Distal radius fractures: what determines the outcome after surgery?

Abstract

This thesis addresses current issues in the outcome of operatively treated distal radius fractures. The general aim was to determine factors associated with adverse events, loss of motion, functional limitations, and opioid use after surgery. Injury In 3D complete articular distal radius fracture models we determined that on average the volar lunate facet fragment is much larger than the dorsal lunate facet fragment and the radial styloid fragment had the greatest average displacement. This suggests that alignment of the volar lunate facet fragment with the radial styloid fragment may be most important in fracture fixation. TreatmentThere is a subset of fractures that can be considered for surgery prior to an attempt at manipulative reduction and immobilization, for example due to a marginal shearing injury, significant displacement, or comminution. Patients can use a decision aid to help them choose between surgery or manipulation and immobilization. For patients who choose surgery before reduction, and who have no nerve or skin issues, we found that it’s safe to forgo reduction – and thus forgo the recommendation made by the Dutch distal radius fracture guidelines to reduce any displaced fracture. Our work also showed that fracture reduction is maintained one year after fixation with a volar locking plate. We found no difference in change in fracture position or range of motion, grip strength or disability between one and two distal screw rows. Routinely using two rows of screws seems to add unnecessary costs, a longer duration of surgery, and more opportunities for a misplaced or overly long screw. The limited association between radiographic deformity and disability is illustrated by the difference in parameters recommended by national societies to define an inadequate reduction and consider surgery. We found that no radiographic parameter was associated with symptoms or objective impairment one year after fracture fixation. The fact that some residual displacement is not associated with impairment or patient reported outcome should be considered when counseling patients on the risks and benefits of surgical treatment. Recovery When finger stiffness and pain intensity are considered out of proportion to what is expected after distal radius fracture, patients are sometimes labeled with illness constructions such as complex regional pain syndrome or reflex sympathetic dystrophy. We found that catastrophic thinking – the tendency to misinterpret or overinterpret nociception – was a consistent and major determinant of finger stiffness at suture removal and six weeks after injury. This shows finger stiffness occurs due to normal human illness behavior (catastrophic thinking) and subsequent fear and avoidance of activity. This causes stiffness and skin changes (swelling, shiny skin, change in hair patterns) associated with disuse. How far the fracture fragments are apart only had a limited effect on the amount of opioids people take in a cohort from the United States. Pathophysiology may not be the main determinant of pain intensity and fewer opioids may achieve similar pain relief. We hope this prevents other countries, like the Netherlands, from moving to an opioid centric pain model like in Canada and the United States.