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Distal Radius Fractures: aspects on radiological and clinical outcome and evaluation of a new classification system
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Distal radius fracture (DRF) is the most common fracture encountered in clinical practice. Every year, more than 20000 people in Sweden suffer from this injury. It has been shown that there is a correlation between malalignment and function following distal radial fractures and malunion may cause persistent pain and disability.

A problem has been in making a correct initial assessment of the fracture. Many fractures are unstable despite an acceptable position on the initial radiographic examination or following a successful closed fracture reduction.

Numerous classification systems have been developed for evaluation of DRF in order to predict the outcome. However, the values of these are limited since they have not shown satisfactory reliability. Furthermore, the utility of these systems to predict radiographic or clinical outcome is not yet proven. These shortcomings may be one reason why optimal DRF management is still controversial. Requests for a new classification system of DRF, predictive of outcome and easy to use, have been made.

Improvement in initial assessment of DRF will benefit a large group of patients, as well as the society, by reducing persistent symptoms and disability.

Study I: In this study we evaluated the interobserver and intraobserver reliability of a new classification system (the Buttazzoni classification). Two hundred and thirty-two patients with acute DRF were blindly evaluated using the new classification by three orthopaedic surgeons twice with a 1-year interval. The new classification showed fair to substantial interobserver and intraobserver reliability, i.e., results comparable with other commonly used classification systems.

Study II: This was a prospective multicenter study of fracture stability in 428 DRF. The study investigated whether cortical comminution and intra-articular involvement, as well as the new classification system, could predict displacement in DRF. Logistic regression analysis showed that initial position of the fracture and volar or dorsal comminution predicted later displacement, while intra-articular involvement did not. Volar comminution was the strongest predictor of displacement. The new classification system, which is the first to include volar comminution as a separate parameter, was highly predictive of fracture instability. Furthermore we found that it is quite common for non-operatively treated fractures to displace at a later stage than two weeks.

Study IV: In study II it was found that late displacement of DRF, still in acceptable radiologic position after 10-14 days, occurred in approximately 1/3 of cases. Despite this, we have not been able to find any study focusing on evaluating the clinical outcome in patients with late displacement. Two hundred and nine unilateral DRF from study II were still in good position after 10-14 days and were included in the study. One hundred and seventy five patients had radiographs taken at a minimum of 3 months and a clinical examination 1 year after the fracture. Late displaced distal radius fractures had significantly higher loss of ROM and grip strength compared to fractures that didn’t displace. No significant differences were seen in subjective outcome.

In conclusion, initial position of the fracture predicted later displacement and was the most important parameter in predicting clinical outcome. Comminution of the fracture also affected radiological stability and clinical outcome. Volar comminuted fractures are highly unstable and need surgical intervention if displacement is to be avoided. Intra-articular involvement affected clinical outcome. Late displacement is common in DRF and may result in loss of range of motion and grip strength. To detect late displacement, DRF should be followed for more than 2 weeks.

The new classification system had a moderate reliability and reproducibility. The classification was found predictive of radiologic and objective clinical outcome. However, it was not predictive of subjective outcome. The classification system was also predictive of fractures at risk for late displacement.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 95 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1782
Keyword [en]
Distal radius fracture, Buttazzoni classification, volar, comminution, reliability, radiological outcome, clinical outcome, late displacement
National Category
Medical and Health Sciences
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-118544ISBN: 978-91-7601-413-4 (print)OAI: oai:DiVA.org:umu-118544DiVA: diva2:913919
Public defence
2016-04-15, Aulan plan 1 sektion blått, Sundsvalls sjukhus, Sundsvall, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-03-24 Created: 2016-03-23 Last updated: 2016-03-24Bibliographically approved
List of papers
1. The Buttazzoni Classification of Distal Radial Fractures in Adults: interobserver and Intraobserver Reliability
Open this publication in new window or tab >>The Buttazzoni Classification of Distal Radial Fractures in Adults: interobserver and Intraobserver Reliability
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2009 (English)In: Hand, ISSN 1558-9447, Vol. 4, no 3, 283-288 p.Article in journal (Refereed) Published
Abstract [en]

Despite the fact that distal radial fracture is the commonest fracture, there is a little evidence-based knowledge about the value of its classification to guide management and predict prognosis. The available classification systems are either complicated or weakly applicable in clinical practice. Older's classification is the most reliable, but does not cover all radial fracture types. We evaluated the interobserver and intraobserver reliability of a new classification system which is a modification of Older's classification covering all radial fracture types. Two hundred and thirty-two consecutive adult patients with acute distal radial fractures were blindly evaluated according to the new classification by three orthopedic surgeons twice with 1-year interval. The interobserver reliability was measured using the Fleiss kappa coefficient, and the intraobserver reliability was measured using the Cohen's kappa coefficient. The new classification showed fair to substantial interobserver and intraobserver reliability, i.e., results comparable to the reliability of commonly used classification systems. The reliability was better for younger patients and when evaluation was carried out by hand-surgery-interested orthopedic surgeons. The new classification system is simple, covers all radial fracture types, and has an acceptable reliability. Further studies are needed to judge its ability to direct management and predict prognosis.

Keyword
Reliability, Classification, Distal radial fractures, Kappa
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-113946 (URN)10.1007/s11552-009-9163-1 (DOI)19172363 (PubMedID)
Available from: 2016-01-07 Created: 2016-01-07 Last updated: 2016-03-23Bibliographically approved
2. Cortical comminution in distal radial fractures can predict the radiological outcome
Open this publication in new window or tab >>Cortical comminution in distal radial fractures can predict the radiological outcome
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2014 (English)In: The Bone & Joint Journal, ISSN 2049-4394, E-ISSN 2049-4408, Vol. 96B, no 7, 978-983 p.Article in journal (Refereed) Published
Abstract [en]

This paper investigates whether cortical comminution and intra-articular involvement can predict displacement in distal radius fractures by using a classification that includes volar comminution as a separate parameter. A prospective multicentre study involving non-operative treatment of distal radius fractures in 387 patients aged between 15 and 74 years (398 fractures) was conducted. The presence of cortical comminution and intra-articular involvement according to the Buttazzoni classification is described. Minimally displaced fractures were treated with immobilisation in a cast while displaced fractures underwent closed reduction with subsequent immobilisation. Radiographs were obtained after reduction, at 10 to 14 days and after union. The outcome measure was re-displacement or union. In fractures with volar comminution (Buttazzoni type 4), 96% (53 of 55) displaced. In intra-articular fractures without volar comminution (Buttazzoni 3), 72% (84 of 117) displaced. In extra-articular fractures with isolated dorsal comminution (Buttazzoni 2), 73% (106 of 145) displaced while in non-comminuted fractures (Buttazzoni 1), 16 % (13 of 81) displaced. A total of 32% (53 of 165) of initially minimally displaced fractures later displaced. All of the initially displaced volarly comminuted fractures re-displaced. Displacement occurred in 31% (63 of 205) of fractures that were still in good alignment after 10 to 14 days. Regression analysis showed that volar and dorsal comminution predicted later displacement, while intra-articular involvement did not predict displacement. Volar comminution was the strongest predictor of displacement.

Place, publisher, year, edition, pages
British Editorial Society of Bone and Joint Surgery, 2014
Keyword
colles fracture, intraarticular fractures, young-adults, instability, displacement, fixation, volar
National Category
Orthopedics Surgery
Identifiers
urn:nbn:se:umu:diva-91751 (URN)10.1302/0301-620X.96B7.32728 (DOI)000338696000021 ()24986954 (PubMedID)
Available from: 2014-08-19 Created: 2014-08-15 Last updated: 2017-12-05Bibliographically approved
3. Cortical comminution and intra-articular involvement in distal radius fractures: clinical outcome at 1 year using a conservative treatment algorithm
Open this publication in new window or tab >>Cortical comminution and intra-articular involvement in distal radius fractures: clinical outcome at 1 year using a conservative treatment algorithm
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(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-118540 (URN)
Available from: 2016-03-23 Created: 2016-03-23 Last updated: 2016-03-23
4. The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life
Open this publication in new window or tab >>The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life
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(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-118541 (URN)
Available from: 2016-03-23 Created: 2016-03-23 Last updated: 2016-03-23

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