Patients with distal radius and ulnar fractures have inferior subjective 1-year outcomes
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Register results showed worse DASH scores at 1 year for patients with combined distal radius and distal ulnar fractures vs. those with any type of distal radius fracture, a presenter said at the Orthopaedic Research Society Annual Meeting.
“In a register, the patient group with both distal radius fracture and distal ulnar fracture, a small subgroup, had substantially worse subjective outcome – DASH 23 [points] vs. 9 [points] – a large difference,” Magnus Tägil, MD, PhD, of Lund University in Lund, Sweden, said.
Investigators in Lund have tracked distal radius fracture outcomes since 2002 with the Lund Wrist Fracture Register and, as part of the treatment protocol, use the DASH score prospectively and consecutively at 3 months and 12 months after treatment. Annually, about 450 adult patients present at Tägil’s hospital with distal radius fractures and are included in the register, according to Tägil.
About 20% of patients are treated operatively and 80% are treated conservatively, which is consistent throughout the 10-year period of this study, he said. “So, the majority gets well after distal radius fracture,” he said.
Subgroup with ulnar fractures
Therefore, Tägil and colleagues studied a subgroup of patients with a distal radius fracture and concomitant distal ulnar fracture further. In the register, “one group we found had substantially worse outcome was the 128 patients with a combined radius and distal ulna metaphyseal fracture – not just an ulnar styloid, but a metaphyseal fracture, having a median DASH of 23 compared to a DASH median 9 in the patients without an ulnar fracture,” he said.
In a distal radius fracture, a concomitant metaphyseal ulnar fracture, which occurs in 6% of patients, “constitutes a substantial risk factor for inferior subjective outcome,” Tägil told Healio Orthopedics.
Researchers reviewed Charlson comorbidity data for patients in the register and classified the distal radius fractures by the AO subclassification with the Q modifier for ulnar fractures and the Biyani radiographic classification. They also studied fracture type, patient characteristics and 1-year patient-reported outcomes.
Comorbidity with combined fracture
The mean age of the 128 patients with combined distal radius and ulnar fractures, or distal radial ulnar fractures (DRUF), was 71 years compared 62 years for the 3,666 patients with a distal radius fracture alone.
“The patients with combined fracture had a high degree of comorbidity. Actually, 39% of patients had a Charlson score of 1 or higher and 61% were using at least one drug, and 23% of these met the criteria for polypharmacy with an intake of more than five drugs regularly,” Tägil said.
Among patients with just a distal radius fracture, 17% underwent surgical treatment and 83% underwent conservative treatment.
“In our series, there was no difference between surgically and conservatively treated fractures,” Tägil told Healio Orthopedics.
“In the combined cohort, half the patients were treated conservatively and almost half the patients were operated for the distal radius fracture. So, in the 61 patients operated in the combination fracture cohort, a little more than half the patients had both the distal radial fracture and a distal ulnar [fracture] fixed. A little less than half had only the distal radial fracture fixed and only one out of the 61 had the distal ulnar fracture alone fixed,” he said during his presentation.
Tägil noted various implants were used for fixation in the DRUF cohort. Surgeons used five methods of ulnar fracture fixation, he said. According to the abstract, 61 patients underwent osteosynthesis of the radius fracture and 36 patients underwent internal fixation.
Tägil told Healio Orthopedics, “Better surgical options and rehab guidelines need to be developed.”
Perspective
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This study looks at a relatively infrequent scenario where patients presented with distal radius and concomitant metaphyseal ulna fractures, and these patients had significantly higher DASH scores at 1 year. The reasons for this discrepancy in the study are unclear, although it could be related to the relatively high number of ulna fractures treated surgically. Fixation of distal ulna fractures can be challenging due to poor bone quality, comminution and possible hardware prominence. In my experience, these fractures can be successfully treated nonsurgically and I suspect the higher DASH scores may be related to the high number of patients being treated with internal fixation. Comparing the DASH scores of patients treated surgically with those treated nonsurgically could shed more light and help guide decision-making in similar patients.
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