Methods
Patient population and screening
The patient population were elderly people who had presented to our institution over a 5-year period with a wrist fracture. Eligible people were identified from an electronic orthopaedic database. Inclusion criteria were: age 65 years and over; treatment of their fracture either by closed reduction and cast immobilization or by open reduction and plate fixation. Exclusion criteria included residency in a nursing home and inability to provide informed consent (e.g. those patients with documented dementia or those with low English proficiency).
Potentially eligible participants were sent a letter informing them of the study (Additional file 1: Appendix S1) and providing them with the opportunity to opt out by contacting the research department. After 2–3 weeks, a follow-up telephone call was made to eligible participants who had not opted out. Efforts were made to contact the entire cohort. If a telephone number could not be found, then a second letter was sent to the eligible participant inviting them to contact the research institute if they were interested in participating in the study.
Those agreeing to participate provided consent and the survey was conducted over the telephone by a researcher (PS).
Outcome measures
The telephone survey (Additional file 2: Appendix S2) was made up of two parts. The first part of the survey was designed to assess patient-perceived deformity and bother. Firstly, participants were asked whether they believed that they had a deformity in the affected wrist using a simple dichotomous question; “Do you consider your wrist to be deformed or crooked?” Secondly, participants were asked about the extent to which they were bothered by the appearance of their wrist on a 5-point Likert scale (1—Not at all, 2—A little, 3—Moderately, 4—Very, 5—Extremely). The format of the bother question was based on the format of questions that make up the bother index in the short musculoskeletal function assessment (SMFA) questionnaire. The SMFA has been assessed as being a reliable and valid tool for use in musculoskeletal disease or injury [14].
The second part of the survey consisted of the Patient-Rated Wrist Evaluation (PRWE) questionnaire. The PRWE is a common and validated measure that is used to assess the pain and function of a patient following a wrist injury [15]. The PRWE is made up of two sections assessing pain and function. The sum of both the pain and function sections produces a single score out of 100 [16], with 0 representing no wrist pain and disability and 100 representing maximum wrist pain and disability. The minimum clinically important difference (MCID) for PRWE scores for wrist fracture patients has been reported as 11.5 points [17].
To assess the reliability of the deformity and the bother questions, participants were asked for their consent to be followed up 1 week after the initial phone interview to be asked the two questions again. The aim of this was to assess the test–retest reliability of these two questions. See Additional file 1: Appendix S1 for entire telephone script including the survey questions.
Statistical analysis
Results were analysed using R-statistical language [18].
Relative risk ratios (RR) and p-values were reported for perceived deformity by treatment-type and for perceived deformity vs bother.
As an indication of wrist function, PRWE scores were calculated. Medians and interquartile ranges of PRWE results were reported, according to associations with treatment-type, perceived deformity and perceived bother. Statistical significance was measured using chi squared tests and Mann–Whitney Wilcoxon tests (U). Means of functional scores were compared between groups using one-way analysis of Variance (ANOVA). Results were statistically significant when p < 0.05.
The test–retest reliability of the deformity and bother questions was analysed using Cohen’s Kappa. Kappa scores between 0.75 and 1.00 were considered to be excellent [19].
Results
Cohort ascertainment
From 1165 recorded cases of wrist fracture presenting between January 2010 and December 2014, there were 98 potentially eligible participants. 9 opted out and 89 eligible patients were contacted by telephone. From these, 41 consented to undertake the initial survey and 27 of these consented to repeating the survey 1-week later. A profile of the study participants is described in Additional file 3 and the participant flow is displayed in Fig. 1
. Participant characteristics were similar to the cohort with regard to age, treatment-type and injured side (left or right). There was a low participation rate of males compared with the cohort.
Incidence of perceived deformity and bother
Of 41 participants, 14 (34%) perceived that they had a wrist deformity and 4 (10%) reported that they were bothered by the appearance of their wrist. Three of these four perceived that they had a wrist deformity. Interestingly, one participant who did not perceive a deformity reported that he or she was bothered by the appearance of his or her wrist. Additional file 4 displays a comparison of the perception of bother (dichotomous; yes/no) with the perception of deformity (yes/no). Those who perceived that they had a deformed wrist were more likely to be bothered by the appearance of it than those who perceived no deformity (RR 5.79, p = 0.07).
Association between perceived deformity and treatment-type/function
In the non-surgical treatment group, 11 out of 20 patients (55%) perceived deformity and in the surgical treatment group, only 3 out of 21 patients (14%) believed that their wrist was deformed. Participants treated non-surgically were more likely to perceive deformity compared to those treated surgically (RR 3.85, p = 0.006).
Figure 2 and Additional file 5 display the distribution of PRWE scores according to whether deformity was perceived. Overall, functional outcomes were poorer for those who perceived deformity, but this was not statistically significant (U = 239, p = 0.15). The mean difference (MD) in PRWE scores between those who perceived deformity and those who did not perceive deformity was 10.9 which was close to the MCID of 11.5 points.
Association between bother and treatment-type/function
All participants who reported that they were bothered by wrist deformity belonged to the non-surgical treatment-type group.
Figure 3 and Additional file 6 display the distribution of PRWE scores by whether bother was reported. There were only four participants who reported that they were bothered by the appearance of their wrist and their functional outcomes were poorer than those who reported that they were not bothered, by both a statistically significant (U = 14, p = 0.006) and by a clinically important (MD = 35.2) margin.
Additional file 7 displays the degrees of bother. Additional file 8 is a scatterplot displaying the distribution of functional scores according to the extent of bother reported. The correlation between the extent of bother and functional scores was significant (r = 0.44, p = 0.004).
Reliability of deformity and bother questions
For the deformity question, all 27 patients who participated in the test–retest component provided a consistent answer on retest, indicating perfect reliability (κ = 1.00) (Additional file 9). For the bother question, 26 participants provided the same answer week-to-week and one changed their answer from a little bothered to not at all bothered. The reliability of the bother question at κ = 0.92 represented “excellent agreement”.
Discussion
The existing evidence concerning wrist deformity following treatment of wrist fractures suggests that deformity is common and that patients are not troubled or bothered by the deformity: A 2005 review of the predictors of patient satisfaction following treatment for wrist fracture concluded that satisfaction was associated with pain relief and grip strength rather than the radiographic findings [20]. A 2011 randomised controlled trial [12] comparing surgical and non-surgical treatment of wrist fractures collected deformity and bother as outcomes but the results were not presented in the report. A 2000 retrospective study on wrist fractures in older patients reported that despite obvious clinical deformity in half of their cohort (14/25), none were “dissatisfied” with the appearance of their wrist [21].
The study most comparable to the current study was a 2009 study of patients over 70 years of age who had undergone surgical or non-surgical treatment for an unstable wrist fracture. That study found that none of the surgical patients had a deformity and that 77% of non-surgical patients had a visual deformity [22]. However, the authors reported that no participant was “dissatisfied with the clinical appearance” of their wrist. In comparison, we found a lower rate of deformity (14/41) and we found that some patients with perceived deformity were bothered by it (4/41). The difference is likely explained in that our study used patient-reported deformity rather than therapist-assessed deformity.
