Abstract
Purpose
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To assess whether distal radius fracture (DRF) malunion is associated with greater patient-reported disability.
Methods
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We searched PubMed, EMBASE, and Cochrane databases up to 21 May 2023. Two reviewers independently screened retrieved titles/abstracts and assessed the full text of potentially eligible articles to identify cohort studies and randomized controlled trials reporting outcomes of DRF in adults at least 12 months after fracture, confirmed radiologically 3 months or longer after fracture. We excluded studies not reporting patient-reported outcomes according to malunion and studies judged to have a high risk of bias, as assessed independently by two reviewers using the Quality In Prognosis Studies tool. To express the overall effect of malunion on patient-reported disability, we calculated the standardized mean difference (SMD) with a 95% CI.
Results
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Six studies with 898 patients (77% women) were included; five involved adults of all ages, and one restricted to patients aged 65 years and older. In the meta-analysis including the five studies with adults of all ages (1047 observations), the SMD was 0.58 (95% CI: 0.42–0.74; P < 0.001), favoring no malunion, with no statistically significant heterogeneity or publication bias. In the meta-analysis including all six studies (1193 observations), the SMD was 0.51 (95% CI: 0.35–0.67; P < 0.001), favoring no malunion, with moderate but significant heterogeneity.
Conclusion
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Malunion of distal radius fracture is associated with significantly greater patient-reported disability with a moderate magnitude in terms of clinical importance. The study does not address the possible influence of age or treatment methods.
Introduction
Fracture of the distal radius is the most common fracture in adults (1, 2). Although a majority of patients with distal radius fracture (DRF) recover well within 6 months, a substantial number continue to have disability and pain years after the fracture (3, 4, 5). Controversy exists regarding whether activity limitation is related to radiological alignment after fracture union, making this issue important to study further since it may influence the choice of treatment.
In current clinical practice, patients with non-displaced or minimally displaced DRF are usually treated with a cast (6). Displaced fractures, if not reduced or if the reduction is not maintained, will heal with malunion, and even minimally displaced fractures could displace during cast treatment, resulting in malunion (7). In patients who develop malunion and experience pain, dysfunction, and/or limited range of motion, corrective osteotomy is considered (8). If malunion after DRF is associated with worse arm-related disability, treatment should aim toward anatomical restoration as prevention of malunion would be an important objective. However, the benefit from a treatment chosen to prevent malunion should exceed the possible harm from complications associated with that treatment. There is presently a gap in the literature supporting this approach.
The aim of this systematic review and meta-analysis was to investigate the association between DRF malunion in adults and patient-reported disability. Our hypothesis was that adults with a DRF that heals with malunion would have worse patient-reported outcomes (PROs) compared to patients without malunion.
Methods
Data sources and searches
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (9), and the study protocol was registered in PROSPERO on 11 February 2021. A systematic literature search in PubMed, EMBASE, and Cochrane databases was performed on January 3, 2021, and updated on May 21, 2023, to identify eligible studies. The search strategy was constructed with the assistance of a clinical librarian (Appendix 1, Supplementary materials, see section on supplementary materials given at the end of this article). After the removal of duplicates, titles and abstracts of retrieved records were screened independently by two reviewers using Covidence (a systematic review software). MA screened all titles and abstracts in pairs with another reviewer (MW, JN, RAA, or EB). Disagreements were resolved by discussion and consensus was reached. Potentially eligible articles were assessed in full text independently by two reviewers (MA and EB) using Covidence. Disagreements were resolved by discussion. If disagreement persisted, a third reviewer (IA) was consulted. The reference lists of all included studies were also screened for additional studies of relevance to this systematic review.
Study selection
The PICOTS format (P = population (adults with acute DRF); I = index prognostic factor (malunion); C = comparator prognostic factor (not applicable); O = outcome (PROs); T = timing (at least 12 months after fracture); S = setting (cohort studies and randomized controlled trials of any setting)) was adopted to formulate the eligibility criteria. The inclusion criteria were cohort studies (prospective and retrospective cohort studies) and randomized controlled trials assessing patient-reported disability after malunited DRF in adults regardless of type of treatment, using one or more of these validated outcome measures: the 30-item Disabilities of the Arm, Shoulder and Hand (DASH), the 11-item QuickDASH, the Patient-Rated Wrist Evaluation (PRWE), and/or the Michigan Hand Questionnaire (MHQ), measured at a minimum of 12 months after fracture. Since no formal definition of malunion has been established in the literature, we applied the definitions used by the included studies. If the definition was not provided, but data regarding PROs according to radiological parameters were available, we used dorsal angulation ≥10º, ulnar variance ≥3 mm, and/or radial inclination ≤15º to define malunion. Similar cut-off values have been used in recent guidelines from different countries regarding the management of DRF (10, 11). The wrist radiographs should have been performed at a minimum of 3 months after fracture to ensure union. No restriction regarding the date of publication was applied, but only studies published in English, Spanish, or Swedish were searched.
The exclusion criteria were studies reporting on skeletally immature individuals, studies not reporting on malunion and/or PROs according to malunion, studies with a follow-up time (i.e. time of collecting PROs data) shorter than 12 months, studies with radiographs performed earlier than 3 months after the fracture, studies with study designs other than cohort studies and randomized controlled trials, studies including only intra-articular fractures, and studies judged to have a high risk of bias (RoB) on full-text review.
Data extraction and risk of bias assessment
Data extraction was performed by one reviewer (MA) using a standard data collection form. A second reviewer (RSR) audited all the extracted data. In the case of missing data, authors were contacted by e-mail and asked to provide additional data. The data extracted from the articles included first author, publication year, number of patients, patient sex, mean and range of patient age, type of fracture (extra-articular or intra-articular), type of treatment, number of patients in the malunion and non-malunion groups, mean and range of follow-up time, definition of malunion, and mean and s.d. of patient-reported outcome measures (PROMs) scores.
Two reviewers (MA and EB) independently assessed RoB of the included studies using the Quality In Prognosis Studies (QUIPS) tool, recommended by the Cochrane Prognosis Methods Group (12). The QUIPS tool consists of six main domains, and each domain includes multiple items that are assessed separately (Supplementary Table 1, Supplementary materials). For each domain, RoB can be classified as low, moderate, or high. To judge the overall RoB for each study, we used the method described by Grooten et al. (13). Any disagreement between the two reviewers was resolved by discussion, and in case disagreement persisted, a third reviewer (IA) was consulted.
Data synthesis and statistical analysis
Studies were included in a meta-analysis if sufficient data were provided about the number of patients in the malunion and non-malunion groups, and the mean and s.d. of PROs scores. A minimum of three studies was required to perform a meta-analysis. If data for more than one PRO were reported by a study, these were included as different inputs in the quantitative synthesis. Because different PROMs were included, we used the standardized mean difference (SMD) to express the overall size of the effect of malunion on PROs. We calculated SMD as Hedge’s g with a 95% CI, using a random effect model with a restricted maximum likelihood method. A P-value of <0.05 for the overall effect size indicated a statistically significant difference. An effect size of <0.5, 0.5–0.8, >0.8 was considered to indicate small, moderate, and large clinical effects, respectively (14). A forest plot was created as a graphical display of the findings from the meta-analysis. We used Cochran´s Q test and the I 2 statistic to assess heterogeneity; a P-value of <0.1 in Q test indicates significant heterogeneity, and I2 value of 25%, 50%, and 75% reflects low, moderate, and high heterogeneity, respectively (15). We assessed publication bias with the Egger regression test, Begg rank correlation test, and a funnel plot. A P-value of <0.10 in the Egger test and a P-value of <0.05 in the Begg test were considered to indicate significant publication bias (16, 17). The statistical analyses were conducted in STATA version 18.0 (Stata Corporation).
Results
Study selection and characteristics
The search yielded 8958 records, and after the removal of duplicates, 6885 records remained for the title and abstract screening (Fig. 1). Of these, 429 articles were read in full-text and considered for inclusion. After the full-text review, 14 articles were considered to potentially fulfill the inclusion criteria (18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31). We contacted nine authors for additional data (19, 21, 22, 23, 24, 25, 26, 28, 30), of whom six responded (19, 21, 22, 23, 28, 30). Two studies (20, 27) were excluded because they represented the same patient populations as two of the included studies (21, 30). Six other studies (22, 24, 25, 26, 29, 31) were judged to have high RoB on the QUIPS tool and were excluded. Thus, six studies were included in the systematic review (Table 1).
Flowchart of the study selection process.
Citation: EFORT Open Reviews 9, 11; 10.1530/EOR-23-0212
Characteristics of the six studies included in the systematic review and meta-analysis.
| Study | Study design | Patients, n | Age, years | Fracture type | Treatment type | Outcome measure | Mean FUT (range) years | Definition of malunion | ||
|---|---|---|---|---|---|---|---|---|---|---|
| Total | Women, n (%) | Mean | Range | |||||||
| Grewal et al. (23) | PCS | 222 | 168 (78) | 55 | 18–89 | EAF | C, CRC, CRPF | DASH, PRWE | 1 | DA >10°, UV ≥3 mm or RI <15° |
| Wilcke et al. (28)a | RCS | 72 | 53 (74) | 59 | 22–95 | EAF, IAF | CRC, EF | DASH | 1.8 (1–2.6) | DA >15°, RS ≥2 mm and/or RI <10° |
| Arora et al. (19) | RCT | 73 | 55 (75) | 77 | 65–89 | AO type A, C | CRC, ORIF | DASH, PRWE | 1 | DA >10°, UV >2 mm, and articular incongruity ≥2 mm |
| Brogren et al. (21)a | PCS | 102 | 78 (76) | 63 | 19–88 | EAF, IAF | CRC, CRPF | DASH | 2 | DA ≥10° and /or UV ≥3 mm |
| Ali et al. (18) | PCS | 63 | 47 (74) | 66 | 36–79 | AO type A, B, C | C, CRC, CRPF | DASH | 13 (12 – 14) | DA ≥10°, UV ≥3 mm, and/or RI ≤15° |
| Schmidt et al. (30) | PCS | 366 | 289 (79) | 57 | 18–75 | AO type A, B, C | C, CRC, CRPF, EF, ORIF | Quick-DASH | 1 | DA ≥10°, UV ≥2 mm, RI ≤10° and/or articular incongruity ≥2 mm |
aData provided by authors.
AO, Arbeitsgemeinschaft für Osteosynthesefragen (the comprehensive classification of fractures (type A, extra-articular; type B, partial intra-articular; type C, complete intra-articular)); C, cast; CRC, closed reduction and cast; CRPF, closed reduction and percutaneous fixation; DA, dorsal angulation; DASH, Disabilities of the Arm, Shoulder and Hand; EAF, extra-articular fractures; EF, external fixation; FUT, follow-up time; IAF, intra-articular fractures; ORIF, open reduction and internal fixation; PCS, prospective cohort study; PRWE, Patient-Rated Wrist Evaluation; RCS, retrospective cohort study; RCT, randomized controlled trial; RI, radial inclination; RS, radial shortening; UV, ulnar variance.
The six studies comprised 898 patients with a DRF (690 women (77%)). The range of mean age was 55–77 years. The range of mean follow-up time was 1.0–13.2 years. The type of treatment was cast (with or without closed reduction) or percutaneous surgical fixation in four cohort studies (18, 21, 23, 28). One cohort study included patients treated with cast, closed reduction and cast, or percutaneous surgical fixation, or open reduction and internal fixation (30). The randomized controlled trial compared closed reduction and cast with open reduction and internal fixation (19).
For malunion involving dorsal angulation, a cut-off value of 10° was used in five studies (18, 19, 21, 23, 30), and 15° in one study (28) (Table 1). The cut-off value for ulnar variance was 3 mm in three studies (18, 21, 23), and 2 mm in three studies (19, 28, 30). For radial inclination, the cut-off value was 15° in two studies (18, 23), and 10° in two studies (28, 30), while two studies did not use radial inclination as part of the malunion definition (19, 21). Only two studies used articular incongruity (step-off ≥2 mm) as part of the malunion definition, with one reporting that no patient had incongruity (19) and the other not reporting the number of patients with articular incongruity (30).
Risk of bias assessment
The RoB assessment of the six studies included in the systematic review and meta-analysis is shown in Table 2. One study was judged to have low RoB in all domains (18). One study was judged to have moderate RoB in one domain, ‘study participation’, because of unclarity but probably adequate participation by eligible persons and low risk in all other domains (30). The remaining four studies were judged to have low RoB in all domains except one: ‘study attrition’, considered as moderate risk because of inadequate description of participants lost to follow-up or inadequate description of attempts to collect information on participants who dropped out (19, 21, 23, 28). However, these four studies had adequate response rates for study participants with a low rate of drop-out and loss of follow-up.
Risk of bias (RoB) assessment of the six studies included in the systematic review and meta-analysis.
| RoB | Grewal et al. (23) | Wilcke et al. (28) | Arora et al. (19) | Brogren et al. (21) | Ali et al. (18) | Schmidt et al. (30) |
|---|---|---|---|---|---|---|
| Domaina | ||||||
| Study participation | Low | Low | Low | Low | Low | Moderate |
| Study attrition | Moderate | Moderate | Moderate | Moderate | Low | Low |
| Prognostic factor measurement | Low | Low | Low | Low | Low | Low |
| Outcome measurement | Low | Low | Low | Low | Low | Low |
| Study confounding | Low | Low | Low | Low | Low | Low |
| Statistical analysis and reporting | Low | Low | Low | Low | Low | Low |
| Overall RoBa | Low | Low | Low | Low | Low | Low |
aFor each domain, the RoB can be classified as low, moderate, or high: a study with low RoB in all six domains, or low RoB in five and moderate in one domain is classified as low RoB; a study with high RoB in at least one domain or moderate RoB in three or more domains is classified as high RoB; all other combinations are classified as moderate RoB (Supplementary materials).
Six studies were judged to have high RoB and were excluded from the systematic review and meta-analysis (Supplementary Table 2, Supplementary materials) (22, 24, 25, 26, 29, 31). All six excluded studies had high RoB in the domain ‘study participation’ due to inadequate participation (<67%) in the study by eligible patients (13); two of the six excluded studies also had high RoB in another domain ‘study attrition’ due to inadequate response rate (<67%) for study participants (13), and four of the excluded studies also had moderate RoB in at least one of the other domains (Supplementary Table 2, Supplementary materials).
Patient-reported outcomes according to malunion
Scores for DASH or QuickDASH were reported in all six studies, and two studies also reported scores for PRWE. None of the included studies reported MHQ scores. Five studies showed significantly worse PROs in patients with malunion compared to patients without malunion (18, 21, 23, 28, 30), whereas one study found no statistically significant difference in PROs between the two groups (19).
Meta-analysis
We could retrieve data on PROs in patients with malunion compared to patients without malunion from all the six studies that were then included in the meta-analysis. The five cohort studies (18, 21, 23, 28, 30) included adults of all ages, while the randomized controlled trial (19) included only patients aged 65 years or older with a mean age of 77 years compared to a mean age ranging from 55 to 66 years for the five cohort studies (Table 1). As the randomized study was an obvious outlier regarding age, and following the Cochrane Statistical Methods Group guidelines (32), we first performed a meta-analysis with the five cohort studies and then performed a meta-analysis including all six studies. The primary meta-analysis (1047 observations) showed that patients with malunion had significantly worse PROs compared to patients without malunion, with an SMD of 0.58 (95% CI: 0.42–0.74; P < 0.001) (Fig. 2). The Q test’s P-value was 0.19 and the I2 was 29%, indicating no significant heterogeneity. The funnel plot (Supplementary Figure 1, Supplementary materials) showed no visual asymmetry, and the P-value for the Egger test and the Begg test were 0.1008 and 0.0603, respectively, indicating no publication bias.
The effect of malunion on patient-reported outcomes, five studies included.
Citation: EFORT Open Reviews 9, 11; 10.1530/EOR-23-0212
The meta-analysis with all six studies included (1193 observations) also showed that patients with DRF malunion had significantly worse PROs compared to patients without malunion, with SMD of 0.51 (95% CI: 0.35–0.67; P < 0.001). However, the Q test’s P-value was 0.08 and the I 2 was 39%, indicating moderate but significant heterogeneity (Fig. 3).
The effect of malunion on patient-reported outcomes, six studies included.
Citation: EFORT Open Reviews 9, 11; 10.1530/EOR-23-0212
Discussion
In this systematic review and meta-analysis, a statistically significant association was found between DRF malunion and greater patient-reported disability as measured with the DASH, QuickDASH, or PRWE, with a moderate effect size in terms of clinical importance.
Our results are in the same direction as those of the only other previously published meta-analysis concerning distal radius malunion and patient-reported disability (33). In that meta-analysis, with a search until October 31, 2016 (582 observations), Mulders et al. reported an association between ‘unacceptable’ radiological reduction of DRF in adults and worse PROs measured with the DASH, QuickDASH, or PRWE. However, the difference in PROs found in the meta-analysis by Mulders et al. was considered by the authors to be small and unlikely to be of clinical importance. One of the six studies in the meta-analysis by Mulders et al. included patients above 55 years of age with less than 12 months of follow-up (34), another included patients with radiographs performed earlier than 3 months after fracture (35), and one study included only patients above 60 years of age with an unclear malunion definition and a possible high RoB regarding the study participation rate (36). Besides, the study by Mulders et al. showed significant heterogeneity among the included studies. Additionally, Mulders et al. used the minimal clinically important difference (MCID) for the quantitative synthesis of the effect of malunion on PROs, while we opted to use the SMD. The MCID is context-specific, with different values for different PROMs, and even for the same PROM, several MCID values have previously been estimated depending on the specific population, patients’ characteristics, and other factors (37). For example, for the DASH, reported MCID values have ranged from 6.5 to 14.5 (37). To our knowledge, no MCID values for the DASH, QuickDASH, or PRWE in patients with DRF malunion have been established. The SMD is used in meta-analyses when the included studies assess an outcome using different outcome measures in order to unify the outcome measures and express the clinical impact of the examined factor (38). Thus, the SMD is more appropriate. The above-mentioned factors in the study by Mulders et al. may explain the small difference found in PROs between patients with and those without malunion. In our meta-analysis, the effect size was moderate, suggesting clinical importance.
In this systematic review and meta-analysis, we excluded studies judged to have a high RoB based on the QUIPS tool. We believe that this approach, previously recommended by other authors (39, 40), will yield results that more accurately reflect the effect of malunion on PROs.
Our study has some strengths and limitations. The search strategy, constructed with the help of a clinical librarian, was comprehensive, and the search criteria aimed to include any study that potentially reported on DRF and presented radiological outcome measures to identify malunion. Another strength was the stringent eligibility criteria applied to include a study in this review. These criteria demanded that PROs had been collected not earlier than 1 year after fracture and that the radiographs had been performed not earlier than 3 months after fracture. Studies with shorter follow-up times may not reflect the long-term effect of malunion on PROs, and relying on radiographs performed early after fracture may underestimate the degree of malunion.
One limitation of our study was that the included studies had some differences in the definition of malunion, reflecting the current lack of consensus regarding which radiological criteria should be used to define malunion. However, the definitions used by the included studies showed only small differences. In fact, five of the six included studies used a cut-off value of >10° of dorsal angulation as part of the definition of malunion. As a cut-off for ulnar variance, three studies used 3 mm and the other three used 2 mm. Although it is unknown whether and to what extent the patients in these studies had knowledge about their radiological outcomes, which potentially may influence self-reported disability scores, it is unlikely that they were informed about the exact radiological values before being asked to complete the scales. Another possible limitation is the different fracture types and treatment methods in the included studies. Besides, in only two of the included studies, open reduction and internal fixation were part of the treatment method (19, 30). That reflects the lack of studies reporting on the clinical effect of malunion. However, our study is a prognostic index factor systematic review and meta-analysis to study the possible association between malunion and PROs regardless of treatment method. Besides, it is uncertain whether malunion after open reduction and internal fixation would behave differently from malunion after other types of treatment.
Although the meta-analysis that included six studies also showed that patients with DRF malunion had significantly worse PROs compared to patients without malunion with a moderate effect size, this analysis showed significant heterogeneity. This meta-analysis included a study involving only patients above the age of 65 years (19). That study did not find a statistically significant association between malunion and PROs. Another included study conducted a subgroup analysis for patients above the age of 65 years and found that the presence of malunion did not influence patient reports of pain and disability measured with the PRWE or the DASH (23). A randomized trial that compared closed reduction and cast with surgical fixation of DRF in patients aged 60 years or older found no significant difference in outcome, measured with MHQ, between patients with malunion and those without malunion two years after fracture (29). This study was, however, excluded from our systematic review because of high RoB due to inadequate participation in the study by eligible patients and inadequate response rate from study participants. With only two available studies, it was by protocol not feasible to perform a meta-analysis to investigate the association between malunion and PROs in adults above the age of 65 years. Data from the above-mentioned studies might indicate that malunion is more tolerable by elderly patients compared to younger individuals, depending on the individual level of activity and functional demands. However, further studies are needed to investigate whether age (or other characteristics) influences the association between malunion and disability.
Conclusion
This systematic review and meta-analysis shows that there is an association of moderate magnitude between DRF malunion and worse patient-reported disability measured with the DASH, QuickDASH, and/or the PRWE. Further studies are needed to address whether age or other characteristics affect patient outcomes after DRF malunion.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-23-0212.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.
Funding Statement
This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Authors contribution statement
MA, RSR, and IA planned and designed the study. MA, MW, JN, RAA, and EB screened titles and abstracts. MA and EB read full texts, included studies in the review, and performed risk of bias assessment. MA and RSR extracted data and performed the statistical analysis. All authors critically revised the article for important intellectual content and gave final approval for the article.
Acknowledgements
The authors thank Krister Aronsson (librarian) for help in constructing the search strategy and Riyad Abd-Ali, MD, for assistance in the process of title and abstract screening.
References
- 1↑
Court-Brown CM, & Caesar B. Epidemiology of adult fractures: a review. Injury 2006 37 691–697. (https://doi.org/10.1016/j.injury.2006.04.130)
- 2↑
Court-Brown CM, Biant L, Bugler KE, & McQueen MM. Changing epidemiology of adult fractures in Scotland. Scottish Medical Journal 2014 59 30–34. (https://doi.org/10.1177/0036933013518148)
- 3↑
MacDermid JC, Roth JH, & Richards RS. Pain and disability reported in the year following a distal radius fracture: a cohort study. BMC Musculoskeletal Disorders 2003 4 24. (https://doi.org/10.1186/1471-2474-4-24)
- 4↑
Dewan N, MacDermid JC, Grewal R, & Beattie K. Recovery patterns over 4 years after distal radius fracture: descriptive changes in fracture-specific pain/disability, fall risk factors, bone mineral density, and general health status. Journal of Hand Therapy 2018 31 451–464. (https://doi.org/10.1016/j.jht.2017.06.009)
- 5↑
Moore CM, & Leonardi-Bee J. The prevalence of pain and disability one year post fracture of the distal radius in a UK population: a cross sectional survey. BMC Musculoskeletal Disorders 2008 9 129. (https://doi.org/10.1186/1471-2474-9-129)
- 6↑
Abramo A, Kopylov P, & Tagil M. Evaluation of a treatment protocol in distal radius fractures: a prospective study in 581 patients using DASH as outcome. Acta Orthopaedica 2008 79 376–385. (https://doi.org/10.1080/17453670710015283)
- 7↑
Mackenney PJ, McQueen MM, & Elton R. Prediction of instability in distal radial fractures. Journal of Bone and Joint Surgery 2006 88 1944–1951. (https://doi.org/10.2106/JBJS.D.02520)
- 8↑
Katt B, Seigerman D, Lutsky K, & Beredjiklian P. Distal radius malunion. Journal of Hand Surgery 2020 45 433–442. (https://doi.org/10.1016/j.jhsa.2020.02.008)
- 9↑
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372 n71. (https://doi.org/10.1136/bmj.n71)
- 10↑
Kamal RN, & Shapiro LM. American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures. Journal of the American Academy of Orthopaedic Surgeons 2022 30 e480–e486. (https://doi.org/10.5435/JAAOS-D-21-00719)
- 11↑
Mellstrand Navarro C. Nationellt vårdprogram för behandling av distala radiusfrakturer. 2021. Available at: https://d2flujgsl7escs.cloudfront.net/external/Nationellt+v%C3%A5rdprogram+f%C3%B6r+behandling+av+distala+radiusfrakturer.pdf.
- 12↑
Hayden JA, van der Windt DA, Cartwright JL, Côté P, & Bombardier C. Assessing bias in studies of prognostic factors. Annals of Internal Medicine 2013 158 280–286. (https://doi.org/10.7326/0003-4819-158-4-201302190-00009)
- 13↑
Grooten WJA, Tseli E, Äng BO, Boersma K, Stålnacke BM, Gerdle B, & Enthoven P. Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS-aspects of interrater agreement. Diagnostic and Prognostic Research 2019 3 5. (https://doi.org/10.1186/s41512-019-0050-0)
- 14↑
Lakens D. Calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and ANOVAs. Frontiers in Psychology 2013 4 863. (https://doi.org/10.3389/fpsyg.2013.00863)
- 15↑
Higgins JPT, Thompson SG, Deeks JJ, & Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003 327 557–560. (https://doi.org/10.1136/bmj.327.7414.557)
- 16↑
Egger M, Davey Smith G, Schneider M, & Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997 315 629–634. (https://doi.org/10.1136/bmj.315.7109.629)
- 17↑
Begg CB, & Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994 50 1088–1101. (https://doi.org/10.2307/2533446)
- 18↑
Ali M, Brogren E, Wagner P, & Atroshi I. Association between distal radial fracture malunion and patient-reported activity limitations: a long-term follow-up. Journal of Bone and Joint Surgery 2018 100 633–639. (https://doi.org/10.2106/JBJS.17.00107)
- 19↑
Arora R, Lutz M, Deml C, Krappinger D, Haug L, & Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. Journal of Bone and Joint Surgery 2011 93 2146–2153. (https://doi.org/10.2106/JBJS.J.01597)
- 20↑
Brogren E, Hofer M, Petranek M, Wagner P, Dahlin LB, & Atroshi I. Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up. BMC Musculoskeletal Disorders 2011 12 9. (https://doi.org/10.1186/1471-2474-12-9)
- 21↑
Brogren E, Wagner P, Petranek M, & Atroshi I. Distal radius malunion increases risk of persistent disability 2 years after fracture: a prospective cohort study. Clinical Orthopaedics and Related Research 2013 471 1691–1697. (https://doi.org/10.1007/s11999-012-2767-8)
- 22↑
Finsen V, Rod O, Rød K, Rajabi B, Alm-Paulsen PS, & Russwurm H. The relationship between displacement and clinical outcome after distal radius (Colles’) fracture. Journal of Hand Surgery 2013 38 116–126. (https://doi.org/10.1177/1753193412445144)
- 23↑
Grewal R, & MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. Journal of Hand Surgery 2007 32 962–970. (https://doi.org/10.1016/j.jhsa.2007.05.009)
- 24↑
Kodama N, Takemura Y, Ueba H, Imai S, & Matsusue Y. Acceptable parameters for alignment of distal radius fracture with conservative treatment in elderly patients. Journal of Orthopaedic Science 2014 19 292–297. (https://doi.org/10.1007/s00776-013-0514-y)
- 25↑
Larouche J, Pike J, Slobogean GP, Guy P, Broekhuyse H, O'Brien P, & Lefaivre KA. Determinants of functional outcome in distal radius fractures in high-functioning patients older than 55 years. Journal of Orthopaedic Trauma 2016 30 445–449. (https://doi.org/10.1097/BOT.0000000000000566)
- 26↑
Quadlbauer S, Pezzei C, Jurkowitsch J, Rosenauer R, Pichler A, Schättin S, Hausner T, & Leixnering M. Functional and radiological outcome of distal radius fractures stabilized by volar-locking plate with a minimum follow-up of 1 year. Archives of Orthopaedic and Trauma Surgery 2020 140 843–852. (https://doi.org/10.1007/s00402-020-03411-9)
- 27↑
Wadsten MÅ, Sjödén GO, Buttazzoni GG, Buttazzoni C, Englund E, & Sayed-Noor AS. The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life. Journal of Hand Surgery 2018 43 131–136. (https://doi.org/10.1177/1753193417721446)
- 28↑
Wilcke MKT, Abbaszadegan H, & Adolphson PY. Patient-perceived outcome after displaced distal radius fractures. A comparison between radiological parameters, objective physical variables, and the DASH score. Journal of Hand Therapy 2007 20 290–8; quiz 299. (https://doi.org/10.1197/j.jht.2007.06.001)
- 29↑
Chung KC, Kim HM, Malay S, Shauver MJ & WRIST Group. Comparison of 24-month outcomes after treatment for distal radius fracture: the WRIST randomized clinical trial. JAMA Network Open 2021 4 e2112710. (https://doi.org/10.1001/jamanetworkopen.2021.12710)
- 30↑
Schmidt V, Gordon M, Tägil M, Sayed-Noor A, Mukka S, & Wadsten M. Association between radiographic and clinical outcomes following distal radial fractures: a prospective cohort study with 1-year follow-up in 366 patients. Journal of Bone and Joint Surgery 2023 105 1156–1167. (https://doi.org/10.2106/JBJS.22.01096)
- 31↑
Hosokawa T, Tajika T, Suto M, & Chikuda H. Relationship between malunion and short-term outcomes of nonsurgical treatment of distal radius fractures in the elderly: differences between early- and late-geriatric patients. Journal of Hand Surgery 2023 S0363-5023(23)00001-1. (https://doi.org/10.1016/j.jhsa.2022.12.013)
- 32↑
Deeks JJ, Higgins J, Altman DG & on behalf of the Cochrane Statistical Methods Group. Chapter 10: analysing data and undertaking meta-analyses. In Cochrane Handbook for Systematic Reviews of Interventions Version 6.2 (updated February 2021), p. 2021. Eds Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, & Welch VA. Cochrane, 2021.
- 33↑
Mulders MAM, Detering R, Rikli DA, Rosenwasser MP, Goslings JC, & Schep NWL. Association between radiological and patient-reported outcome in adults with a displaced distal radius fracture: a systematic review and meta-analysis. Journal of Hand Surgery 2018 43 710–719.e5. (https://doi.org/10.1016/j.jhsa.2018.05.003)
- 34↑
Synn AJ, Makhni EC, Makhni MC, Rozental TD, & Day CS. Distal radius fractures in older patients: is anatomic reduction necessary? Clinical Orthopaedics and Related Research 2009 467 1612–1620. (https://doi.org/10.1007/s11999-008-0660-2)
- 35↑
Bentohami A, Bijlsma TS, Goslings JC, de Reuver P, Kaufmann L, & Schep NW. Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome. Journal of Hand Surgery 2013 38 524–529. (https://doi.org/10.1177/1753193412468266)
- 36↑
Nelson GN, Stepan JG, Osei DA, & Calfee RP. The impact of patient activity level on wrist disability after distal radius malunion in older adults. Journal of Orthopaedic Trauma 2015 29 195–200. (https://doi.org/10.1097/BOT.0000000000000235)
- 37↑
Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, & Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). Journal of Orthopaedic and Sports Physical Therapy 2014 44 30–39. (https://doi.org/10.2519/jospt.2014.4893)
- 38↑
Andrade C. Mean difference, standardized mean difference (SMD), and their use in meta-analysis: as simple as it gets. Journal of Clinical Psychiatry 2020 81 20f13681. (https://doi.org/10.4088/JCP.20f13681)
- 39↑
Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, Gluud C, Martin RM, Wood AJG, & Sterne JAC. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 2008 336 601–605. (https://doi.org/10.1136/bmj.39465.451748.AD)
- 40↑
Harvey LA, & Dijkers MP. Should trials that are highly vulnerable to bias be excluded from systematic reviews? Spinal Cord 2019 57 715–716. (https://doi.org/10.1038/s41393-019-0340-y)
