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Functional decline after incident wrist fractures—Study of Osteoporotic Fractures: prospective cohort study

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3324 (Published 08 July 2010) Cite this as: BMJ 2010;341:c3324

Functional decline may not be due to wrist fractures alone.

I read with interest the article by Edwards et al entitled,
“Functional decline after incident wrist fractures—Study of Osteoporotic
Fractures: prospective cohort study” and would like to make the following
points.

As mentioned in their discussion, intra-articular fractures are more
likely to be associated with poor functional outcome. The authors cite
other articles to support this finding but there is no mention in their
study of the type of distal radius fracture with regards to the severity
or whether or not the joint surface was involved. Instead the inclusion
criteria of a wrist fracture was defined as either distal radius or ulna
or both bones. The authors also mention colles fractures which is
classically described as an extra-articular dorsally displaced distal
radius fracture. Were other types of distal radius fractures not
classically described as a colles fracture excluded from the study such as
Smith’s (volar displacement) and Barton (articular involvement with carpal
subluxation) type distal radius fractures?

There is no mention on the treatment received for these fractures.
This would be important as complications can arise from conservative
management (e.g. malunion) or operative fixation (tendon rupture, nerve
damage, scarring) which can all affect the functional outcome. The
“incident fracture” group seem to be a heterogeneous group of patients
treated in a variety of ways and the functional outcomes of these patients
may be more dependent on the treatment they received and the possible
complications rather than the “wrist” fracture itself and therefore may
represent a confounding variable in the study.

The authors do not mention the mechanism of injury resulting in a
wrist fracture. Whilst the authors excluded patients with previous wrist,
vertebral or hip fractures there is no mention of associated injuries at
the time of the wrist fracture affecting the upper limb which may also
impact on the functional outcome. Were the 41 (15%) of patients with poor
functional outcome sustained fractures from a simple fall or were some of
these related to more high energy injuries such as road traffic collisions
raising the possibility of multiple injuries other than a wrist fracture?
There is evidence to show that distal radius fractures can be associated
with scapholunate ligament injury in up to 21% of fractures and triangular
fibrocartilage complex (TFCC) tears in 53% of fractures where the
preoperative radiographs have no predictive value for interosseous
ligament injury (1). Forward et al found that patients with treated distal
radius fractures and associated untreated scapholunate ligament injury had
significant wrist pain at 1 year attributed to the scapholunate injury.
They highlighted that their findings may represent an important
confounding factor in distal radial fracture outcome studies (2). Could
the 41 patients with poor outcomes represent a more severe unnoticed and
untreated carpal ligament injury associated with the wrist fracture that
continued to cause problems after satisfactory healing of the wrist
fracture? The fracture group did not seem to be adequately defined with
respect to fracture mechanism, fracture severity and associated injuries
and treatment modality which all could be confounding factors to
functional outcomes. Therefore, functional decline may not be attributable
to the wrist fracture alone.

References

1.Richards RS, Bennett JD, Roth JH, Milne K, Jr.: Arthroscopic
diagnosis of intra-articular soft tissue injuries associated with distal
radial fractures. J Hand Surg Am 1997:22:772-776.

2.Forward DP, Lindau TR, Melsom DS: Intercarpal ligament injuries
associated with fractures of the distal part of the radius. J Bone Joint
Surg Am 2007:89:2334-2340.

Competing interests:
None declared

Competing interests: No competing interests

26 July 2010
Kanthan Theivendran
Trauma & Orthopaedics ST5
West Midlands Deanery: Birmingham Orthopaedic Training Programme, B31 2AP