To Örebro University

Distal radius fractures (DRFs) are the most common fractures, yet many patients experience suboptimal recovery. Radiological parameters and patient factors guide treatment decisions, and surgical treatment is aimed at restoring the anatomy. However, the radiological result correlates poorly with the outcome, and so other factors impactingt he outcome must be considered. The present thesis addresses this matter by investigating the outcome and factors potentially influencing the outcome, such as socioeconomic factors, decreased finger motion, and surgical technique. Using data from the Swedish Fracture Register (SFR) and prospectively collected data, four studies were conducted:

• Study I: Analysed the epidemiology, treatment, and outcomes of intraarticular DRFs in the SFR.

• Study II: Examined decreased finger motion in relation to outcomes in 140 patients.

• Study III: Investigated the impact of socioeconomic factors on DRF recovery.

• Study IV: Assessed the risk of median neuropathy associated with the volar central approach in a cohort of 38 patients.

Key findings included the following: a considerable proportion of patients with intraarticular fractures experience disability 1 year after the fracture. Country of birth significantly affects DRF recovery, with non-European patients having higher risk of reported poor outcomes. Patients with decreased finger motion at 4 weeks post-surgery report worse outcomes up to 1 year after the surgery, suggesting its potential as a prognostic tool. The volar central approach carries a considerable risk of median neuropathy, and should be used only when optimal visualization of the distal radius is needed.

This study aimed to investigate the association of socioeconomic factors, country of birth and comorbidities with poor patient-reported outcome 1 year after a distal radial fracture. The patient population was obtained from the Swedish Fracture Register. In the study, 17,468 patients 18 years or older were included. Poor outcome was the dependent variable in a multivariate logistic regression analysis. The factors with the strongest association with poor outcome were country of birth outside the European Union (odds ratio (OR) = 2.28; 95% CI = 1.91-2.73), high-energy trauma mechanism (OR = 1.76; 95% CI = 1.46-2.12), a history of anxiety or depression (OR = 1.46; 95% CI = 1.26-1.70), and a Charlson comorbidity index ≥3 (OR = 1.51; 95% CI = 1.17-1.94). Alleviating the effects of these factors could potentially decrease the proportion of patients with a disability after a distal radial fracture.Level of evidence: III.

BACKGROUND: In distal radius fracture (DRF) surgery with volar locking plates, the flexor carpi radialis approach is commonly used. However, the volar central approach (VCA), between the median nerve and the finger flexors, may improve visualization of the volar ulnar corner. A similar approach has been linked with a higher risk of iatrogenic median neuropathy. This study evaluated the risk of median neuropathy after operative treatment using the VCA.

METHODS: Thirty-eight patients with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C DRF were assessed prospectively with sensory nerve conduction studies preoperatively and at 6 weeks, 3 months, and 12 months postoperatively.

RESULTS: At 6 weeks, 30 of the 38 patients exhibited median neuropathy, decreasing to 12 of the 35 at 12 months. Subjective sensory deficit was reported by 12 of the 38 patients at 6 weeks and 8 of the 37 at 12 months. Patients with median neuropathy (MN) had significantly higher frequency of subjective sensory deficit of the median nerve 12 months postoperatively, but did not have significantly worse patient-reported outcome.

CONCLUSIONS: Our results suggest that the VCA should be reserved for cases needing optimal exposure of the volar ulnar corner.

INTRODUCTION: Several factors can influence the outcome after a distal radius fracture (DRF). The aim of this study was to assess whether postoperative pulp-to-palm (PTP) distance correlated with functional outcomes after plate fixation of DRF. MATERIALS &

METHODS: This is a secondary analysis of a randomized controlled trial aimed to investigate the effects of plate fixation in patients with type-C fractures. Subjects (N = 135) were divided into 2 groups based on PTP distance (equal to or higher than 0 cm) at 4 weeks postoperatively. Outcome measures were collected prospectively at 3, 6 and 12 months and included Patient-Rated Wrist Evaluation (PRWE), Quick Disabilities of the Arm Shoulder and Hand (QuickDASH) scores, wrist range of motion (ROM), Visual Analog Scale (VAS) pain scores, and hand grip strength.

RESULTS: Overall, at 3 and 6 months patients with PTP > 0 cm had significantly worse outcomes (PRWE, QuickDASH, wrist ROM) than those with PTP =0 cm. At 12 months, QuickDASH and wrist ROM were still significantly worse. In the volar-plating subgroup, patients with PTP > 0 cm had significantly worse wrist ROM and grip strength at 3 months, but no significant differences were found in subsequent follow-ups. In the combined-plating group, patients with PTP > 0 cm had significantly worse QuickDASH, wrist ROM and grip strength at 3 months. At 6 and 12 months, wrist ROM was still significantly worse.

CONCLUSIONS: Measurement of PTP distance appears to be useful to identify patients likely to have worse outcome after plating of a DRF. This could be a tool to improve the allocation of hand rehabilitation resources.

The aim of this study was to examine the epidemiology, treatment, and patient-reported outcome of AO/OTA type C distal radius fractures (DRF) using data from a large national fracture register. We used prospectively collected data from the Swedish Fracture Register covering all AO/OTA type C DRFs registered between April 2012 and December 2018. Data on fracture type, epidemiology, trauma-mechanism, and treatment had been recorded by the treating physician. Patients had been sent an outcome questionnaire including EQ-VAS, EQ-5D, and the SMFA at the time of injury and 12 months after. A total of 12 199 cases with AO/OTA type C fracture were identified. AO/OTA type C1 fracture was most common, with 5400 cases, followed by AO type C2 with 4304 and AO/OTA type C3 with 2495. Cast treatment and surgical treatment with volar locking plate fixation were the most common treatments. Patient-reported outcome measures worsened significantly one year after the fracture, and 56% reported moderate problems with pain and discomfort one year after the fracture. Patients treated with a volar plate reported a significantly larger deterioration in EQ-5D outcome compared to patients treated with a cast. No treatment method was found to be superior. A good outcome after a type C fracture is possible, but many patients do not recover completely. Our findings indicate a relatively better self-reported outcome for patients treated with a cast, but as treatment was not randomized the clinical relevance is unclear.

BACKGROUND: The distal radius fracture (DRF) is the most common fracture in adults. With an ageing population, the number of wrist fractures in the superelderly (≥ 80 years) is expected to rise. Optimal treatment for displaced DRFs remains controversial, especially in the superelderly group. In addition, basic knowledge of the outcome after a DRF in this heterogenic group is lacking. The aim of this study was to study injury characteristics, treatment and outcome of DRFs in superelderly patients using data from a large national register.

METHODS: We used prospectively collected data from the Swedish Fracture Register. All distal radius fractures registered between April 2012 and December 2018 in patients ≥ 80 years of age were included. Data on epidemiology, fracture type, trauma mechanism and treatment are registered by the physician treating the patient. Patients are also sent a subjective outcome questionnaire including EQ-5D, EQ-VAS and Short Musculoskeletal Function Assessment questionnaire (SMFA-score) at the time of injury and after 12 months. The 12-month questionnaire was sent to those who had completed the questionnaire at the time of injury. A Mann-Whitney U-test was used to assess differences between treatment methods.

RESULTS: Mean age for this population was 86 years (80-105 years), a majority of the patients were female (86.7%). The dominating injury mechanism was a simple fall (74.6%) in the patient's residence. The majority of fractures were AO type A (70%) followed by AO type C (20.9%) and type B (8.6%). The incidence of open fractures was significantly higher in females (2.6%) compared to males (1.5%). A majority of the fractures were treated with a cast (87.5%) with volar locking plate as the second most common treatment method (6.6%). Patient-reported outcome measures (PROMs) EQ-5D, EQ-VAS and the Arm Hand Function Index of the SMFA-score deteriorated somewhat one year after injury compared to pre-injury. PROMs did not correlate to treatment with cast or a volar plate.

CONCLUSIONS: This nationwide register study provides detailed data on DRFs in the superelderly regarding epidemiology, treatment and self-reported outcome. A good self-reported outcome is possible, but many patients do not recover completely. PROMs did not correlate to type of treatment. The frequency of open fractures was significantly higher in females. The reason for this is unclear but different skin thickness in older males versus females may be one explanation.