent loss of the palmar angle and radial shortening of the distal radius are associated with persisting wrist pain; the presence of postoperative radio-carpal articular incongruity with a ‘step-off’ of 1 mm or more is associated with loss of wrist dorsiflexion and persisting wrist dysfunction; there is no obvious correlation between the AO and Frykman fracture type and the functional outcome although, for the types of unstable fractures investigated (23-A2, -A3, -C1 and -C2), the AO fracture type correlates with persisting loss of wrist palmarflexion; the results of the present study must be interpreted in the context of the studied age group, type of injury and the applied treatment method.
References 1. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long-term results of conservative treatment of fractures of the distal radius. Clin Orthop 1986;206:202—10.
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