The evolution of radiological measurements and the association with clinician and patient reported outcome following distal radius fractures in non-osteoporotic patients: what is clinically relevant?

Figures & data

Figure 1. (A) Posteroanterior measurement guidelines: (1) The center of the radial shaft is determined at 3 cm and 5 cm below the mid-region of the proximal lunate articular surface. This line represents the central axis of the radius. (2) A line perpendicular to the central long axis of the radius is drawn at the level of the most distal aspect of the radial articular surface. (3) A line perpendicular to the central long axis of the radius is drawn at the level of the ulnar margin of the distal radial articular surface. (4) The radial and ulnar margins of the distal radial articular surface are connected. (5) A line perpendicular to the central long axis of the radius is drawn at the level of the distal ulnar articular surface. (B) Lateral measurement guidelines: (1) The center of the radial shaft is determined at 3 cm and 5 cm below the mid-region of the proximal lunate articular surface. This line represents the central long axis of the radius. (2) A line perpendicular to the central long axis of the radius is drawn at a convenient level. (3) The dorsal and anterior margins of the distal radial articular surface are connected. (C) Step-off and gap measurement. (1) Step-off at the articular surface of the distal radius was measured parallel to the central long axis of the radius by drawing perpendicular lines from the most distal margin of each side of the articular incongruence. (2) Gap deformity was measured along a perpendicular line to the central long axis of the radius. UV: ulnar variation; RL: radial length; RI: radial inclination; DT: dorsal tilt; SL: scapholunate ligament; DRUJ: distal radioulnar joint.

Table 1. Reference values, error magnitudes for radiological measurements and SDCs and MICs for CROs and PROs.

Radiological measurements	Normal ranges	Error magnitudes [10]
Ulnar variance (mm)	−4 to 2 [4,5]	2–4
Radial length (mm)	8–17 [5]	4–6
Radial inclination (°)	16–29 [6,7]	6–8
Dorsal angulation (°)	0–22 [8,9]	6–8
SL distance (mm)	<2.0 [47]
DRUJ distance (mm)	Related to uninjured wrist [48,49]
Step-off (mm)	NA	1–2
Gap (mm)	NA	1–2
CROs	Mean (SD) [50]	SDC	MIC
Range of motion (°)
Flexion/extension	150 (20)	4.3–5.0	5.0–7.1 [27]
Ulnar/radial deviation	61 (12)
Supination/pronation	164 (14)
Grip strength measurements (kg)
Grip strength	45.1 (14.3)	6.5	6.5 [28]
Sustained grip strength	29.6 (10.6)
Key pinch strength	9.0 (2.4)
PROs	Mean (SD) [50]	SDC	MIC
DASH	3 (6)	10.8	10.8 [29]
PRWE
Pain	1 (2)	6.5	1.5 [31]
Function	0 (1)	4.5	10
Total	1 (3)	11.0	11.5

SDC: smallest detectable change; MIC: minimal important change: CROs: clinician reported outcomes; PROs: patient reported outcomes; DASH: disability of arm, shoulder and hand questionnaire; PRWE: patient reported wrist evaluation; MHQ: Michigan Hand Questionnaire, SF36: short form3.

Table 2. Patient characteristics.

	Total population (N = 73)
Age at time of the injury (years)
Mean (SD)	33.5 (9.2)
Follow up (months)
Median (IQR)	62.0 (53.0; 84.5)
	N (%)
Gender
Male	41 (56.2)
Female	32 (43.8)
Energy trauma
Low energy	20 (27.4)
High energy	45 (61.6)
Unknown	8 (11.0)
AO/OTA Classification
A	14 (19.2)
B	30 (41.1)
C	29 (39.7)
Dominant hand injured	37 (50.7)
Left sided dominancy	2 (5.4)
Right sided dominancy	30 (81.1)
Ambidexter	5 (13.5)
Treatment
Cast	33 (45.2)
Closed reduction/cast	12 (16.4)
Surgical	28 (38.4)

N: number of patients; SD: standard deviation; IQR: interquartile range; AO/OTA: Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopedic Trauma Association classification.

Table 3. Radiological measurements at baseline, 6 weeks and follow up.

		Baseline	6 weeks	Follow-up	Baseline versus 6 weeks		6 Weeks versus follow-up
Radiological measurements	N	Mean (SD)	Mean (SD)	Mean (SD)	Mean difference (SD)	p-value (95% CI of mean difference)	Mean difference (SD)	p-value (95% CI of mean difference)
Ulnar variance (mm)	48	0.4 (2.0)	0.5 (1.8)	1.1 (1.9)	−0.7 (1.2)	−0.7 (1.2)	−0.7 (1.2)	<0.001 (−1.1; −0.4)*
Radial length (mm)	47	12.2 (2.5)	12.8 (2.0)	12.7 (2.1)	−.7 (1.2)	0.817 (−0.6; 0.5)	0.2 (1.3)	0.897 (−3; 0.4)
Radial inclination (°)	49	23.7 (4.1)	24.4 (3.9)	25.2 (3.9)	0.2 (1.3)	0.113 (−1.4; 0.2)	−0.9 (2.8)	0.028 (−1.7; -0.1)*
Dorsal angulation (°)	46	−0.6 (7.3)	−0.2 (7.9)	−0.2 (7.3)	−0.9 (2.8)	0.288 (−2.1; 0.6)	0.0 (5.2)	0.978 (−1.5; 1.5)
SL distance (mm)	34	2.2 (0.5)	2.2 (0.4)	2.1 (0.4)	0.0 (5.2)	0.627 (−2.1; 1.3)	0.1 (0.4)	0.114 (−0.0; 0.3)
DRUJ distance (mm)	43	2.0 (0.7)	2.4 (0.8)	2.4 (0.8)	0.1 (0.4)	0.660 (−0.2; 0.1)	−0.0 (0.7)	0.843 (0.2; 0.2)
Step-off (mm)	37	0.6 (1.2)	0.5 (1.0)	0.1 (0.4)	−0.0 (0.7)	0.024 (−0.6; -0.0)*	0.3 (0.9)	0.032 (0.0; 0.7)*
Gap (mm)	43	1.7 (1.6)	1.7 (1.8)	0.5 (1.4)	0.3 (0.9)	0.845 (−0.3; 0.3)	1.0 (1.6)	0.001 (0.5; 1.6)*

Results of paired samples T test.

N: number of patients; SD: standard deviation; 95% CI: 95% confidence interval; *significant difference; SL: scapholunate ligament; DRUJ: distal radioulnar Joint°degrees; mm: millimeters.

Table 4. Radiological measurements of the inured and uninjured wrist at follow-up.

		Follow up injured wrist	Follow-up uninjured wrist		Significance
Radiological measurements	N	Mean (SD)	Mean (SD)	Mean difference (SD)	p-value (95% CI of mean difference)
Ulnar variance (mm)	73	0.9 (1.8)	0.4 (1.6)	0.4 (1.9)	0.063 (−0.0; 0.9)
Radial length (mm)	73	13.0 (2.1)	13.2 (2.1)	−0.2 (2.1)	0.318 (−0.7; 0.2)
Radial inclination (°)	73	25.5 (3.6)	26.4 (3.8)	−0.9 (4.2)	0.079 (−1.9; -0.1)
Dorsal angulation (°)	73	−1.3 (6.6)	−5.1 (4.1)	3.8 (6.5)	<0.001 (2.3; 5.3)*
SL distance (mm)	45	2.1 (0.4)	2.0 (0.4)	0.1 (0.5)	0.099 (−0.0; 0.3)
DRUJ distance (mm)	72	2.4 (0.8)	2.3 (0.8)	0.1 (0.7)	0.224 (−0.1; 0.3)

Results of paired samples T test.

N: number of patients; SD; standard deviation; 95% CI: 95% confidence interval; *significant difference; SL: scapholunate ligament: DRUJ: distal radioulnar Joint; °degrees; mm: millimeter.

Table 5. CROs derived from injured and uninjured wrist at follow-up.

	Follow up injured wrist		Follow-up uninjured wrist			Significance
aROM (N = 73)	Mean	SD	Mean	SD	Mean difference (SD)	p-value (95% CI of mean difference)
Flexion/extension (°)	141.3	18.2	152.5	13.4	−11.2 (12.6)	<0.001* (14.1; −8.2)
Ulnar/radial deviation (°)	58.1	10.7	64.9	11.3	−6.9 (9.9)	<0.001* (−9.2; −4.6)
Pro/supination (°)	146.7	13.0	152.0	10.9	−5.3 (11.0)	<0.001* (−7.9; −2.8)
Grip strength (N = 73)
Grip strength (kg)	43.5	13.2	46.1	12.7	−2.6 (6.0)	<0.001* (−4.0; −1.2)
Sustained grip strength (kg)	24.6	10.9	25.0	9.6	−0.4 (6.4)	0.574 (−1.9; 1.1)
Key pinch strength (kg)	8.5	2.8	8.7	2.5	−0.1 (2.0)	0.547 (−0.6; 0.3)

Results of paired samples T test.

CROs: clinician reported outcomes; N: number of patients; SD: standard deviation; 95% CI: 95% confidence interval; *significant difference; °degrees; kg: kilogram; MCD: minimal detectable change; MCID: minimal clinically important difference.

Table 6. PROs at follow up compared to measurements of healthy controls.

	All patients (N = 73)	Healthy controls [50] (N = 22)
PROs	Mean (SD)	Mean (SD)	Difference	MIC
DASH	9 (12)	3 (6)	6	10.8 [29]
PRWE
Pain	9 (11)	1 (2)	8	1.5 [31]
Function	10 (15)	0 (1)	10	10
Total	14 (17)	1 (3)	13	11.5
MHQ	84 (16)	98 (3)	14
SF36
Physical functioning	92 (12)	93 (15)	1
Social functioning	90 (19)	95 (12)	5
Role model physical problem	86 (28)	88 (30)	2
Role model emotional problem	90 (27)	95 (21)	5
Mental health	83 (13)	89 (11)	6
Vitality	71 (18)	82 (15)	11
Pain	81 (19)	90 (14)	9
General health experience	73 (18)	78 (14)	5
Health change	52 (20)	51 (14)	1

Results of paired samples T test.

PROs: patient reported outcomes; DASH; disability of arm, shoulder and hand questionnaire; PRWE: patient reported wrist evaluation; MHQ: Michigan Hand Questionnaire; SF36: Short Form36; SDC: smallest detectable change; MIC: minimal important change.

Table 7. Univariable regression analyses of radiological measurements and CROs.

Radiological factors	aROM
	Flexion/extension			Ulnar/radial deviation			Pro/supination
	B	95% CI	p	B	95% CI	p	B	95% CI	p
Ulnar variance (mm)	0.050	−2.2; 2.4	0.966	−0.714	−2.1; 0.6	0.298	−0.523	−2.2; 1.1	0.532
R Radial length (mm)	−0.034	−2.0; 2.0	0.973	−0.459	−1.6; 0.7	0.440	−0.720	−2.1; 0.7	0.318
Radial inclination (°)	0.856	−0.3; 2.0	0.153*	−0.052	−0.8; 0.7	0.882	−0.250	−1.1; 0.6	0.562
Dorsal angulation (°)	0.078	−0.6; 0.7	0.812	0.167	−0.3; 0.6	0.475	0.167	−0.3; 0.6	0.475
SL distance (mm)	−5.853	−17.0; 5.3	0.296	4.281	−3.2; 11.7	0.254	10.490	2.2; 18.8	0.014*
DRUJ distance (mm)	−0.051	−5.6; 5.4	0.985	−3.468	−6.6; −0.3	0.030*	0.130	−3.8; 4.1	0.947
Step-off (mm)	−12.9	−27.9; 2.2	0.092*	−6.759	−14.6; 1.1	0.089*	1.105	−8.4; 10.6	0.816
Gap (mm)	−5.154	−9.3; −1.0	0.016*	−3.070	−5.3; −0.8	0.008*	−5.149	−7.8; −2.5	<0.001*
Radiological factors	Strength measurements
	Grip strength			Sustained grip strength			Key pinch strength
	B	95% CI	p	B	95% CI	p	B	95% CI	p
Ulnar variance (mm)	0.7	−1.0; 2.4	0.384	0.4	−0.9; 1.8	0.549	−0.1	−0.4; 0.3	0.768
Radial length (mm)	2.8	1.5; 4.1	<0.001*	2.1	1.0; 3.2	<0.001*	0.5	0.2; 0.7	<0.001*
Radial inclination (°)	0.4	−1.5; 1.3	0.361	0.3	−0.4; 1.0	0.458	0.1	−0.1; 0.2	0.266
Dorsal angulation (°)	0.2	−0.3; 0.6	0.486	0.1	−0.3; 0.5	0.767	0.0	−0.1; 0.1	0.362
SL distance (mm)	5.0	−4.1; 14.2	0.273	2.1	−5.9; 10.2	0.600	0.5	−1.1; 2.0	0.530
DRUJ distance (mm)	2.0	−2.0; 5.9	0.324	1.7	−1.4; 5.1	0.279	−0.1	−0.8; 0.6	0.783
Step-off (mm)	0.2	−9.8; 10.2	0.968	−0.5	−8.6; 7.6	0.903	−1.2	−3.1; 0.7	0.218
Gap (mm)	1.2	−1.8; 4.2	0.440	0.5	−1.9; 2.8	0.711	−0.2	−0.8; 0.4	0.563

aROM: active range of motion; B: regression coefficient; 95% CI: 95% confidence interval, p: p-value; *significant difference; SL: scapholunate ligament; DRUJ: distal radioulnar joint; mm: millimeter.

Table 8. Univariable regression analyses for radiological measurements and PROs.

	PROs
Radiological factors	DASH			PRWE									MHQ			SF 36
Subscales				Pain			Function			Total						Physical component			Mental component
	B	95% CI	p	B	95% CI	p	B	95% CI	p	B	95% CI	p	B	95% CI	p	B	95% CI	p	B	95% CI	p
Ulnar variance (mm)	0.9	−0.6; 2.3	0.238	1.1	−0.3; 2.4	0.113*	1.8	−0.1; 3.6	0.060*	2.0	−0.1; 4.1	0.068*	−0.4	−2.4; 1.7	0.741	0.3	−1.8; 2.4	0.781	1.3	−0.7; 3.3	.200*
Radial length (mm)	−0.2	−1.5; 1.1	0.760	−0.1	−1.2; 1.1	0.914	−0.8	−2.4; 0.8	0.339	−0.5	−2.3; 1.4	0.625	1.1	−0.7; 2.8	0.230	0.1	−1.7; 1.9	0.933	0.5	−1.3; 2.3	.597
Radial inclination (°)	0.2	−0.6; 1.0	0.596	−0.1	−0.8; 0.6	0.807	−0.2	−1.2; 0.7	0.624	−0.2	−1.3; 0.9	0.700	0.3	−0.7; 1.3	0.569	−0.5	−1.6; 0.5	0.327	−0.3	−1.4; 0.8	.569
Dorsal angulation (°)	0.0	−0.4; 0.4	0.943	−0.1	−0.5; 0.3	0.668	0.1	−0.4; 0.6	0.680	−0.1	−0.6; 0.6	0.927	−0.2	−0.8; 0.4	0.455	−0.1	−0.6; 0.5	0.830	0.1	−0.5; 0.7	.773
SL distance (mm)	0.9	−6.6; 8.4	0.809	2.3	−5.0; 9.7	0.528	1.8	−9.2; 12.9	0.742	3.2	−8.9; 15.4	0.594	−4.7	−15.8; 6.5	0.404	−10.1	−20.9; 0.6	0.063*	−7.2	−17.2; 2.8	.155*
DRUJ distance (mm)	−0.7	−4.2; 2.8	0.686	0.7	−2.5; 3.9	0.658	−2.4	−6.8; 2.0	0.280	−0.5	−5.6; 4.6	0.841	2.5	−2.2; 7.3	0.289	3.2	−1.6; 8.0	0.193*	2.4	−2.5; 7.2	.335
Step-off (mm)	1.1	−8.8; 11.0	0.817	0.3	−8.7; 9.2	0.956	−1.3	−14.3; 11.8	0.849	−0.2	−14.8; 14.4	0.977	−7.7	−21.6; 6.2	0.272	−5.8	−19.1; 7.5	0.383	−9.5	−22.1; 3.1	.138*
Gap (mm)	1.3	−1.6; 4.2	0.376	0.2	−2.5; 2.8	0.902	0.8	−3.1; 4.6	0.699	0.6	−3.7; 4.9	0.784	−2.0	−6.1; 2.1	0.330	−0.3	−4.2; 3.5	0.872	−0.5	−4.2; 3.1	.772

PROs: patient reported outcomes; DASH: disability of arm, shoulder, hand questionnaire; PRWE: patient rated wrist evaluation; MHQ: Michigan Hand outcomes Questionnaire: SF-36: Short Form 36; B: regression coefficient; 95% CI: 95% confidence interval; p: p-value; *p < 0.200; SL: scapholunate ligament; DRUJ: distal radioulnar Joint; mm: millimeter.

Table 9. Multivariable regression analyses of radiological measurements and CROs.

Dependent	Explanatory variables	B (SE)	p-Value	95% CI
Flexion/extension	Step-off	−36.8 (12.8)	0.006*	−62.6; −11.1
	Constant	143.3 (2.5)	<0.001*	138.3; 148.4
Ulnar/radial deviation	Step-off	−17.9 (7.0)	0.013*	−32.0; −3.9
	Constant	58.9 (1.4)	<0.001*	56.2; 61.7
Pro/supination	Constant	59.1 (1.6)	<0.001*	55.8; 62.5
Grip strength	Radial length	2.8 (.7)	<0.001*	1.5; 4.1
	Constant	7.2 (8.6)	0.403	−9.9; 24.4
Sustained grip strength	Radial length	2.1 (.6)	<0.001*	1.0; 3.2
	Constant	−2.9 (7.2)	0.681	−17.4; 11.4
Key pinch strength	Radial length	.5 (.1)	<0.001*	0.2; 0.7
	Constant	2.4 (1.6)	0.135	−0.8; 5.5

CROs: clinician reported outcome; B: regression coefficient: SE: standard error; 95% CI: 95% confidence interval; *significant difference.

Table 10. Multivariable linear regression analysis for radiological measurements and PROs.

Dependent	Explanatory variables	B (SE)	p-Value	95% CI
SF 36 physical component	SL distance	−10.1 (5.3)	0.063	−20.9; 0.6
	Constant	105.4 (11.6)	<0.001*	82.2; 128.6
SF 36 mental component	Step-off	−15.4 (5.5)	0.008*	−26.6; −4.2
	Constant	86.8 (2.0)	<0.001*	82.8; 90.7

PROs: patient reported outcomes; SF36: Short Form 36; B: regression coefficient: SE: standard error; 95% CI: 95% confidence interval; *significant difference; SL: scapholunate ligament.

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