Department of Orthopedics, Kristianstad and Hässleholm Hospitals, Hässleholm, Sweden.
Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden.
J Bone Joint Surg Am. 2018 Apr 18;100(8):633-639. doi: 10.2106/JBJS.17.00107.
The long-term effect of distal radial fracture malunion on activity limitations is unknown. Between 2001 and 2002, we conducted a prospective cohort study of all patients with distal radial fracture treated with casting or percutaneous fixation in northeast Scania in Sweden. In that original study, the patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at baseline and at 2 years. We performed a long-term follow-up study of patients who were 18 to 65 years of age at the time of the fracture to investigate the association between fracture malunion and activity limitations.
In this long-term follow-up, patients who had participated in the original study completed the DASH questionnaire and a visual analog scale (VAS) for pain and for satisfaction (scored, 0 [best] to 100) and underwent radiographic and physical examinations at 12 to 14 years after the fracture. We defined malunion as dorsal angulation of ≥10°, ulnar variance of ≥3 mm, and/or radial inclination of ≤15°. We also assessed the presence of radiocarpal osteoarthritis and ulnar styloid nonunion. The primary outcome was the change in DASH score from baseline. Secondary outcomes were DASH, pain, and satisfaction scores, wrist range of motion, and grip strength at the time of the follow-up.
Of 85 eligible patients, 63 (74%) responded to the questionnaires and underwent examinations. Malunion was found in 25 patients, osteoarthritis was found in 38 patients, and styloid nonunion was found in 9 patients. Compared with patients without malunion, those with malunion had significantly worse DASH scores from baseline to 12 to 14 years (p = 0.002); the adjusted mean difference was 11 points (95% confidence interval [CI], 4 to 17 points). Similarly, follow-up scores were significantly worse among patients with malunion; the adjusted mean difference was 14 points (95% CI, 7 to 22 points; p < 0.001) for DASH scores, 10 points (95% CI, 0 to 20 points; p = 0.049) for VAS pain scores, and 26 points (95% CI, 11 to 41 points; p = 0.001) for VAS satisfaction scores. No differences were found in range of motion or grip strength. Osteoarthritis (mostly mild) and styloid nonunion had no significant association (p > 0.05) with DASH scores, VAS pain or satisfaction scores, or grip strength.
Patients who sustain a distal radial fracture at the age of 18 to 65 years and develop malunion are more likely to have worse long-term outcomes including activity limitations and pain.
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
桡骨远端骨折畸形愈合对活动受限的长期影响尚不清楚。2001 年至 2002 年，我们对瑞典斯科讷东北部接受石膏或经皮固定治疗的所有桡骨远端骨折患者进行了前瞻性队列研究。在最初的研究中，患者在基线和 2 年时完成了手臂、肩部和手部残疾（DASH）问卷。我们对骨折时年龄在 18 至 65 岁之间的患者进行了长期随访研究，以调查骨折畸形愈合与活动受限之间的关系。
在这项长期随访中，参加过最初研究的患者完成了 DASH 问卷和视觉模拟量表（VAS）的疼痛和满意度评分（评分范围 0 [最佳]至 100），并在骨折后 12 至 14 年进行了影像学和体格检查。我们将畸形愈合定义为背侧成角≥10°，尺侧骨量≥3mm 和/或桡骨倾斜度≤15°。我们还评估了腕骨关节炎和尺骨茎突骨不连的存在。主要结局是从基线到 DASH 评分的变化。次要结局包括 DASH、疼痛和满意度评分、腕关节活动范围和随访时握力。
在 85 名符合条件的患者中，63 名（74%）对问卷进行了回复并接受了检查。25 名患者存在畸形愈合，38 名患者存在腕骨关节炎，9 名患者存在尺骨茎突骨不连。与无畸形愈合的患者相比，有畸形愈合的患者 DASH 评分从基线到 12 至 14 年显著恶化（p=0.002）；调整后的平均差异为 11 分（95%置信区间[CI]，4 至 17 分）。同样，畸形愈合患者的随访评分也明显更差；调整后的平均差异为 14 分（95%CI，7 至 22 分；p<0.001），DASH 评分 14 分（95%CI，0 至 20 分；p=0.049），VAS 疼痛评分 10 分（95%CI，0 至 20 分；p=0.049），VAS 满意度评分 26 分（95%CI，11 至 41 分；p=0.001）。在运动范围或握力方面没有差异。（主要为轻度）关节炎和尺骨茎突骨不连与 DASH 评分、VAS 疼痛或满意度评分或握力无显著相关性（p>0.05）。
18 至 65 岁发生桡骨远端骨折并出现畸形愈合的患者，其长期结局（包括活动受限和疼痛）更差。
预后 II 级。有关证据水平的完整描述，请参见作者说明。
