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Trauma: D. P. Forward, T. R. C. Davis, and J. S. Sithole Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg Br 2008; 90-B: 629-637 [Abstract] [Full text] [PDF]

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Authors' Reply

Daren P Forward, Tim RC Davis   (9 July 2008)

Malunited distal radius fractures

Benedict A Rogers, Joideep Phadnis   (30 June 2008)

Authors' Reply 9 July 2008
Daren P Forward, Specialist Registrar Nottingham University Hospitals, Tim RC Davis Send letter to journal: Re: Authors' Reply daren.forward{at}virgin.net Daren P Forward, et al.	Sir, We thank Messrs Rogers and Phadnis for their interest in our article. They very reasonably have some concerns relating to the methodology, which we attempted to highlight. We hope readers will acknowledge that performing a study with an average follow-up of 38 years will have inherent methodological flaws which the researcher may not be able to overcome, but that the research has value nonetheless. Two observers reviewed the radiographs, one a consultant orthopaedic surgeon who was not an author on the paper, and one a research fellow (DPF). Classification was only into intra- or extra- articular in an attempt to overcome the problems highlighted in point 1 and recognised in point 3. We also recognised that further sub-classification by any technique has not been shown to be predictive, and as such was unlikely to be helpful, even if accurate. No attempt was made to evaluate general health status. The DASH score collects more global upper limb data than the PEM, both of which we were interested in, and we wished to avoid questionnaire fatigue. We still do not feel that the absence of the original radiographs is a significant impairment to the results of this study. We argue that if it has a confounding effect, then it will be to worsen the results of the intra-articular fractures as many simple intra-articular fractures may have been considered extra-articular. Our paper does, of course, take into account dorsal tilt, carpal malalignment and loss of radial height, as these were assessed from the final radiographs. It may in fact be the case that many studies without late radiographs fail to fully consider these deformities if early radiographs, taken before complete union and consolidation, are used in isolation. While we are unable to assess initial fracture comminution directly, the reference cited and others suggest that dorsal comminution acts as a predictor of late radiographic instability, and loss of restoration of palmar tilt, again something which was accounted for in our study, since any late fracture instability will have been viewed on the radiographs. We do have information on immobilisation and return to work. This was not reported in the article as it relied entirely on the patient’s recollection and as such could not be considered accurate. Both mean and mode for immobilisation were five weeks. People appeared to remember this consistently. Most reported returning to work immediately, but this appeared less well remembered. There were no significant differences in grip strength, range of motion, PEM or DASH scores between volar and dorsally malunited fractures. With regard to the implementation of the results of this study, we took care to consider this in our conclusions given the methodological problems inherent in such work. We continue to suggest that anatomical reduction should be the goal of fracture treatment in young adults, even though the relationship between malunion and loss of function is not clear. The treating surgeon must, however, recognise that anatomical reduction may not always be achieved without negative effects on outcome that could outweigh any benefit. We take the view that there is no evidence of clinically significant benefit to long-term prevention of post-traumatic osteoarthritis following fixation of distal radius fractures and no longer use this as a reason to operate or advise patients to undergo surgery. There may be short-term functional benefits to operative treatment, and if this is felt to be of value to the patient following discussion, then operative fixation may be recommended. Outcome following these fractures is clearly complex and in our view involves a combination of factors, including improved radiological reduction, negative effects of fixation, unquantifiable chondral damage at the time of injury, unrecognised ligamentous injury, and psychological factors. D.P. Forward, Specialist Registrar, T.R.C. Davis, Nottingham University Hospitals, Nottingham, UK.
Malunited distal radius fractures 30 June 2008
Benedict A Rogers, Specialist Registrar St Peter's Hospital, Chertsey, UK, Joideep Phadnis Send letter to journal: Re: Malunited distal radius fractures benedictrogers{at}hotmail.com Benedict A Rogers, et al.	Sir, Working at a unit where the preferred treatment for patients with unstable fractures of the distal radius who are medically fit is to undertake volar plate fixation we read the study by Forward et al1 on outcome following distal radial fractures with great interest and have the following points to make. 1. The classification of wrist fractures, using a variation of classification systems, has been shown to have a poor inter-observer and intra-observer agreement.2 A recent study performed in our department on reliability of classification systems for distal radius fractures has confirmed this, even with digital imaging. How many observers, with what level of training and experience, reviewed the radiographs and what was the inter-observer and intra-observer agreement? 2. For a study considering the long-term morbidity relating to a distal radius fracture, was any general health status evaluation made, for example using the SF-12 or SF-36?3,4 3. As mentioned in the methods section, no original radiographs were used and the study used the latest follow-up radiographs to classify fractures into intra- or extra- articular. This may be a misleading classification of the original injury since there are numerous confounding factors (i.e. original fracture comminution, amount of dorsal tilt, carpal malalignment5 and loss of radial height), all of which independently predict functional outcome,6 that are not considered. 4. Do the authors have any information on how long each patient was immobilised following the fracture and how long it took for them to return to work? 5. Was there any significant difference in grip strength and function for fractures with a volar angulated malunion compared with dorsal angulated malunions? 6. As a result of this study, do the authors in their practice accept a greater degree of “non-perfect” anatomical reduction when treating distal radius fractures conservatively or operatively? B.A. Rogers, Specialist Registrar, J. Phadnis, St Peter's Hospital, Chertsey, UK. 1. Forward DP, Davis TRC, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg [Br] 2008;90-B:629-37. 2. Andersen DJ, Blair WF, Steyers CM Jr, et al. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg[Am] 1996;21:574-82. 3. Garratt AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT. The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993;306:1440-4. 4. Jenkinson C, Coulter A, Wright L. Short form 36 (SF36) health survey questionnaire: normative data for adults of working age. BMJ 1993;306:1437-40. 5. Batra S, Debnath U, Kanvinde R. Can carpal malalignment predict early and late instability in nonoperatively managed distal radius fractures? Int Orthop 2007 [Epub]. 6. Leone J, Bhandari M, Adili A, et al. Predictors of early and late instability following conservative treatment of extra-articular distal radius fractures. Arch Orthop Trauma Surg 2004;124:38-41.