Distal Radius Fracture:

A Prospective Outcome Study of 275 Patients

Joy c. MacDermid, BScPT, MSc, PhD

Co-director, Clinical Research Laboratory
Hand and Upper Limb Centre
St. Joseph's Health Centre
London, Ontario, Canada

Robert S. Richards, MD
Surgeon and
Co-director, Clinical Research Laboratory
Hand and Upper Limb Centre
St. Joseph's Health Centre
London, Ontario

James H. Roth, MD
Medical Director, Surgeon, and
Co-director, Clinical Research Laboratory
Hand and Upper Limb Centre
St. Joseph's Health Centre
London, Ontario

Distal radius fractures are the most prevalent of all
fractures.' They occur in all age groups secondary to
trauma'< but have an increased incidence in post-
menopausal women because of osteoporotic changes
in the bones.3-6 Fractures of the distal radius com-
prise 74.5% of all forearm fractures? The incidence of
distal radius fractures has recently been estimated as
27 (16 males, 37 females) per 10,000 population per
year.f Estimates from other studies indicate an over-
all rate between 23 and 67 per 10,000 population.'
Data from Rochester, Minnesota, suggest that inci-
dence rates may be higher in North American com-
munities." This study, based on a 30-year population
cohort, showed that the incidence of distal radius
fractures among female residents of Rochester,
Minnesota, rose from 100 (per 100,000 person years)
among those between 35 and 44 years of age to more
than 500 for those aged 55 to 75 years. On the basis of
the Minnesota data, it has been estimated that the
Address correspondence and reprint requests to Joy C MacDerrnid,
BScPT, PhD, Co-director, Clinical Research Lab, Hand and Upper
Limb Centre, St. Joseph's Health Centre, PO Box 5777, London,
Ontario, N6A 4L6; e-mail: <jmacderm@julian.uwo.ca>.
lifetime risk of distal radius fracture for white
women at age 50 years is 15%.10,11 Among persons
under 40 years of age, men and boys are 1.4 times
more likely to have a wrist fracture than women and
girls. Thereafter, the rise in the incidence among
women is nearly linear, with women 60 to 94 years of
age being 6.2 times more likely to sustain a distal
radius fracture than men in the same age groupY
ETIOLOGY
A fracture of the distal radius typically occurs as the
result of a fall on an outstretched hand. There is gener-
ally a sharp fracture on the palmar aspect of the radial
metaphyseal area, and those that have a shear or com-
pression component produce intra-articular fractures
that are more unstable. A Colles fracture involves the
distal metaphysis of the radius, which is dorsally dis-
placed and angulated. It occurs within 2cm from the
distal end of the radius but may extend into the radio-
carpal or ulnocarpal joint. Dorsal angulation, dorsal
displacement, radial angulation, and radial shortening
are expected. There may be an accompanying fracture
of the ulnar styloid. A Smith fracture is a volar angu-

I S4 JOURNAL OF HAND THERAPY

lated fracture of the distal radius that occurs relatively
rarely. A Barton fracture is a fracture-dislocation in
which the rim of the radius is displaced with the hand
and the carpus. The association of specific persons'
names with certain types of distal radius fractures has
diminished, and the use of fractures names that are
more descriptive and/or relate to a comprehensive
classification system tend to be used. Components of
injury that are thought to be indications of severity of
anatomic disruption include involvement of the joint
surfaces, the extent of displacement of bone fragments,
and the number of fragments. H - 15
Associated soft tissues are often injured with a frac-
ture. Ligament or triangular fibrocartilage complex
(TFCC) injuries are common and can be missed dur-
ing initial treatment, as thel may not be evident on
radiographic examination. 1 It has been demonstrat-
ed that chondral lesions occur in 32% of intra-articu-
lar distal radius fractures. In these fractures, TFCC
tears occur in 78% of cases, and the scapholunate lig-
ament is at least partially torn in 54% of cases.F Soft
tissue injuries may account for impairment in the
presence of well-healed fractures.l" Although soft tis-
sue injuries have an effect on the impairment experi-
enced by a patient with a distal radius fracture, they
are not directly assessed by radiographs or account-
ed for in classification schemes.
Stability is related to the type and extent of anatom-
ic disruption. Instability has therapeutic implications,
since unstable fractures require more sophisticated
interventions to maintain anatomic position. Stable
fractures are usually extra-articular, with mild to
moderate displacement, so that when reduced they
do not redisplace to their original deformity.
Unstable fractures are more commonly comminuted
and shortened and have articular fractures that
involve not only the radiocarpal joint but also the dis-
tal radioulnar joint.
TREATMENT
Intervention following distal radius fracture is
directed at restoring anatomic alignment of fractured
bones, promoting repair of injured structures, and
fostering normal function of these structures during
the healing process.1 9-2I A number of studies have
proposed various treatment regimens for distal
radius fracture, although few randomized trials in
this area have been reported. 22- 27 Fractures require
reduction and fixation sufficient to maintain reduc-
tion.28-34 Fracture fixation can occur through brac-
ing, casting}5-4I percutaneous pinning,25,34,42--60 open
reduction and internal fixation,61-76 or external fixa-
tion 25,28,33,77-I06 or combinations of these meth-
odS.29,107,108 In external fixation, a variety of devices
are available, some providing uniplanar and some
multiplanar ligamentotaxis.r'' Bone cement109 or bone
grafting has also been used. 73,79,107,110
Radiographs and other imaging techniques are used
to assess the anatomic positioning before and after
fracture reduction. Arthroscopy can be used to visual-
ize fracture fragments during reduction to imrrove
alignment of intra-articular fractures." ,66,111
Arthroscopic guided reduction is indicated when
articular step-off greater than 2 mm remains after
attempted closed reduction or when a carpalligamen-
tous injury or distal radioulnar instability is suspected.
Arthroscopy aids in restoration of the articular surface
and also allows for removal of small loose bodies of
bony or cartilaginous material. Associated ligamen-
tous injuries that are not apparent on radiographs may
be visualized and treated arthroscopically.
Various positions and durations of immobilization
and rehabilitation procedures have been described
for distal radius fractures. 3,m Both supination and
dorsiflexion have been commonly advocated as posi-
tions of immobilization.39,113
The various modes of treatment offer different
ways of achieving anatomic reduction of fractures.
Different fracture patterns may require specific types
of fixation to maintain anatomic reduction, although
often fractures can respond to a variety of treatment
options. 8,15,30,85 The treatment plan for a patient is
individualized and based on a number of factors,
including the fracture pattern, bone quality, com-
minution, soft tissue damage, medical conditions,
patient age, mental status, and compliance. 15,85
In general, casting or immobilization tends to be
used for undisplaced or stable fractures' and K-wires
or pinning tends to be used in fractures with no more
than two fragments." whereas comminuted, severe-
ly displaced, or unstable fractures tend to be treated
with external fixation. 80,81,114
Cooney'? describes a treatment algorithm that
coincides with the universal classification system. He
suggests that undisplaced extra-articular, stable dis-
placed extra-articular, and undisplaced intra-articu-
lar fractures should be treated with cast immobiliza-
tion. Displaced unstable extra-articular fractures are
treated with percutaneous pins, whereas displaced
reduced intra-articular fractures are treated with
external fixation/ percutaneous pins. Displaced irre-
ducible intra-articular fractures should be treated
with open reduction, external fixation, and K-wires
or T-plates (or both). Complex fractures are treated
with open, arthroscopic, or closed reductions, exter-
nal fixation, bone grafting, supplemental K-wires,
and intercarpal ligament repairs. ll5 This algorithm
describes the decision-making process that surgeons
use to formulate a treatment plan.
A number of options for reduction and treatment
exist for all but the more simple fractures, which
shows that physician preferences and experience
remain an influence in treatment selection.
McMurtry and JupiterI5 emphasize that a repertoire
of treatment choices enables the orthopedic surgeon
April-June 200 I 155
to match the patient needs and fracture type to the
treatment option most likely to provide for success.
Despite improvements reported in outcome in com-
minuted fractures, there remains difficulty in con-
trolling impacted die-punch fragments and difficulty
in controlling the reduction of an unstable distal
radioulnar joint.81
Hand therapy management of distal radius frac-
tures is aimed at restoring normal mobility, strength,
and function of the injured extremity. The type and
severity of an impairment presenting to a hand ther-
apist depends on a variety of factors, including the
severity of the injury, associated injuries, patient fac-
tors, the effectiveness of treatment, and the effects of
treatment complications. The therapy management
of distal radius fractures is diverse, and clinical prac-
tice guidelines tend to cover a wide spectrum of
interventions. Furthermore, practice guidelines'I"
have not been based on systematic review of the lit-
erature and therefore cannot be considered definitive
recommendations. Thus, treatment planning is high-
ly dependent on the clinical decision making of the
hand therapist. Knowledge of expected outcomes is
essential for hand therapists to ensure that their clin-
ical decisions are well founded.
ISSUES IN RATING OUTCOME AFTER
DISTAL RADIUS FRACTURE
The World Health Organization defined terminolo-
gy and concepts around health in 1980.117 Levels of
health descriptors were described as impairment,
disability, and handicap. Impairment is any loss or
abnormality of psychological, physiologic, or
anatomic structure or function. Disability is any
restriction of the ability to perform an activity in the
manner and within the range considered normal for
a human being. Handicap is the disadvantage of a
specific person that limits or prevents fulfillment of a
role that is normal for that person and thus, by
nature, includes age, sex, social, and cultural factors.
Although previous orthopedic literature has
focused on impairment measures of outcome, a shift
in measurement of outcome has occurred to focus on
disability.U" Measures of impairment for upper
extremity orthopedics focus on either indicators of
abnormal anatomy (e.g., radiographs) or loss in
physical capacity (e.g., grip strength and range of
motion [ROM] of the wrist joints). Other impair-
ments, such as loss of sensation, decreased forearm
and pinch strength, and loss of dexterity, are known
to occur after a distal radius fracture but are infre-
quently reported.P"
Several outcome rating scales for distal radius frac-
tures focus on impairment. Gartland and Wertl ey120
published a scale that was modified by Sarmiento et
al. l2l This scale is a demerit scoring system, i.e.,
patients lose points if they have certain clinical prob-
156 JOURNAL OF HAND THERAPY
lems. The scale provides a score based on the pain
and disability recorded by the clinician, ranges of
motion, strength, complications, and radiographic
appearance. This scale has not been formally validat-
ed, but its use has been frequently reported in case
series. It has been suggested that the scale may be
"flattering," in that to have a "poor" result-i.e., a
loss of 21 points-a patient would have to complain
of pain, stiffness, and restricted activity and have a
deformed wrist, loss of dorsiflexion and supination,
and severe osteoarthritic changes in the joint. A study
that used a modified scale incorporating direct meas-
urement of motion and strength concluded found
that only 56% of patients had good to excellent
results, compared with 81% when evaluated by the
Gertland and Werley system.P'
A radiographic outcome scale was proposed by
Lidstrom in 1959.135 This scale addresses dorsal
angulation and shortening and has four levels.
Although useful for describing the anatomic results,
radiographic appearance cannot be considered to
represent functional performance.l ?
Patient-rated outcome is an important aspect of
clinical evaluation. The development of instruments
to measure upper extremity disability (e.g., the
Disabilities of the Arm, Shoulder and Hand [DASH]
questionnaire)123,124 or wrist pain and disability (e.g.,
the Patient-rated Wrist Evaluation [PRWE])125,126 has
allowed hand therapists to capture this important
information in standardized manners.
Another approach to outcome evaluation is to use
generic health status instruments-e.g., the Short
Form 36 (SF_36)127,128_as outcome tools. The advan-
tage of generic tools is that they address a variety of
health domains and allow comparison across a variety
of health problems, including mental and physical dis-
orders. The concern in hand therapy is that these tools
may not be sensitive to upper extremity pathology.F"
There are a variety of outcomes after injury and
treatment. The definition of outcome varies accord-
ing to the problem, the purpose of an evaluation, and
the perspective from which the evaluation is per-
formed. Distal radius fractures cause immediate pain
and loss of function. Problem pain, motion loss, and
weakness may result from malalignment, soft tissue
injuries, and complications.
Many reports of outcome after distal radius frac-
ture are plagued by a variety of problems related to
conceptualization of outcome, experimental design,
and lack of precision in measurement of outcome. To
date, measurement of outcome has focused on meas-
ures of impairment, such as radiographic position,
grip strength, and ROM. Evidence of patient-rated
outcomes is lacking in particular. Despite these limi-
tations, it is known that distal radius fracture can
cause significant disability in the performance of
activities of daily living, occupation, or leisure.
Outcome after distal radius fracture can range from a
complete return to normal function to severe long
term impairments. 103,129
Fracture reduction and fixation are the immediate
goals of intervention in all fractures. Selection and
application of appropriate treatment are essential to
attaining the best possible outcome. Treatment selec-
tion is not fully defined for distal radius fractures. Few
randomized trials exist, and case series are the pri-
mary source of evidence in this area. Case series show
that even with similar fractures and treatment regi-
mens, outcomes can vary widely. A variety of non-
treatment factors may affect outcome. Some of these
factors may be present at basellne,130 and others mar
be complications that develop during treatment. 131,13
Although certain baseline characteristics have been
previously reported as predictors of outcome,133 these
factors have most often been studied through univari-
ate analysis of retrospective studies. Several authors
have supported the viewpoint that restoration of artic-
ular congruency is an important contributor to the
long-term clinical and radiographic results after distal
radius fracture.133 However, controversy exists as to
whether anatomy is an important indicator. A
prospective three-year follow-up study of 90 consecu-
tive distal radius fractures looked at Pearson correla-
tions between a variety of variables, including grip,
radiographic parameters, and ROM. Shortening of the
radius at one week was the most significant correlate
of grip strength. Shorteninl?: also influenced range of
wrist flexion and rotation. 33 This finding was sUE-
ported by others in retrospective reviews. 134- 37
However, some authors note that even patients with
arthrosis experienced good or excellent functional
results after distal radius fracture.138
A preponderance of studies suggest that anatomic
factors play a role in outcome. Radial shorteninffi
appears to be the most predictive of these.P
However, numeric measurements of radiographic
parameters are infrequently reported in the medical
record 139 and are rarely accessible to the average
hand therapist who is treating patients clinically.
Furthermore, studies to date have focused primarily
on measured impairments rather than on pain, dis-
ability, and handicap. In addition, a number of
anatomic studies determine the relationship between
final anatomic position and outcome. Therapists may
be interested in predicting outcome from baseline
(initial assessment) information to assist in planning
treatment, communicating with payers, guiding
patient decisions, and informing employers.
McMurtry and Jupiter15 suggest that treatment and
outcome are multifactorial, and considerations
include fracture type, comminution, bone quality,
energy of injury, displacement, and patient consider-
ations. Patient considerations specifically mentioned
include substance abuse, age, hand dominance, occu-
pation, and lifestyle. Few studies have addressed
patient factors as predictors of outcome.
STUDY PURPOSES
A comprehensive measurement of outcome
includes measures of impairment, disability, and
handicap. The development of instruments that are
valid and reliable for measurement of outcome in
patients with distal radius fractures has permitted
therapists to collect information on pain, disability,
and handicap in a standardized manner. If compara-
tive data were available, therapists could compare
findings from their patients with these data.
The primary purpose of this study was to provide
descriptive data on scores for grip strength, ROM,
pain and disability, upper extremity disability, and
general health during the first year after distal radius
fracture, and stratify the data according to age, sex,
and compensation status. Pain and disability were
assessed by use of the PRWE questionnaire, upper
extremity disability by the DASH, and general health
by SF-36.
A second purpose was to describe the course of
recovery from distal radius fracture over the year.
A third purpose of this study was to determine
whether knowledge of the baseline score for an out-
come measure and basic information about the patient
and the fracture (e.g., age, sex, compensation status,
AO fracture type, dominant-hand injury, energy of
injury) can be used to predict one-year outcome.
METHODS
Testing Schedule
Patients completed standardized testing during
their first (baseline) visit to the hand center as well as
2, 3, 6, and 12 months after their fracture. When a
fracture occurs, patients typically attend their nearest
emergency department, where they receive primary
management. This may include reduction, casting,
and radiography. They are then referred to hand clin-
ic for definitive management. More distant commu-
nity hospitals tend to manage uncomplicated, ade-
quately reduced fractures and refer only more com-
plicated cases or those that lose reduction.
Thus, the initial, or baseline, hand clinic visit nor-
mally occurs within the first week after primary care
at the emergency department. During this visit, the
questionnaires (PRWE, DASH, and SF-36) were com-
pleted by the patients and demographic data were
obtained. Inclusion in this study was not dependent
on referral for hand therapy, which varies according
to surgeon with respect to timing and indications.
Recruitment
Patients with distal radius fractures attending the
Hand and Upper Limb Centre for primary care were
identified by clinic lists and attending physicians. All
April-June 200 I 157
 TABLE 1. Patient Characteristics (n=250)
Percentage Percentage
Type of fracture": Post menopausal (women): 67
A (extra-articular) 17
Smoker?
B (partial articular) 24
Yes 20
C (complete articular) 59
Quit 30
Sex: No 50
Male 34 Alcohol consumption:
Female 66
Never 16
Dominance: Occasionally 56
Right 92 More than 7 drinks/week 28
Left 8 Education:
Injured hand: Did not complete high school 24
Right 50 Completed high school 28
Left 50 Some post-secondary 16
Finished post-secondary 32
Dominant hand injured?
Yes 51 Occupation:
No 49 Retired 23
Homemaker 14
Mechanism of injury:
Clerical 10
Fall on ice or snow 17
Laborer 13
Other fall 75
Professional 14
Other 8
Service 9
Energy of injury:
Occupational demands on hand use:
Fall from level (low) 61
Low 41
Fall from height or with speed (medium) 31
Moderate 29
High-force trauma 8
High 30
Other pathology in injured armt:
Had therapy?
Yes 22
Yes 83
No 78
No 17
Pathology in uninjured armt:
Therapy was helpful?
Yes 24
Extremely 50
No 26 Quite a bit 27
Other medical problems: Moderately 15
None 62 Slightly 5
Heart 3 Not at all 2
Arthritis 7
Satisfaction with care:
Diabetes 1
Extremely 72
Other 24
Quite a bit 26
History of falling? Moderately 2
Yes 9 Slightly 1
No 91 Not at all 1

*AO type not recorded for 133 fractures.

t Data missing for 93 fractures.
:j:Data missing for 94 fractures.

identified patients were enrolled in the outcome eval- Questionnaires .

uation process, unless they were unable to partici-
pate because of incompetence. A total of 250 patients
were tested (Table 1).
Patients who failed or were unable to comply with
their scheduled medical appointments were contact-
ed by phone to determine whether they could
reschedule their appointments. Two patients com-
pleted the PRWE but not the other questionnaires for
their one-year follow-up. Where items were missing
from a questionnaire, the mean score for that visit
was substituted.
All patients completed the PRWE,125,140
DASH,l2"3,124,141 and SF_36127,128 at baseline and again
2, 3, 6 and 12 months after fracture. A research assis-
tant administered the questionnaires verbally to
patients who were unable to read or write. When
patients were unable to understand English, the
questionnaires were translated and administered
verbally with the assistance of a bilingual family
member or friend. The questionnaires were scored
according to the authors' instructions.

158 JOURNAL OF HAND THERAPY

Range of Motion
Patients were tested for the ROM/ grip at the visit
following hardware or cast removal, usually at the 2-
month visit.
Range-of-motion measures were performed on the
NK computerized hand evaluation system (NK
Biotechnical Corporation, Minneapolis, Minnesota).
Wrist extension/flexion was measured with a proto-
col known to provide reliable results for dorsal place-
ment of the goniometer. 142 Radial and ulnar devia-
tion was performed accordin~ to an established pro-
tocol. 143 One axis was aligned with the third
metacarpal and the other along the radius. The axis
of the goniometer was aligned over the center of the
wrist joint in neutral.
Range of motion in pronation/supination was per-
formed as described in our previous reliability
study.l44 From this study we were able to determine
that reliable results were possible for pronation/
supination measures with both inexperienced and
experienced testers as long as a standard measure-
ment protocol was used. Pronation/supination was
performed by aligning the arm of the goniometer
with the superior side of the arm along specific
anatomic landmarks. These landmarks were the
proximal wrist crease for supination and just distal to
the ulnar head in pronation. The other goniometer
arm was aligned with the vertical plane. All ROM
measurements were performed on the NK computer-
ized goniometer operated by a foot switch.
Grip Strength
Grip strength testing was performed with the NK
DIGIT -Grip device, according to the standard proto-
col described by the American Society for Hand
Therapists. 145 Previous authors have described reli-
able grip strength scores in patients with cumulative
trauma disorders146 and in subjects without patholo-
gy147 using this protocol. We also have obtained high
reliability coefficients using this test protocol and
device on subjects without pathology.l"
Data Analysis
Descriptive statistics were calculated for the
PRWE, DASH, SF-36, and the physical performance
scores (grip, ROM, and strength). Data for these out-
come variables were stratified according to patients'
ages, sex, and compensation status. Compensation
was defined as "yes" if patients had a legal case or
worker's compensation case attributed to their wrist
fracture. Previous research has shown this to be the
single most significant predictor, from a wide range
of baseline factors, for six-month outcomes.P"
Forward step-wise multiple regression was used to
determine prediction equations for each of the ques-
tionnaires. Independent variables included age, sex,
AO fracture type, energy of impact (mild, moderate,
or severe), dominant injury (yes or no), compensa-
tion for injury, and the baseline questionnaire score.
Separate analyses were performed for the PRWE,
DASH, and Physical Component Summary Scale of
the SF-36.
All analyses were performed in SPSS version 10.0
(SPSS Inc., Chicago, Illinois)Yo
RESULTS
This study provided comparative data for grip,
ROM, and strength and for PRWE, DASH, and SF-36
results. One-year outcomes are shown in Table 2 and
Figures 1 through 6-specifically, scores for the
PRWE, DASH, and physical function subscale of the
SF-36 (Figure 1); scores for ROM and grip strength
(Figures 2 through 5); and summary scores for the SF-
36 physical and mental components (Figure 6). The
wrist outcome questionnaire is shown in its entirety
in Figure 7.
The patient data shown in Table 1 describe the type
of patients with wrist fractures who are seen at our
center. The high prevalence of articular fractures
reflects the nature of referrals to specialized hand
centers. The majority of patients incurred a fracture
through a fall from level ground. The majority of
women were post-menopausal. Most patients had
therapy and found it helpful.
The PRWE scores showed the most change over
one year, being 75 at baseline and decreasing to 15 at
one year. The DASH showed more change than the
physical function subscale of the SF-36 (Figure 1).
Flexion and extension improved at each evaluation
over the year, and their improvements paralleled
each other (Figure 2). Supination was more impaired
than pronation, and both rotations improved over
the course of the year (Figure 3). Wrist deviations
improved at each evaluation over the year, and the
improvements occurred in parallel.
Grip strength of the affected hand was markedly
impaired at the 8-week point and improved at each
evaluation, but never equaled that of the unaffected
side (Figure 5). Distal radius fracture had minimal
effect on the mental component of the general health
and quality of life evaluation, the SF-36. However, a
marked impact on the physical component of the SF-
36 was observed (Figure 6).
Data on patients of both sexes in four age groups,
expressed separately for compensated and non-com-
pensated patients, are shown in Table 2. Age and sex
did not contribute to differences in PRWE, DASH, or
ROM scores. Therefore, the most stable comparative
data for these measures are in the "All" category (the
last two columns of the table). In this category, data
Text continues on p. 165
April-June 200 I 159
0-
TABLE 2. Mean Outcome (and SO) for the PRWE, DASH, SF-36, and Physical Measures, for 250 Sequential Wrist Fractures
Cl
18-35 years 36-50 years 51-65 years >65 years
(5 All
C Male Female Male Female Male Female Male Female
;lC --
Z se No se se No se se No se se No se se NoSe se No se se No se se Nose se Nose
:>
r (5) (28) (2) (22) (5) (21) (3) (42) (2) (19) (6) (45) (0) (4) (2) (44) (25) (225)
0
"'TI PRWE:
I
:>
Z Pain 11 9 23 8 17 13 12 7 24 11 30 7 - 2 23 7 21 8
0 (6) (10) (5) (6) (18) (13) (8) (8) (8) (13) (8) (2) (27) (11) (14) (9)
-l
I
m
Specific activities 3 3 8 5 14 8 9 3 16 10 33 7 - 4 19 7 17 6
> (4) (7) (5) (9) (20) (12) (11) (5) (9) (17) (10) (5) (26) (11) (18) (10)
~
Usual activities 3 3 7 4 8 5 5 2 14 5 15 3 - 1 5 9 9 3
(2) (6) (6) (6) (9) (8) (6) (3) (6) (10) (6) (2) (6) (14) (8) (6)

Total PRWE score 14 11.5 30 13 27 19 18 9 39 19 54 12 - 5 34 13 34 13

(9) (15) (10) (12) (31) (20) (16) (11) (15) (12) (4) (5) (43) (19) (26) (16)

DASH~ 10 7 18 7 27 13 13 9 21 14 45 11 - 4 M 16 23 11
(7) (9) (10) (8) (28) (17) (13) (11) (12) (7) (13) (2) (16) (18) (13)

SF-36:

Physical function: 93 96 85 94 85 82 90 91 80 86 53 80 - 88 M 69 80 83
(16) (8) (7) (9) (21) (22) (14) (16) (17) (29) (26) (20) (25) (21) (22)

Physical role: 92 79 63 84 50 71 100 84 0 68 0 82 - 100 M 61 54 75

(14) (38) (17) (32) (71) (41) (35) (41) (34) (0) (46) (47) (39)

Bodily pain 77 78 52 80 70 68 71 80 41 64 38 77 95 M 67 59 74
(61 (23) (15) (16) (44) (24) (42) (24) (22) (15) (21) (9) (29) (25) (24)

General health 86 87 43 88 90 66 91 83 67 71 61 78 85 M 73 74 77
(15) (12) (2) (8) (10) (17) (13) (14) (25) (22) (17) (3) (22) (21) (18)

Vitality 87 64 43 80 75 60 83 65 65 65 48 70 82 M 66 67 66
(15) (22) (4) (16) (18) (18) (4) (20) (23) (7) (16) (7) (18) (20) (18)

Social function 96 89 38 97 75 81 88 89 88 82 79 90 100 M 81 78 87

(7) (12) (18) (8) . (35) (24) (18) (22) (24) (7) (17) (0) (24) (23) (20)

Role-emotional 100 93 33 100 100 80 100 90 0 84 22 94 - 100 M 75 64 87

(0) (19) (47) (0) (0) (33) (0) (26) (35) (39) (21) (0) (37) (46) (29)
 Mental health 95 81 58 80 86 73 88 75 96 74 72 86 - 88 M 77 81 78
(5) (11) (3) (8) (8) (21) (6) (9) (21) (7) (2) (7) (6) (6) (6)

SF-36 (cont):

Physical component 52 53 46 53 46 47 52 53 38 47 33 49 - 54 M 44 45 49
summary (4) (7) (3) (7) (7) (8) (9) (8) (9) (2) (11) (4) (2) (11) (0)

Mental component 61 53 33 55 57 50 58 57 51 51 47 55 - 58 M 53 52 53
summary (2) (6) (l) (3) (2) (9) (l) (1) (2) (2) (6) (3) (11) (11) (9)

Grip (kg):
Affected side 41 43 32 25 38 37 24 24 21 32 12 20 - 24 M 17 N/A N/A
(7) (2) (5) (8) (9) (5) (5) (0) (6) (5) (5) (4)

Unaffected side 50 49 32 28 59 43 25 28 31 42 19 23 - 28 M 19 N/A N/A

(8) (0) (5) (21) (0) (4) (5) (6) (6) (95) (l) (4)

ROM (0), affected side:

Flexion 64 63 58 57 42 51 62 58 43 44 36 51 - 58 M 52 50 53
(8) (14) (10) (22) (22) (l) (0) (4) (9) (4) (7) (13) (7) (5)

Extension 61 65 68 60 47 56 59 60 50 48 3 62 - 58 M 59 55 59
(4) (7) (4) (3) (0) (0) (12) (3) (11) (8) (2) (0) (2)

Pronation 82 78 76 78 77 77 85 83 81 77 76 80 - 74 M 79 79 79
(3) (1) (0) (9) (9) 0) (4) (0) (5) (9) (0) (9) (6) (9)

Supination 73 79 85 67 59 74 79 72 59 64 59 73 - 76 M 76 67 73
(11) (8) (7) (6) (7) (6) (9) (20) (5) (1) (7) (10) (13) (2)

Radial deviation 17 19 13 18 14 15 24 18 21 17 12 17 - 16 M 20 16 18
(8) (6) (4) (6) (5) (l) (6) (5) (3) (6) (1) (6) (6) (6)

» Ulnar deviation 31 29 28 27 20 25 22 29 22 21 20 25 - 25 M 23 24 25
"'C
:::l. (2) (9) (7) (4) (8) (4) (6) (7) (8) (7) (7) (7) (6) (7)
J:c:
:J NOTE: Data are subgrouped by age, sex, and secondary compensation (SC) subgroups. The SC subgroup included only those patients who had a legal or worker's compensation case related to the
l!)
wrist fracture; other patients are considered noncompensated (No SC) patients. Test scores and SDs are not shown if a subgroup was too small for SDs to be calculated.
t-.l
0 A blank H indicates missing data for the few patients (i.e., older compensated women) who did not complete the DASH or SF-36. Since age and sex did not affect PRWE, DASH, or ROM scores,
0
the most stable estimates of these parameters are the group results. The data for compensated and noncompensated patients are separated because of the strong effect compensation seems to have
on outcome. Scores on the physical health subscales of the SF-36 also tend to be age dependent; therefore, age-matched data comparisons are advisable.
0- Grip results for male and female subjects are not pooled because they are sex dependent, and comparisons should be made with the age- and sex-specific results; in other words, grouped data
for these results are not applicable (N / A).
 Score
90
82
79 80
SF-36 PF
75 75

70 FIGURE 1. Scores (N = 250) for

the Patient-rated Wrist Evaluation
(PRWE), the Disabilities of the
Arm, Shoulder and Hand ques-
tionnaire (DASH), and the
50 Physical Function subscale of the
SF-36 (SF-36 PF) at baseline, 8
weeks, 3 months, 6 months, and 1
year after distal radius fracture.
30 Average scores are notedabove the
lines.
15

10
Baseline 8 weeks 3 months 6 months One year
Time

Score
70

____________________________________________________________ 59_
60 57

53
FIGURE 2. Scores (N = 250) for
50 flexion and extension active range
of motion at baseline, 8 weeks, 3
Extension 45 months,6 months,and 1 yearafter
distal radius fracture. Average
40 scores are notedabove the lines.
Flexion 36

30
Baseline 8 weeks 3 months 6 months One year
Time

Score
90

80 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -18- - - - - - - - - - - - .7_9_
76
73
Pronation 70
72
FIGURE 3. Scores (N = 250) for
70 pronation and supination active
range of motion at baseline, 8
weeks,3 months, 6 months, and 1
60 - - - -Supination 58 - - - year after distal radius fracture.
Averagescores are notedabove the
lines.
50 ----- --------- ---- -- ---- - - - -- - -- -- - -- -- - - - -- -- - - -- -- - -- -- -- ---

40
Baseline 8 weeks 3 months 6 months One year
Time

162 JOURNAL OF HAND THERAPY

 Score
30
25
25 23
22
- - - - - - - - - - - - - - - - - - - - - - - - -1-8-
20
17
FIGURE 4. Scores (N = 250) for
ulnar and radial active range of 15
motion at baseline, 8 weeks, 3 Radial 11
months, 6 months,and 1 yearafter 10
distal radius fracture. Average
scores are notedabove the lines.
5

o
Baseline 8 weeks 3 months 6 months One year
Time

Score
35
Unaffected 30 30
30 - - - - - - - - - - - - - - 28 - - - - - - - - - - - - - -29- - - - - - - - - - -

25
25 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -23- - - - - - - - - - - --

FIGURE 5. Scores (N = 250) for 20

grip strength of the unaffected and
affected handsat baseline, 8 weeks, 15
3 months, 6 months, and 1 year
after distal radius fracture. 10 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
Average scores are notedabove the
lines.
5

o
Baseline 8 weeks 3 months 6 months One Year

Score
60

55
Mess 52 52
53

46_--------,
51
50
FIGURE 6. Scores (N=250) for 50 48 48
the SF-36 physical (PCSS) and
mental (MCSS) component sum- 45
maries at baseline, 8 weeks, 3
months, 6 months,and 1 yearafter
distal radius fracture. Average 40
scores arenotedabove the lines.
35

30
Baseline 8 weeks 3 months 6 months One year
Time

April-June 200 I 163

 Name _ Date _

PATIENT RATED WRIST EVALUATION

The questions below will help us understand the amount of difficulty you have had with your wrist in the past week. You will be
describing your average wrist symptoms over the past week on a scale from 0 to 10. Please provide an answer for ALL questions.
If you did not perform an activity, please ESTIMATE the pain or difficulty you would expect. If you have never performed the activ-
ity, you may leave it blank.

1. PAIN
Rate the average amount of pain in your wrist over the past week by circling the number that best describes your pain on a scale from
o to 10. A zero (0) means that you did not have any pain, and a ten (10) means that you had the worst pain you have ever experienced
or that you could not do the activity because of pain.

Sample scale: o1 2 3 4 5 6 7 8 9 10
No Pain Worst Ever

RATE YOUR PAIN:

At rest o1 2 3 4 5 6 7 8 9 10
When doing a task with a repeated wrist movement o1 2 3 4 5 6 7 8 9 10
When lifting a heavy object o1 2 3 4 5 6 7 8 9 10
When it is at its worst o1 2 3 4 5 6 7 8 9 10

How often do you have pain? o1 2 3 4 5 6 7 8 9 10

Never Always

2. FUNCTION

A. Specific Activities
Rate the amount of difficulty you experienced performing each of the items listed below, over the past week, by circling the num-
ber that best describes your difficulty on a scale of 0 to 10. A zero (0) means you did not experience any difficulty, and a ten (10)
means it was so difficult you were unable to do it at all.
Sample scale o1 2 3 4 5 6 7 8 9 10
No Difficulty Unable to Do

Turn a door knob using my affected hand o 1 2 3 4 5 6 7 8 9 10

Cut meat using a knife in my affected hand o 1 2 3 4 5 6 7 8 9 10

Fasten buttons on my shirt o 1 2 3 4 5 6 7 8 9 10

Use my affected hand to push up fro a chair o 1 2 3 4 5 6 7 8 9 10

Carry a 10-lb object in my affected hand o 1 2 3 4 5 6 7 8 9 10

Use bathroom tissue with my affected hand o 1 2 3 4 5 6 7 8 9 10

B. Usual Activities
Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past
week, by circling the number that best describes your difficulty on a scale of 0 to 10. By "usual activities" we mean the activities that
you performed before you started having a problem with your wrist. A zero (0) means you did not experience any difficulty, and a
ten (10) means it was so difficult you were unable to do any of your usual activities.

1. Personal care activities (dressing, washing) o1 2 3 4 5 6 7 8 9 10

2. Household work (cleaning, maintenance) o1 2 3 4 5 6 7 8 9 10
3. Work (your job or everyday work) o 2 3 4 5 6 7 8 9 10
4. Recreational activities o1 2 3 4 5 6 7 8 9 10

Comment / interpretations:

164 JOURNAL OF HAND THERAPY

 TABLE 3. Baseline Prediction of One-year Outcome: Multiple Step-wise Regression Results of Prediction Models
Outcome Prediction Equation R2 Accuracy
SF-36 PCSS 1 year PCSS = baseline PCSS (0.4) - (0.2) age + 42 0.27 Low

DASH 1 year DASH =baseline DASH (0.4) - 9 0.21 Low

PRWE 1 year PRWE = baseline PRWE (0.4) - 16 + 18 (if secondary compensation present) 0.22 Low
NOTES: ~F-36 PCSS.indic~t~s S.F-36 physical component summary score; DASH, Disabilities of the Arm, Shoulder and Hand' PRWE atient-
~te~~nst eval~ahon. R mdlca~es the p~rcent~ge of variance in the one-year outcome that can be predicted on the basis'of the ~:uation
ana es entere were the baseline questionnaire score, age, sex, and secondary compensation. .

Text continued from p. 159 cli~ical practice with an awareness of how typical
patients respond during this time provides therapists
are subdivided only into compensated and non-com-
with a more detailed and standardized means of
pensated groups.
assessing their patients.
Strength is known to be significantly affected by
In addition to determining how an individual
sex and, to a lesser extent, by age. Therefore, clinical
patient changes over time, it is now possible to com-
data for strength scores should be compared with
pare a patient's scores with average outcome scores
appropriate age- and sex-matched data. Similarly,
at different times. This study provides mean scores
this study and others have demonstrated that scores
and SDs for patients with wrist fractures. It would be
on the physical health subscale of the SF-36 are influ-
expected that 95% of the time, the average score for a
enced by age. Age-stratified SF-36 scores in this
patient would fall within the mean plus or minus the
cohort are appropriate for comparison with data
standard deviation times 2. This allows a score for a
obtained at other hand centers in patients with distal
specific pat~ent to be compared with a group average.
radius fractures.
On the baSIS of these data, the therapist can deter-
mine whether a patient's progress is following the
DISCUSSION
anticipated "pattern," or "slope," of recovery.
The one-year data were stratified according to a
This study provided data on a large cohort of dis-
number of potential predictors. Not all factors that
tal radius fracture patients, which may be useful to
affect outcome were considered. Thus, patients with
therapists who want to compare their outcomes with
a number of factors expected to adversely affect out-
results from other hand centers. An outcome study
come should be expected to fall below the group
can generally be conducted retrospectively, as a case
average when the group is based on age, sex, and
series, or prospectively, as a cohort study.
compensation stratifications. To predict outcomes,
Measurement of impairment, disability, and handi-
multivariate regression equations would be needed
cap in a prospective cohort provides data obtained in
to account for the relatively substantial number of
a standardized way, which are therefore more mean-
factors that could affect outcome. These data are use-
ingful than data from a case series, in which follow-
ful to "place" a patient's status, based on the score on
up time~ and patients available for study can vary.
a given questionnaire, against what is "average."
The SIze of an outcome study is also relevant to
Data in this study and our previous research sug-
ho~ valid the data are for comparative purposes.
gest that compensation is a powerful determinant of
This large cohort provides relatively stable estimates
PRWE scores. I30 For this reason we have presented
of patient outcomes, compared with smaller studies.
data for compensated and noncompensated patients
Finally, the validity of the data depends on the valid-
s~para~ely. The prediction equations (Table 3) quan-
ity of the measurements themselves, and only vali-
tify this effect mathematically, in that 18 (pain and
dated outcome measures were used in this study.
disability) points are added to the one-year PRWE
Data from patient questionnaires can be obtained
score if injury compensation is involved. This effect
from baseline to 8 weeks when impairments are not
wa~ n?t significant for the DASH or SF-36 , although
measurable. This allows a therapist to appreciate the
a similar trend for poorer scores in compensated
effects of interventions during this critical period of
patients was observed.
time. Incorporating one or more questionnaires into
The reasons for the more dramatic effect on the
PRWE is unclear. The effect was observed on all three
subscales of the PRWE, so it was not related to pain
FIGURE 7. The Patient-rated Wrist Evaluation. The scale con- perception alone. Because the PRWE clearly focuses
sists ~f three subscales. Pain is rated as 50% (summation of five on the wrist, it is possible that the effects of compen-
questions, each rated a to 10). Function is rated as 50% (sum-
matio~s of 10 questions rated a to 10, divided by 2). The total
sation for wrist injury are more distinct on this scale.
sco:e IS expressed as points out of 100, with a higher score indi- This would also explain why the observed effect was
eating morepainand disability. relatively larger for the DASH than for the SF-36.

April-June 200 I 165

 Figure 1 shows that the PRWE scores changed
more dramatically than the DASH scores, while both
changed more dramatically than the scores for the
physical function subscale of the SF-36. This is con-
sistent with the relative responsiveness of these three
instruments in a cohort of 59 patients. 126
Almost every outcome showed improvement at
each successive evaluation. The rate of improvement
leveled off to a small increment between 6 and 12
months. Nevertheless, it is impossible to state that
these one-year outcomes represent the final out-
comes, since some improvement may have occurred
over the next year. We are now investigating this by
conducting two-year follow-ups. We expect difficul-
ty in retaining patient interest for these two-year fol-
low-ups; we also expect that improvement, if it
exists, will be small, based on the small changes
observed between 6 and 12 months. However, it is
important to establish whether improvement does
continue from 12 to 24 months or if this is true for
only a specific subgroup of patients.
The prediction equations derived in this cohort
show that any definitive prediction of outcome, at
least on the on the basis of a manageable number of
readily available predictors, is problematic. Baseline
scores for each of the questionnaires were the most
influential predictors of one-year outcomes on those
same questionnaires. Interestingly, the coefficient
was the same for all three equations. The other vari-
ables entered did not for the most part contribute
additional information, with the exception of age for
the PCSS and compensation for the PRWE.
Only 21% to 27% of the variations in final scores
could be explained by these prediction models. It is
likely that complex models-including baseline
patient and injury factors, treatment variables, compli-
cations and, perhaps, environmental and occupational
variables-would be needed to raise predictive ability
to a high level. This type of modeling is beyond the
realm of the clinician; therefore, ongoing re-evaluation
and experience remain a therapist's best guide to pre-
dicting outcome for any specific patient.
This study provides comparative data that will also
be useful for clinical research. Clinical investigators
who want to report the outcome of treatment for case
series or outcome studies could use these data for sta-
tistical comparisons. Future data stratified by other
predictors and case series on specific types of frac-
tures will make it possible to compare our outcomes
with an average and also describe whether an out-
come is typical for specific subgroups of patients.
Therapists are encouraged to use standardized
questionnaires to assess patient-rated outcome and
determine both how their patient's scores change
from baseline to discharge and how those scores
compare with the average score for patients with a
similar injury. Since baseline patient scores are the
most influential predictors of final status, the final
166 JOURNAL OF HAND THERAPY
scores of patients who score poorly at baseline might
also be expected to be poor. Some patients may con-
tinue to improve up to a year after fracture, and pos-
sibly beyond. Others may plateau earlier, indicating
that either a final status has been achieved or that
interventions are no longer effective.
When therapists incorporate these questionnaires
into their routine clinical practice--growing accus-
tomed to interpreting both changes in scores over time
and making comparisons with the average for specific
patients-the usefulness of these standardized meas-
ures of patient ratings of outcome is enhanced. For
patient-rating questionnaires, as for other elements of
clinical examination, appropriate instruments and
comparative data are imperative, and skill at interpre-
tation and synthesis of the information obtained from
them improves with experience.
REFERENCES
1. Larsen CF, Lauritsen J. Epidemiology of acute wrist trauma.
Int J Epidemiol. 1993;22:9114,.
2. Lawson GM, Hajducka C, McQueen MM. Sports fractures of
the distal radius: epidemiology and outcome. Injury.
1995;26:33-6.
3. Dias H, Wray CC, Jones JM, Gregg PI. The value of early
mobilization in the treatment of Colles' fractures. J Bone Joint
Surg.1987;69B:463-7.
4. Lauritzen JB, Schwarz P, Lund B, McNair P, Transbol 1.
Changing incidence and residual lifetime risk of common
osteoporosis-related fractures. Osteoporos Int. 1993;3:127-32.
5. Lauritzen JB, Schwarz P, McNair P, Lund B, Transbol 1.
Radial and humeral fractures as predictors of subsequent hip,
radial or humeral fractures in women, and their seasonal
variation. Osteoporos Int. 1993;3:133-7.
6. Mallmin H, Ljunghall S. Distal radius fracture is an early sign
of general osteoporosis: bone mass measurements in a popu-
lation-based study. Osteoporos Int. 1994;4:357-61.
7. Alffram PA, Goran CHB. Epidemiology of fractures of the
forearm. J Bone Joint Surg. 1962;44A:I05-14.
8. Doczi J, Renner A. Epidemiology of distal radius fractures in
Budapest: a retrospective study of 2,241 cases in 1989. Acta
Orthop Scand. 1994;65:432-3.
9. Owen RA, Melton LJ, Johnson KA, Ilstrup DM, Riggs BL.
Incidence of Colles fracture in a North American community.
Am J Public Health. 1982;72:607.
10. Cummings SR, Kelsey JL, Nevitt Me, O'Dowd KJ.
Epidemiology of osteoporosis and osteoporotic fractures.
Epidemiol Rev. 1985;7:178-208.
11. Peltier LF. Fractures of the distal end of the radius: an histor-
ical account. Clin Orthop. 1984;187:18-22.
12. Singer BR, Mclauchlan GJ, Robinson CM, Christie J.
Epidemiology of fractures in 15000 adults. J Bone Joint Surg.
1998;80B:243-8.
13. Jupiter JB. Current concepts review: fractures of the distal
end of the radius. J Bone Joint Surg. 1991;73A:461-9.
14. Graham TJ. Surgical correction of malunited fractures of the
distal radius. J Am Acad Orthop Surg. 1997;5:270-81.
15. McMurtry RY, Jupiter JB. Fractures of the distal radius. In:
Browner BD, Jupiter JB, Levine AM, Trafton PG. Skeletal
Trauma. Philadelphia, Pa.: Saunders, 1996:1063-93.
16. Fischer M, Denzler C, Sennwald G. [Carpal ligament lesions
associated with fresh distal radius fractures: arthroscopic
study of 54 cases]. Swiss Surg. 1996;2:269-72. German.
17. Richards RS, Bennett JD, Roth JH, Milne KJ. Arthroscopic
diagnosis of intra-articular soft tissue injuries associated with
 distal radial fractures. J Hand Surg. 1997;22A:772--6.
18. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal
radius farctures of the radius in young adults: a descriptive
arthroscopic study in 50 patients. J Hand Surg.
1997;22B:638-43.
19. Ark ], Jupiter JB.The rationale for precise management of dis-
tal radius fractures. Orthop Clin North Am. 1993;24:205-10.
20. Collins De. Management and rehabilitation of distal radius
fractures. Orthop Clin North Am. 1993;24:365-78.
21. Jupiter JB. Fractures of the distal radius. Surg Annu. 1992;24
(part 1):143--60.
22. Axelrod TS. A prospective randomized trial of external fixa-
tion and plaster cast immobilization in the treatment of distal
radius fractures. J Orthop Trauma. 1991;5:114-5.
23. Cohen MS, Frillman T. Distal radius fractures: a prospective
randomized comparison of fibreglass tape with QuickCast.
Injury. 1997;28:305-9.
24. Home G. A prospective randomized trial of external fixation
and plaster cast immobilization in the treatment of distal
radius fracture. J Orthop Trauma. 1991;5:246.
25. Hutchinson DT, Strenz GO, Cautilli RA. Pins and plaster vs
external fixation in the treatment of unstable distal radial
fractures. A randomized prospective study. J Hand Surg.
1995;20B:365-72.
26. Roumen RM, Hesp WL, Bruggink ED. Unstable Colles' frac-
tures in elderly patients: a randomised trial of external fixa-
tion for redisplacement. J Bone Joint Surg. 1991;73B:307-11.
27. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic
external fixation of unstable fractures of the distal part of the
radius: a prospective, randomized comparison with static
external fixation. J Bone Joint Surg. 1994;76A:1149--61.
28. Agee JM. Distal radius fractures: multiplanar ligamentotaxis.
Hand Clin. 1993;9:577-85.
29. Bass RL, Blair WF, Hubbard PP. Results of combined internal
and external fixation for the treatment of severe A0-C3 frac-
tures of the distal radius. J Hand Surg. 1995;20A:373-81.
30. Cooney WP. Fractures of the distal radius: a modern treat-
ment-based classification. Orthop Clin North Am.
1993;24:211--6.
31. Ledingham WM, Wytch R, Goring CC, Mathieson AB,
Wardlaw D. On immediate functional bracing of Colles' frac-
ture. Injury. 1991;22:197-201.
32. Mennen U, Labuschagne FJ. An alternative method of treat-
ing comminuted intra-articular fractures of the distal radius.
S Afr J Surg. 1993;31:81-4.
33. Raskin KB, Melone CPJ. Unstable articular fractures of the
distal radius: comparative techniques of ligamentotaxis.
Orthop Clin North Am. 1993;24:275-86.
34. Rayhack JM. The history and evolution of percutaneous pin-
ning of displaced distal radius fractures. Orthop Clin North
Am. 1993;24:287-300.
35. Altissimi M, Mancini GB, Ciaffoloni E, Pucci G. Comminuted
articular fractures of the distal radius: results of conservative
treatment. Ital J Orthop Traumatol. 1991;17:117-23.
36. Altissimi M, Antenucci R, Fiacca C. Mancini GB. Long-term
results of conservative treatment of fractures of the distal
radius. Clin Orthop. 1986;206:202-10.
37. Chester MH. Segmental manifestation of reflex sympathetic
dystrophy syndrome limited to one finger. Anesthesiology.
1990;73:558--61.
38. Pool e. Colles fracture: a prospective study of treatment. J
Bone Joint Surg. 1973;55B:540.
39. Sarmiento A, Zagorski JB, Sinclair WF. Functional bracing of
Colles' fractures: a prospective study of immobilzation in
supination vs pronation. Clin Orthop. 1980;146:175-83.
40. Stewart HD, Innes AR, Burke FD. Functional cast-bracing for
Colles' fractures: a comparison between cast-bracing and
conventional plaster casts. J Bone Joint Surg. 1984;66B:749-53.
41. Tang JB, Shi D, Gu YQ, and Zhang QG. Can cast immobiliza-
tion successfully treat scapholunate dissociation associated
with distal radius fractures? J Hand Surgery. 1996;21A:583-90.
42. Bennett GL, Leeson MC, Smith BS.Intramedullary fixation of
unstable distal radius fractures: a method of fixation allowing
early motion. Orthop Rev. 1989;18:210--6.
43. Carrozzella J, Stem PJ. Treatment of comminuted distal
radius fractures with pins and plaster. Hand Clin.
1988;4:391-7.
44. Casteleyn PP, Handelberg F, Haentjens P. Biodegradable
rods versus Kirschner wire fixation of wrist fractures: a ran-
domized trial. J Bone Joint Surg. 1992;74B:858--61.
45. Chapman DR, Bennett JB, Bryan WJ, Tullos HS.
Complications of distal radius fractures: pins and plaster
treatment. J Hand Surg. 1982;7:509-12.
46. Clancey GJ. Percutaneous Kirschner-wire fixation of Colles'
fractures. J Bone Joint Surg. 1984;66A:1008-14.
47. Cole JM, Obletz BE. Comminuted fractures of the distal end
of the radius treated by skeletal fixation in plaster cast: an
end-result study of thirty -three cases. J Bone Joint Surg.
1966;48A:931-45.
48. De Palma AF. Comminuted fractures of the distal end of the
radius treated by ulnar pinning. J Bone Joint Surg.
1952;34A:651--62.
49. Greatting MD, Bishop AT. Intrafocal (Kapandji) pinning of
unstable fractures of the distal radius. Orthop Clin North
Am. 1993;24:301-7.
50. Green DP. Pins and plaster treatment of comminuted frac-
tures of the distal end of the radius. J Bone Joint Surg.
1975;57A:304-10.
51. Habernek H, Weinstabl R, Fialka C. Schmid L. Unstable dis-
tal radius fractures treated by modified Kirschner wire pin-
ning: anatomic considerations, technique, and results. J
Trauma. 1994;36:83-8.
52. Harper Me. A modified pins-and-plaster technique incorpo-
rating early motion for fractures of the distal radius. J Orthop
Trauma. 1989;3:300-5.
53. Hochwald NL, Levine R, Tornetta P. The risks of Kirschner
wire placement in the distal radius: a comparison of tech-
niques. J Hand Surg. 1997;22A:580-4.
54. Jensen CH, Jensen CM. Biodegradable pins versus Kirschner
wires in hand surgery. J Hand Surg. 1996;21B:507-10.
55. Lenoble E, Dumontier C. Goutallier D, Apoil A. Fracture of
the distal radius: a prospective comparison between trans-sty-
loid and Kapandji fixations. J Bone Joint Surg. 1995;77B:562-7.
56. Lucas GL, Sachtjen KM. An analysis of hand function in
patients with Colles fractures treated by rush rod fixation.
Clin Orthop. 1981;155:172-9.
57. Milliez PY, Dallaserra M, Defives T, el Ayoubi L, Thomine
JM. Effectof early mobilization following Kapandji's method
of intrafocal wiring in fractures of the distal end of the radius:
results of a prospective study of 60 cases. Int Orthop.
1992;16:39-43.
58. Naidu SH, Capo JT, Moulton M, Ciccone W, Radin A.
Percutaneous pinning of distal radius fractures: a biome-
chanical study. J Hand Surg. 1997;22A:252-7.
59. Parry BR. Colles' fracture: efficacy of pins and plaster. Am J
Orthop. 1997;26:45- 50.
60. Scheck M. Long-term follow-up of treatment of cominuted
fractures of the distal end of the radius by transfixation with
Kirshner wires and cast. J Bone Joint Surg. 1962;44A:337-51.
61. Agee JM, Szabo RM, Chidgey LK, King FC, Kerfoot e.
Treatment of comminuted distal radius fractures: an
approach based on pathomechanics. Orthopedics.
1994;17:1115-22.
62. Axelrod T, Paley D, Green J, McMurtry RY. Limited open
reduction of the lunate facet in comminuted intraarticular
fractures of the distal radius. J Hand Surg. 1988;13A:372-7.
63. Axelrod TS, McMurty RY. Open reduction and internal fixa-
tion of comminuted, intra-articular fractures of the distal
radius. J Hand Surg. 1990;15A:1-11.
64. Bradway JK, Amadio Pc. Cooney WP. Open reduction and
April-June 2001 167
 internal fixation of displaced, comminuted intra-articular
fractures of the distal end of the radius. J Bone Joint Surg.
1989;71A:839--47.
65. Culp RW, Osterman AL. Arthroscopic reduction and internal
fixation of distal radius fractures. Orthop Clin North Am.
1995;26:739--48.
66. Geissler WB. Arthroscopically assisted reduction of intra-
articular fractures of the distal radius. Hand Clin.
1995;11:19-29.
67. Geissler WB, Fernandez DL. Percutaneous and limited open
reduction of the articular surface of the distal radius. J Orthop
Trauma. 1991;5:255--64.
68. Gesensway D, Putnam MD, Mente PL, Lewis JL. Design and
biomechanics of a plate for the distal radius. J Hand Surg.
1995;20A:1021-7.
69. Hastings H, Leibovic SJ. Indications and techniques of open
reduction: internal fixation of distal radius fractures. Orthop
Clin North Am. 1993;24:309-26.
70. Hove LM, Nilsen PT, Fumes 0, Oulie HE, Solheim E, Molster
AO. Open reduction and internal fixation of displaced
intraarticular fractures of the distal radius: 31 patients fol-
lowed for 3-7 years. Acta Orthop Scand. 1997;68:59~3.
71. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D.
Operative treatment of volar intra-articular fractures of the
distal end of the radius. J Bone Joint Surg. 1996;78:1817-28.
72. Leung KS, Tsang HK, Chiu KH. An effective treatment of
cominuted fractures of the distal radius. J Hand Surg.
1990;15A:11-7.
73. McBirnie J, Court Brown CM, McQueen MM. Early open
reduction and bone grafting for unstable fractures of the dis-
tal radius. J Bone Joint Surg. 1995;77:571-5.
74. Melone CPo Open treatment for displaced articular fractures
of the distal radius. Clin Orthop. 1986;202:103-11.
75. Rader CP, Rauber C, Rehm KE, Koebke J. Internal fixation of
the distal radius: a comparative, experimental study. Arch
Orthop Trauma Surg. 1995;114:340-3.
76. Rikli DA, Regazzoni P. Fractures of the distal end of the
radius treated by internal fixation and early function: a pre-
liminary report of 20 cases. J Bone Joint Surg. 1996;78:588-92.
77. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal
radius: a cadaveric study to determine if ligamentotaxis
restores radiopalmar tilt. J Hand Surg. 1990;15:18-21.
78. Braun RM, Gellman H. Dorsal pin placement and external
fixation for correction of dorsal tilt in fractures of the distal
radius. J Hand Surg. 1994;19:653-5.
79. Cannegieter DM, Juttmann JW. Cancellous grafting and
external fixation for unstable Colles' fractures. J Bone Joint
Surg. 1997;79B:428-32.
80. Clyburn TA. Dynamic external fixation for comminuted
intraarticular fractures of the distal end of the radius. J Bone
Joint Surg. 1987;69A:248-54.
81. Cooney WP, Linscheid RL, Dobyns JH. External pin fixation
for unstable Colles' fractures. J Bone Joint Surg.
1979;61A:84Q-5.
82. Fernandez DL, Flury Me. History, evolution and biomechan-
ics of external fixation of the wrist joint. Injury.
1994;25:SD2~.
83. Frykman GK, Peckham RH, Willard K, Saha S. External fixa-
tors for treatment of unstable wrist fractures: a biomechani-
cal, design feature, and cost comparison. Hand Clin.
1993;9:555~5.
84. Goslings [C, Tepic S, Broekhuizen AH, Jakob RP, Perren SM.
Three-dimensional dynamic AO external fixation of distal
radial fractures: a preliminary report. Injury. 1994;25(suppl
4):SD85-9.
85. Graff S, Jupiter J. Fracture of the distal radius: classification of
treatment and indications for external fixation. Injury.
1994;25(suppI4):SD14-25.
86. Horesh Z, Volpin G, Hoerer D, Stein H. The surgical treat-
ment of severe comminuted intraarticular fractures of the dis-
168 JOURNAL OF HAND THERAPY
tal radius with the small AO external fixation device: a
prospective three-and-one-half-year follow-up study. Clin
Orthop.1991;(263):147-53.
87. Hove LM, Fumes 0, Nilsen PT, Oulie HE, Solheim E, Molster
AO. Closed reduction and external fixation of unstable frac-
tures of the distal radius. Scand J Plast Reconstr Hand Surg.
1997;31:159--64.
88. Huch K, Hunerbein M, Meeder PJ. External fixation of intra-
articular fracture of the distal radius in young and old adults.
Arch Orthop Trauma Surg. 1996;115:38--42.
89. Jakim I, Pieterse HS, Sweet MB. External fixation for intra-
articular fractures of the distal radius. J Bone Joint Surg.
1991;73:302~.
90. Jakob RP. Development of the small AO fixator to the current
set. Injury. 1994;25(suppI4):SD26-7.
91. Jenkins NH, Jones DG, Mintowt Czyz WJ. External fixation
and recovery of function following fractures of the distal
radius in young adults. Injury. 1988;19:235-8.
92. Lennox JD, Page BJ2,Mandell RM. Use of the Clyburn exter-
nal fixator in fractures of the distal radius. J Trauma.
1989;29:326-31.
93. Melik N, Togninalli D, Biegger P. Retrospective analysis of
consecutively treated distal radius fractures with the external
fixator. Unfallchirurg. 1994;97:645-8.
94. Nakata RY, Chand Y, Matiko JD. External fixators for wrist
fractures: a biomechanical and clinical study. J Hand Surg.
1985;lOA:845-51.
95. Patterson RM, Nicodemus CL, Viegas SF, Elder KW,
Rosenblatt J. Normal wrist kinematics and the analysis of the
effect of various dynamic external fixators for treatment of
distal radius fractures. Hand Clin. 1997;13:129--41.
96. Pennig DW. Dynamic external fixation of distal radius frac-
tures. Hand Clin. 1993;9:587~02.
97. Schuind F, Donkerwolcke M, Rasquin C, Burny F. External
fixation of fractures of the distal radius: a study of 225 cases.
J Hand Surg. 1989;14A:404-7.
98. Seitz WHJ. External fixation of distal radius fractures.
Indications and technical principles. Orthop Clin North Am.
1993;24:255--64.
99. Seitz WH Jr, Froimson AI, Leb RB. Reduction of treatment-
related complications in the external fixation of complex dis-
tal radius fractures. Orthop Rev. 1991;20:169-77.
100. Seitz WH [r, Froimson AI, Brooks DB, et al. Biomechanical
analysis of pin placement and pin size for external fixation of
distal radius fractures. Clin Orthop. 1990;(251):207-12.
101. Seitz WR, Putnam MD, and Dick HM. Limited open surgical
approach for external fixation of distal radius fractures. J
Hand Surg. 1990;15A:288-93.
102. Simpson NS, Wilkinson R, Barbenel Jc, Kinninmonth AW.
External fixation of the distal radius: a biomechanical study.
J Hand Surg. 1994;19B:188-92.
103. Steffen T, Eugster T, Jakob RP. Twelve years' follow-up of
fractures of the distal radius treated with the AO external fix-
ator. Injury. 1994;25(suppI4):SD44-54.
104. Vandersluis R, Richards RS, Roth JH. Use of the external fix-
ation apparatus for percutaneous insertion of pins in the dis-
tal one-third of the radius: an anatomic study. Can J Surg.
1993;36:517-9.
105. Verhaven E, Haentjens P, Casteleyn PP, De Boeck H,
Opdecam P. Nonunion of a comminuted intra-articular wrist
fracture after external fixation: a case report and review of the
literature. Arch Orthop Trauma Surg. 1991;110:118-20.
106. Zanotti RM, Louis DS. Intra-articular fractures of the distal
end of the radius treated with an adjustable fixator system. J
Hand Surg. 1997;22:428--40.
107. Leung KS, Shen WY, Leung rc. Kinninmonth AW, Chang rc.
Chan GP. Ligamentotaxis and bone grafting for comminuted
fractures of the distal radius. J Bone Joint Surg.
1989;71:838--42.
108. Putnam MD, Fischer MD. Treatment of unstable distal radius
 fractures: methods and comparison of external distraction
and ORIF versus external distraction-ORIF neutralization. J
Hand Surg. 1997;22:238-51.
109. Schmalholz A. Bone cement for redislocated Colles' fracture:
a prospective comparison with closed treatment. Acta
Orthop Scand. 1989;60:212-7.
110. [ebson PI, Blair WF. A surgical protocol for combined inter-
nal and external fixation of complex intraarticular distal
radius fractures using dorsal and volar approaches. Iowa
Orthop J. 1996;16:35-8.
111. Whipple TL. The role of arthroscopy in the treatment of intra-
articular wrist fractures. Hand Clin. 1995;11:13-8.
112. Christensen OM, Christiansen TG, Krasheninnikoff M,
Hansen FF. Length of immobilisation after fractures of the
distal radius. Int Orthop. 1995;19:26-9.
113. Gupta A. The treatment of Colles' fracture: immobilisation
with the wrist dorsiflexed. J Bone Joint Surg. 1991;73:312-5.
114. Howard PW, Stewart HD, Hind RE, Burke PD. External fixa-
tion or plaster for severely displaced comminuted Colles'
fractures? A prospective study of anatomical and functional
results. J Bone Joint Surg. 1989;71:68-73.
115. Cooney WP, Berger RA. Treatment of complex fractures of
the distal radius: combined use of internal and external fixa-
tion and arthroscopic reduction. Hand Clin. 1993;9:603--12.
116. Schunk C, Reed K. Wrist/Hand. In: Schunk C, Reed K.
Clinical Practice Guidelines: Examination and Intervention
for Rehabilitation. Gaithersburg, Md.: Aspen Publishers,
2000:335-80.
117. World Health Organization. International Classification of
Impairments, Disabilities and Handicaps: A Manual of
Classification Relating to the Consequences of Disease.
Geneva, Switzerland: WHO, 1995.
118. Jette AM. Outcomes research: shifting the dominant research
paradigm in physical therapy. Phys Ther. 1995;75:965-70.
119. Amadio PC, Silverstein MD, Ilstrup DM, Schleck CD, Jensen
LM. Outcome after Colles fracture: the relative responsive-
ness of three questionnaires and physical examination meas-
ures. J Hand Surg. 1996;21B:781-7.
120. Gartland JJ, Werley CWo Evaluation of healed Colles' frac-
tures. J Bone Joint Surg. 1951;33A:895-907.
121. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles' frac-
tures: functional bracing in supination. J Bone Joint Surg.
1973;57A:311-7.
122. Bain GI, Roth JH, Pugh D, MacDermid JC Matched hemire-
section interposition arthroplasty of the distal radioulnar
joint. J Hand Surg. 1995;20A:944-50.
123. Upper Extremity Collaborative Group. Measuring disability
and symptoms of the upper limb: a validation study of the
DASH questionnaire. Arthritis Rheum. 1996;39:5112.
124. Upper Extremity Collaborative Group. The DASH Outcome
Measure: User's Manual. Toronto, Ontario, Canada: Institute
for Work & Health, 1999.
125. MacDermid JC Development of a scale for patient rating of
wrist pain and disability. J Hand Ther. 1996;9:178-83.
126. MacDermid Je. Donner A. Richards RS, Bellamy N, Roth JH.
Responsiveness of the SF-36, DASH, patient-rated wrist eval-
uation and physical impairments in evaluating recovery after
a distal radius fracture. J Hand Surg. 2000;25A:330-40.
127. Ware JE, Snow KS, Kosinski M, Gandek B. SF-36 Health
Survey Manual and Interpretation Guide. Boston, Mass.: The
Health Institute, New England Medical Center, 1993.
128. Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental
Health Summary Scales: A User's Manual. 3rd ed. Boston,
Mass.: The Health Institute, New England Medical Center, 1994.
129. Field I, Warwick D, Bannister GC, Gibson AG. Long-term
prognosis of displaced Colles' fracture: a 10-year prospective
review. Injury. 1992;23:529-32.
130. MacDermid JC, Donner A. Richards RS, Bellamy N, Roth JH.
Baseline predictors of pain and disability six-months after a distal
radius fracture. In: MacDermid JC Baseline Predictors of Pain
and Disability Six Months Following Distal Radius Fracture.
London, Ontario: University of Western Ontario, 1999:222-52.
131. Altissimi M, Mancini GB, Azzara A, Ciaffoloni E. Early and
late displacement of fractures of the distal radius: the predic-
tion of instability. Int Orthop. 1994;18:61-5.
132. Kwasny 0, Fuchs M, Schabus R. Opening wedge osteotomy
for malunion of the distal radius with neuropathy: 13 cases fol-
lowed for 6 (1-11) years. Acta Orthop Scand. 1994;65:207-8.
133. Villar RN, Marsh D, Rushton N, Greatorex RA. Three years
after Colles' fracture: a prospective review. J Bone Joint Surg.
1987;69B:635-8.
134. Eelma I, McElfresh EC Colles fractures in young adults.
Minn Med. 1983;66(8):487-90.
135. Lidstrom A. Fractures of the distal end of the radius: a clini-
cal and statistical study of end results. Acta Orthop Scand.
1959;(supp141):1-118.
136. Older TM, Stabler EV, Cassebaum WHo Colles fracture: eval-
uation and selection of therapy. J Trauma. 1965;5:469-76.
137. van der Linden W, Ericson R. Colles fracture: how should its
displacement be measured and how should it be immobi-
lized? J Bone Joint Surg. 1981;63A:1285-8.
138. Catalano LW, Cole RI, Gelberman RH. Displaced intra-artic-
ular fractures of the distal aspect of the radius: long-term
results in young adults after open reduction and internal fix-
ation. J Bone Joint Surg. 1997;79A:1290-302.
139. MacDermid Je. Richards RS, Donner A, Bellamy N,
Hildebrand KA. Reliability of hand fellows measurements
and classifications from radiographs of distal radius frac-
tures. Can J Plast Surg. 2001; in press.
140. MacDermid rc. Turgeon T, Richards RS, Beadle M, Roth JH.
Patient rating of wrist pain and disability: a reliable and valid
measurement tool. J Orthop Trauma. 1998;12:577-86.
141. Beaton DE, Katz IN, Fossel AH, Wright JG, Tarasuk V,
Bombardier C Measuring the whole or parts? Validity, reliabil-
ity and responsiveness of the DASH outcome measure in differ-
ent regions of the upper extremity. J Hand Ther. 2000;14:128-46.
142. LaStayo Pe. Wheeler DL. Reliability of passive wrist flexion
and extension goniometric measurements: a multicenter
study. Phys Ther. 1994;74:162-74.
143. Norkin e. White DJ. Measurement of Joint Motion: A Guide
to Goniometry. Philadelphia, Pa.: Davis, 1995.
144. Armstrong AD, MacDermid [C, Chinchalkar S, Stevens RS,
King GJ. Reliability of range-of-motion measurement in the
elbow and forearm. J Shoulder Elbow Surg. 1998;7:573--80.
145. Fess EE.Grip strength. In: Casanova JS (ed). Clinical Assessment
Recommendations. 2nd ed. Chicago, Ill.: ASHT, 1992:41--b.
146. MacDermid JC, Kramer JF, Woodbury MG, McFarlane RM,
Roth JH. Interrater reliability of pinch and grip strength
measurements in patients with cumulative trauma disorders.
J Hand Ther. 1994;7:10-4.
147. Mathiowetz V, Weber K. Volland G, Kashman N. Reliability
and validity of grip and pinch strength evaluations. J Hand
Surg.1984;9A:222-6.
148. MacDermid JC, Alyafi T, Richards RS. Test-retest reliability
of static and endurance grip strength tests performed on the
Jamar and NK. Physiother Can. 2001;53:48-54.
April-June 200I 169