Marjolein A.M. Mulders

Determinants of Grip Strength in Healthy Subjects Compared to That in Patients Recovering From a Distal Radius Fracture

PURPOSE Grip strength is influenced primarily by body mass index, sex, and age. It is also partly voluntary and correlates with symptoms of depression. This study examined whether psychological factors influence grip more in the setting of injury than in healthy volunteers. METHODS Grip strength was evaluated in one hundred subjects, 50 healthy individuals and 50 patients 6 weeks after a nonsurgically treated fracture of the distal radius. Grip strength was measured as the mean of 3 attempts, and patients completed questionnaires for arm-specific disability (Disabilities of the Arm, Shoulder, and Hand), depression, pain anxiety, catastrophic thinking, and negative thoughts in response to pain. RESULTS The mean grip strength in the injured group was 55% of the uninjured side. Pain anxiety accounted for 9% of the variability in grip strength in injured wrists. Among healthy patients, sex was the only correlate of dominant-side grip strength, and body mass index accounted for 8% of the variation in the grip strength of the nondominant side divided by the dominant side. CONCLUSIONS The majority of the variation in grip strength remains unaccounted for, but physical factors correlate best with grip strength and percent grip strength of the nondominant side divided by the dominant side in healthy patients, and psychological factors correlate best with absolute grip in patients recovering from distal radius fractures. CLINICAL RELEVANCE The influences on grip strength are complex, but the differences among recovering and healthy patients demonstrate a role for nonphysical factors in grip strength during recovery.

Creation of the Abbreviated Measures of the Pain Catastrophizing Scale and the Short Health Anxiety Inventory: The PCS-4 and SHAI-5

Abstract Objective: In patients with arm and upper extremity illness, pain catastrophizing and health anxiety are important factors in disability, pain and patient satisfaction. The aim of this study was to develop a shorter version of the 13-item Pain Catastrophizing Scale [PCS] and 18-item Short Health Anxiety Inventory [SHAI]. Methods: One hundred and sixty-four patients [54% women, mean age of 51 years] with a variety of upper extremity diagnoses enrolled in this study. Patients completed the PCS, the SHAI, the Disabilities of Arm Shoulder and Hand questionnaire [DASH] for disability, the Patient Health Questionnaire-9 [PHQ-9] for depressive symptoms and a scale to measure pain. Inter-correlation analyses were conducted on each of the subscales of the PCS and the SHAI and questions were selected based on the magnitude of their inter-item correlation. Results: Questions 3, 6, 8 and 11 remained in the PCS-4 and showed good internal consistency [α = 0.86] and correlated highly with the original PCS [r = 0.96]. Questions 2, 3, 12, 15 and 17 were chosen for the SHAI-5. The SHAI-5 had α = 0.67 and had a correlation or r = 0.87 with the SHAI-18. Both the SHAI-5 and PCS-4 had equal correlations with DASH, PHQ and pain as the original questionnaires. Conclusions: We found that the PCS-4 and SHAI-5 were comparable to the original questionnaires, but further studies should be conducted in order to confirm our findings. This study provides preliminary evidence that the PCS-4 and SHAI-5 could be used to screen for health anxiety and pain catastrophizing in busy orthopedic settings. Level of Evidence: Diagnostic Level II

Non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes, however at the expense of 40% subsequent surgeries

BACKGROUND Although secondary displacement following closed reduction and plaster immobilisation is high, several guidelines still recommend non-operative treatment for displaced distal radius fractures with an adequate closed reduction. PURPOSE The purpose of this study was to evaluate functional outcomes, measured with the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, in non-operative treated patients with displaced distal radius fractures and an adequate closed reduction confirmed on radiograph. MATERIALS AND METHODS From a retrospective database, we reviewed non-operative treated adult patients with an unilateral displaced distal radius fracture and adequate closed reduction confirmed on radiograph. The primary outcome was the DASH score at 12months. DASH scores were prospectively collected pre-trauma and at three, six and 12months. Secondary outcome was the number of subsequent surgeries due to secondary displacement or a symptomatic malunion, and their possible predictors. Additionally, the difference in DASH scores between patients who were treated due to secondary displacement and asymptomatic malunion was compared. RESULTS One-hundred and sixteen patients were included. The median age was 62 years and 79% was female. Fractures were classified according to the AO/OTA classification as follows: AO/OTA type A (49%), AO/OTA type B (3%), AO/OTA type C (48%). After 12months the median DASH score was 15. Forty-six (40%) patients underwent subsequent surgery due to a secondary displacement or symptomatic malunion. No significant differences in DASH scores between patients who were treated non-operatively and patients who received subsequent surgery were found. Younger patients were more likely to undergo subsequent surgery. Patients with a symptomatic malunion had significant higher DASH scores compared to patients with secondary displacement. DISCUSSION Non-operative treatment of displaced distal radius fractures after adequate closed reduction confirmed on radiograph leads to acceptable functional outcomes after 12months, however, at the expense of 40% subsequent surgeries. LEVEL OF EVIDENCE Level IV, retrospective cohort study.

Functional outcomes of distal radius fractures with and without ulnar styloid fractures: a meta-analysis

The aim of this meta-analysis was to compare the functional outcomes of patients with a distal radius fracture with and without a concomitant fracture of the ulnar styloid process. A systematic literature search was performed to identify all studies comparing patients with a distal radius fracture with and without an ulnar styloid process fracture. The initial search revealed 511 articles, of which 12 articles with a total of 2243 patients were included; 1196 patients with and 1047 patients without an ulnar styloid process fracture. A statistically significant mean difference of 3.40 points (95% CI 1.33–5.48) in the Disability of the Arm, Shoulder, and Hand score was found in favour of patients without an ulnar styloid process fracture. This difference is less than 10 and therefore not clinically important. No significant difference was found in Patient-Rated Wrist Evaluation scores, range of motion, grip strength, visual analogue scale pain scores, ulnar-sided wrist pain and distal radio-ulnar joint instability between patients with and without an ulnar styloid process fracture after 1 year of follow-up. Moreover, no significant differences were found between ulnar styloid base and nonbase fractures. Level of evidence: I

Association Between Radiological and Patient-Reported Outcome in Adults With a Displaced Distal Radius Fracture: A Systematic Review and Meta-Analysis

PURPOSE To evaluate the association between alignment, as determined by plain radiographs, and patient-reported outcome in adults with a displaced distal radius fracture. We also determined which specific radiological parameters are associated with patient-reported outcomes. METHODS We performed a systematic literature search to identify studies that evaluated the association between radiological and patient-reported outcome in adults with a displaced distal radius fracture and who had an average follow-up of at least 12 months. Radiological outcome was determined as acceptable or unacceptable reduction, defined by radiological parameters. Patient-reported outcome was assessed with the Disability of the Arm, Shoulder, and Hand, the Quick-Disability of the Arm, Shoulder, and Hand, and the Patient-Rated Wrist Evaluation questionnaires. RESULTS Sixteen articles were included, comprising 1,961 patients with a distal radius fracture. A significant mean difference of 4.15 points in patient-reported outcomes (95% confidence interval [CI], 0.26-8.04) was found in favor of an acceptable radiological reduction. Moreover, a significant mean difference of 5.38 points in patient-reported outcomes (95% CI, 1.69-9.07) was found in favor of an acceptable dorsal angulation, and 6.72 points (95% CI, 2.16-11.29) in favor of an acceptable ulnar variance. CONCLUSIONS An unacceptable radiological reduction is significantly associated with worse patient-reported outcomes in adults with a displaced distal radius fracture. Dorsal angulation and ulnar variance are the most important radiological parameters. Despite the statistical significance, the mean difference of each association did not meet the threshold of the minimally clinically important difference and therefore were unlikely to be clinically important. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.

Normative data for the Patient-Rated Wrist Evaluation questionnaire

Study Design: Cross‐sectional study. Introduction: The Patient‐Rated Wrist Evaluation (PRWE) questionnaire is used to evaluate functional outcomes after treatment of wrist and hand injuries and nontraumatic conditions. Since patients commonly present with an injury, it is impossible to assess preinjury physical functioning. Therefore, it is important to be aware of the population‐based normative data. Purpose of the Study: The aim of this study was to determine the normative data for the PRWE questionnaire. Secondary, we aimed to determine if there were factors influencing these normative data. Methods: Visitors and employees of 4 hospitals were requested to participate. Excluded were all participants who were scheduled for surgery or were in treatment or after treatment for an injury of the wrist or hand within 1 year after trauma. All participants were asked to complete the PRWE questionnaire and were asked for their age, sex, history of wrist or hand fracture or surgery, daily activities, and the type of employment. The socioeconomic status was determined based on the zip code. Results: The median PRWE score was 0 (interquartile range: 0‐8.5) and the mean score 7.7 (standard deviation: 15.0). Women had significantly higher scores compared to men, and younger individuals had significantly lower scores. Participants with a history of wrist or hand fracture or surgery, and participants who were unfit for work had significantly higher scores. Socioeconomic status was not correlated with the PRWE score. Discussion: The purpose was to provide an representative overview of the normative data for the normal population. We did not want to present the data of an unnatural healthy population, which is not representative of the normal population. Deleting patients with chronic wrist or hand complaints, would have resulted in normative values which are not representable for the normal, average population. Conclusion: Low scores are observed for the PRWE in the general population. These scores are age and sex dependent and are higher in individuals with a history of wrist or hand fracture or surgery or who are unfit for work.