Clinician reported outcome

Function following a DRF can be captured using clinician reported outcomes (CROs), such as range of motion (ROM) and grip strength. PA following a DRF was associated with poorer CROs in some studies [11, 14, 15]. However, other studies did not find this association [16,17].

Patient reported outcome

The patient’s opinion regarding wrist function, pain or satisfaction following a DRF can be captured in Patient Reported Outcomes (PROs). A number of studies did not find a significant association between PA and PROs [10, 18, 19]. In contrast, recent literature reported a significant association between presence of PA following DRF and poorer outcomes reported on the SF-36 questionnaire in a heterogeneous age group [20, 21]. Two studies described that a higher age predicted worse PROs 1–6 years following a DRF [20, 22]. The physical component scale of the SF-36 was poorer in older patients. The mental component scale of the SF-36 was similar or even better in younger patients [20, 21, 23]. It has been suggested that patients with preexisting osteoporosis following a DRF have better scores on PROs than those without osteoporosis [21, 24]. Age and/or preexisting osteoporosis seem to be independent factors influencing PROs following a DRF.

Purpose of the study

Conflicting results in literature have been presented on the association between outcomes and PA following DRFs. There is a need for better understanding of the clinical relevance of radiological PA following a DRF in non-osteoporotic patients. Determination of specific outcome measures predicting PA could be helpful in guiding individual treatment strategies and to decide what rehabilitation goals should be pursued in the follow-up of these patients. In addition, such outcomes could be used to prepare patients on the expected return of function and possible necessary adjustments in everyday life.

The objectives of this systematic review were to analyze (1) the prevalence of PA following a DRF, (2) associations of PA with CROs and PROs and (3) predictors of PA following a DRF in non-osteoporotic patients.

Literature search

Eligible for this review were studies reporting adult patients, women between 18 and 49 years, and men between 18 and 59 years at the time of sustaining a DRF. These age selection criteria were applied to eliminate the risk of preexistent osteoporosis, because of the high prevalence of osteoporosis reported in literature in older patients, especially in postmenopausal women [25,26]. Furthermore, at least one of the CROs (ROM, grip strength) or PROs (Disability of Arm, Shoulder and Hand questionnaire (DASH), Patient Rated Wrist Evaluation (PRWE), Michigan Hand Questionnaire (MHQ), Short Form-36 (SF-36)) had to be described. Follow-up duration had to be at least one year after the DRF. All study designs were included. Excluded were studies with less than 5 patients and studies reporting outcome measures that integrate CROs and PROs, such as the Gartland and Werley score or the Green and O’Brien score, since separate relations of CROs or PROs with PA cannot be established from such measures [21,27]. Studies describing open fractures were also excluded. Last, studies written in languages other than English, German or Dutch were excluded as were articles that only comprised of a supplement or abstract for a congress.

Quality assessment

Posttraumatic arthritis assessment

In all studies the classification for PA according to Knirk and Jupiter was applied; grade 0 represents no signs of PA and grade 3 representing bone-on-bone PA with osteophyte and cyst formation [8]. To exclude any chance of bias regarding the severity of PA as graded in the different studies, PA was computed as a dichotomous value; presence or no presence of PA.

Clinician reported outcome

Range of motion was expressed in degrees. To minimize the effect of the different units of measurement of grip strength (kilograms, kilopascal or pounds), grip strength of the injured wrist as a percentage of the uninjured wrist was calculated. No correction for dominance of hand was performed, in concordance with other studies [14, 29, 30].

Patient reported outcome

Characteristics of the PROs are described in Appendix 1.

Data analysis

Regarding reporting data from all studies, associations will be presented when reported in the studies. If associations were presented using Spearman’s r, interpretation of effect size was performed using Cohen’s guideline (weak ±0.2, moderate ±0.5, strong ±0.8) [31]. Pooling of open source data was applied to analyze outcomes and associations. The Chi-Square test was used to analyze associations between dichotomous and/or categorical variables. T test was used to analyze a dichotomous grouping variable and continuous outcome variables, normal distribution and equality in variances being present. P-plots were used to evaluate normal distribution of data and Levene’s test was used to assess the equality of variances. If there was no normal distribution of data and/or no equality in variances, Mann–Whitney U analysis was performed and medians and interquartile ranges (IQR) were presented. In the statistical analysis of the open source data, PA was transformed to a dichotomous variable (presence or no presence of PA). Significance was achieved when p < 0.05. All statistical analyses were performed using IBM SPSS, version 22.

Study selection

The study selection was performed in three stages. First, one reviewer (CL) retrieved 1026 articles from the patient database with the help of an information specialist. All studies where imported in RefWorks^®. After removing duplicates, a total of 842 studies remained. Second, two reviewers (CL and TD) assessed independently titles and abstracts. A total of 110 papers remained. The same reviewers assessed the full text papers. In case of persistent disagreement a third reviewer (CS) was consulted to reach consensus. Reasons for exclusion were; not retrievable (n = 1), written in Chinese language (n = 3), written in Spanish (n = 1), supplements or abstracts for a congress (n = 11) and not meeting the inclusion criteria (n = 73). Twenty studies met the inclusion criteria, of which two of the selected publications were conducted by the same research group and described the same patient population [14, 32]. Therefore one of these studies was excluded, resulting in 19 included studies (Fig. 1) [32]. If this was presented in the studies, open source data was collected.

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Study and patient characteristics

Association between PA and CRO: range of motion

Association between PA and CRO: grip strength

Association between PA and PROs

PROs were reported in few studies (Table 3). It was decided not to report nor perform statistical analysis on these limited results.

Predictors of PA

Prevalence of PA

The high prevalence of PA in this non-osteoporotic population is worrisome. However, from the included studies we could not derive sufficient information on the restrictions or limitations these patients experienced when executing activities of daily living, leisure time activities, work or other societal roles. Further research on PA in non-osteoporotic patients with DRF should elaborate on the impact of PA on patients’ activities or participation. Since most studies comprise of small study populations and because the open source data showed that a longer follow-up duration is associated with a higher prevalence of PA, specifically open source studies may provide unique chances to gather such data. However, currently no uniform set of evaluation instruments is available, which results in difficulty of pooling data.

Association between PA and CROs

Wrist motion is dependent on complex articulations of the scaphoid, lunate and the radio carpal joint [41]. Biomechanically, flexion–extension and radio-ulnar deviation are a result of motion of the scaphoid and lunate in respect to the distal radius, which relies on the ligamentous stability between these two carpal bones and movement in the adjacent joint surfaces [42]. The majority of the DRFs in non-osteoporotic patients result from high-energy trauma and, therefore frequently are intra-articular fractures. It is imaginable that the direction of the intra-articular force associated with this type of fracture causes intercarpal ligamentous injury as well as joint surface changes. Recent literature describes an incidence of 38% of associated scapholunate (SL) or lunotriquetral (LT) ligamentous injuries in distal radius fractures. [43] Associated SL or TL ligamentous injuries could be an explanation for the limited radial deviation and flexion and early PA as described in this systematic review. Furthermore, malalignment of the distal radius following a fracture can cause alterations of the distal radio-ulnar joint with anatomical change of the radio-ulnar contact area, resulting in limited pronation and supination [44]. Based on the results of this systematic review, it can be concluded that grip strength does not seem to be influenced by PA. This emphasizes that grip strength might not be an important determinant of wrist function and is not one of the first symptoms of PA, but merely a reflection of overall muscle strength and condition [45]. Ageing is typically associated with a progressive loss of skeletal muscle mass and occurs at a rate of 3–8% each decade after the age of 30 years [46, 47]. Although age is a confounding factor for grip strength, our results indicate that in this relatively young group of patients grip strength is not influenced to a significant extent by age. A recent Cochrane reported on different rehabilitation methods following distal radius fractures in adults was published [48]. Twenty-six trials were included which turned out to be inhomogeneous with regards to patient characteristics (i.e. age) and were qualified as low or very low quality evidence. The authors therefore concluded that available evidence is insufficient to establish the relative effectiveness of different rehabilitation methods. It is suggested by the authors to precede rehabilitation research regarding outcome in patients with distal radius fractures with a clear aim [48]. From our systematic review it is suggested that rehabilitation in non-osteoporotic patients with distal radius fractures should have a broad approach, with special focus on wrist motion (radial deviation and flexion). Although we did not find an association between grip strength and radiological PA, it is still an important determinant of total outcome and should be addressed appropriately in rehabilitation treatment.

Associations between PA and PROs

No conclusions could be drawn regarding the association between PA and PROs, because of limited data. This is indicative of a gap in knowledge on the clinical relevance of radiological PA as measured by PROs, despite the high prevalence of PA in this group.

Predictive factors for PA

A high prevalence of PA was shown, and a longer follow-up duration was associated with a higher prevalence of PA. As such, development of PA seems to be a dynamic process and progresses over time. In addition, articular incongruence was predictive for PA: patients with a step or a gap had a higher prevalence of PA. This outcome resembles the conclusions drawn in studies regarding associations between articular incongruence and PA following a DRF [10, 11,12, 13]. When articular incongruence is associated with the development of PA, it might be assumed that the AO/OTA classification of the fracture type would also have an association with PA. This association was not found in this study. The reason no statistical significant differences were found between AO/OTA type B and C fractures regarding the development of PA could be that inter- and intraobserver variability of the AO/OTA classification of distal radius fractures has been reported to be moderate to poor [49]. Another explanation could be that the DRFs have been surgically treated if a large incongruence was present and only the residual deformity or articular incongruence will affect the development of PA. It is hypothesized that with surgical treatment (with or without direct arthroscopic control), better anatomical reduction of the articular surface can be achieved and, therefore may diminish the chance of developing PA [17, 33]. Conflicting results regarding several radiological measurements predicting PA were presented in literature. However, analysis of our open source data suggests that dorsal angulation, radial length, ulnar variance and radial inclination do not predict PA. These conflicting results on predicting radiological factors could be due to a substantial variability in how these factors are defined in literature. It has been suggested to develop guidelines to ensure consistency when interpreting different radiographic measurements reported in literature [50].

Strength and weaknesses

This study is the first systematic review presenting CROs and PROs and the association with PA following DRFs in non-osteoporotic patients. Because of the extent of this systematic review and the pooling of the open source data, we believe this study is a contribution to the insight in the prevalence and clinical relevance of PA in non-osteoporotic patients following a DRF. Recent literature has encouraged pooling of open source data from clinical trials and cohort studies and reporting this in systematic reviews and meta-analyses to compare outcome in a more reliable and efficient manner [51, 52]. Although we believe pooling of the open source data in this systematic review contributes to the strength of the conclusions, variability between raters and the way measurements have been performed, should be acknowledged. Some other limitations of our systematic review should be acknowledged. We have chosen an age selection criteria (men 18–59 years, women 18–49 years) to eliminate the risk of preexisting osteoporosis. Despite our selection criteria, some of the included patients may still have had osteoporosis. All studies included in this systematic review were cohort studies or case–control studies (level of evidence II and III) with relatively small populations and moderate methodological quality [53]. These restrictions should be taken into account when interpreting the results of this meta-analysis. In general, research in the field of rehabilitation and injuries should be more transparent by presenting open source data, especially when describing small populations, to be able to compare data in a reliable way. In addition, despite our extensive literature search, very limited data was retrieved regarding PROs. We decided not to report on these limited results and, therefore no conclusions could be drawn regarding PROs following DRFs in non-osteoporotic patients. Furthermore, a new scoring method was used to assess the methodological quality of the studies, with equal weights for each quality category, except for the comparability category [28]. It could be argued that the quality categories should be scored separately instead of a combined total score to provide optimal insight into the quality of the different studies. Most included studies reported statistical significance of their results, but the weight of the associations was poorly described. Several authors have described associations between the residual articular incongruence and PA.

Further research

The high prevalence rate of PA found in the (pooled open source) data shows that investigation of outcome in non-osteoporotic patients with a long active and working life ahead should have more attention. To direct treatment strategy, rehabilitation and to decide what an acceptable level of rehabilitation is in the follow-up of non-osteoporotic patients with a DRF there is a need for a reliable interpretation of PROs and the association with PA investigated by using randomized controlled trials with or without implementing pooling of open source data. For patients and therapists it would be of great value to be able to work towards an evidence-based rehabilitation goal. It would also be very beneficial to gain more insight in the influence of radiological characteristics following fracture reduction, such as radial shortening and radial inclination on CROs, PROs and PA.