Distal radius fractures : epidemiology and aspects of surgical management

Abstract

Distal radius fractures (DRFs) are the most common fractures treated by physicians. About 20% of all DRFs are treated surgically. The main surgical methods are volar plate fixation, external fixation and percutaneous pinning. The spectrum and frequency of associated complications vary considerably between surgical methods. DRF surgery is often performed in a day surgery setting. Anesthesia is achieved by either regional anesthesia (RA) or general anesthesia (GA). An important aspect of treatment outcome evaluation is patient-reported outcome measures (PROMs). The EQ-5D questionnaire is a well-known generic PROM, which measures health-related quality of life (HRQoL). The overall aim of this thesis was to study DRF epidemiology and aspects of surgical management and treatment evaluation.

In Study I, the internal and external responsiveness of EQ-5D index score was assessed for 132 patients aged 50-74 years with a surgically treated DRF, whom within the context of a previous randomized controlled trial completed the EQ-5D and the Patient-Rated Wrist Evaluation (PRWE-Swe) questionnaires at baseline (preinjury state), and at 3 and 12 months postoperatively. PRWE-Swe was used as the external criterion. The study showed that EQ-5D index score displayed an overall acceptable to good responsiveness in patients with a surgically treated DRF, and thus may be used as a measure of HRQoL in this patient group.

Study II was a single-center randomized clinical trial comparing RA (with a supraclavicular plexus blockade) and GA in 88 patients aged 18-74 years with a displaced DRF treated with volar plate fixation in day surgery. Outcomes included opioid equivalent consumption (OEC) during the first 3 postoperative days, VAS for pain, perioperative time consumption, and functional outcomes and PROMs at 6 months. The study showed that the anesthesia method significantly influenced the early patterns of postoperative pain and opioid consumption after DRF surgery, as well as the perioperative time consumption. Neither total OEC over the first 3 postoperative days, nor longer-term outcomes differed between the groups.

Study III was a national descriptive cross-sectional register study using data from the Swedish Fracture Register (SFR). Included were 23,394 DRFs in 22,962 patients aged 18 years or older. The study provided comprehensive descriptive data on the epidemiology, classification, injury characteristics, treatment regimens and mortality of DRFs. The most common type of patient was an elderly woman who sustained a DRF through a simple fall at her own residence and whose fracture was extra-articular and treated non-surgically.

Study IV was a nation-wide cohort study linking data from two population-based health-care registers, assessing the rate of surgical site infections after DRF surgery for the three main surgical methods, as well as factors associated with a surgical site infection. A dispensed prescription of Flucloxacillin and/or Clindamycin within eight weeks after DRF surgery was used as a proxy for a surgical site infection. A total of 31,807 patients 18 years or older with a surgically treated DRF were included. The rate of surgical site infection was 28% for external fixation, 12% for percutaneous pinning and 5% for plate fixation.