Introduction: Distal radius fractures (DRF’s) are one of the most common types of fractures,especially in elderly women. In the last decade, there has been a shift in the treatment methodemployed for DRF’s from the traditional non-operative to an operative method using plates andscrews even though there is no evidence to suggest that this method has superior outcomes. Aim: The primary objective of this study was to identify risk factors for complications and reoperationsin the treatment of DRF’s. Method: The study was designed as a retrospective cohort study. Patients treated for DRF’sbetween 2016-2017 were included through the Swedish Fracture Register and complementedwith the patients’ charts and classification of X-Ray Images from The Orthopedic Clinic at TheCentral Hospital in Karlstad. The risk for re-operation was valued through treatment methodsand fracture classification and presented as Odds Ratio. Result: Positive ulnar variance was correlated to having an increased risk for re-operation, OR4.8 (95% CI 1.7-13.8). Those who had volar comminution in their fracture had a greater risk forre-operation, OR 12.4 (95% CI 4.6-34.1, p<0.001), but also a greater risk for correctiveosteotomy, OR 12.6 (95% CI 1.4-113.9, p=0.024). Conclusion: Volar comminution and positive ulnar variance are associated with an increasedrisk for re-operation. However, the degree of the risk is difficult to measure due to the lowincidence of re-operations.

In Sweden approximately 25000 distal radius fractures occur annually, which is 37 % of all fractures related to osteoporosis. In this thesis, risk factors for osteoporosis, bone mineral density (BMD) and health-related quality of life (the SF-36) were compared in patients who suffered a distal radius fracture after low energy trauma with a control group matched on the basis of age, gender, and municipality of residence. The aim was also to analyse, among these patients, whether a risk factor questionnaire, tests on dynamic and static balance and a one-leg rise test could identify those, who have osteopenia or osteoporosis, and run a risk of new falls. Moreover, in a three-year follow-up, mortality, the need for in- and outpatient care, and health-related quality of life after radius fracture were investigated and compared between the patients and matched controls. Finally, the effect of a preventive intervention program including patient education and self-training was evaluated. Falls were reported in a risk factor questionnaire and in a fall diary. The patients aged 45-64 years showed lower, although not statistically significant, BMD, compared with the controls of the same age, but there was no difference concerning their history of falls. In contrast, the patients aged 64 years or older had a history of falling more often than the corresponding controls, but no difference in BMD was found. For all other risk factors, except falls, no differences were found between the patients and the controls. The results of the one-leg rise test were associated with those of dynamic and static balance, but none of the functional tests were associated with the number of falls. Decreased height and cigarette smoking were the only risk factors, which predicted osteopenia and osteoporosis. Five patients, although none of the controls, died during the study time. The patients needed statistically significantly more episodes as inpatients than the controls. The patients also had lower SF-36, Role Physical scores, than the controls at three months. This difference disappeared by the time of the follow-up. Both the patients, who participated in a four-week intervention program, “the osteoporosis school” followed by a one-year home-based exercise program, and the controls showed statistically significantly improved dynamic and static balance, ability to walk backwards and to stand on one leg with eyes open and closed at the end of the study. However, no significant differences were found between the patients and the controls in any of the tests, in BMD or in the number of the falls. The thesis shows that, except for the falls in patients aged over 64 years, there were no significant differences between patients and controls with respect to BMD and other risk factors related to osteoporosis. Consequently, in patients aged 45-64 years and older, the underlying cause of a distal radius fracture is more related to falls than to osteoporosis. Furthermore, the thesis shows that the functional tests and the risk factor questionnaire seem to be of limited value for identifying 8 people with a radius fracture, who are at risk of falling or have osteopenia or osteoporosis. If, in spite of this, functional tests on musculoskeletal function are considered for testing of functional ability in patients with a recent radius fracture, the one leg-rise test may be sufficient. There seems to be an increased mortality and morbidity necessitating inpatient care among patients with a recent radius fracture. The osteoporosis school had no significant effect on BMD, balance, muscle strength or falls in this thesis. Therefore, the lack of proven efficacy of the osteoporosis school for the secondary prevention of distal radius fractures highlights the need for more and long-term randomised controlled follow-up studies in this specific population.

Adherence is considered a prerequisite for the success of exercise programs for musculoskeletal disorders. The negative effects of non-adherence to exercise recommendations impact the cost of care, and also treatment effectiveness, treatment duration, the therapeutic relationship, waiting times, the efficiency of personnel and use of equipment. Adherence to therapeutic exercise intervention is a multifaceted problem. The World Health Organization (WHO) established the multidimensional adherence model (MAM). The MAM describes five interactive dimensions (socioeconomic, healthcare team and system, condition-related, therapy-related, and patient-related factors) that have an effect on patient adherence. The first purpose of this dissertation was to explore the MAM dimension of condition-related factors to determine the Quick Disabilities of the Arm Shoulder and Hand (QDASH) minimal clinical important difference (MCID) for three distal upper extremity conditions. The second purpose was to explore the MAM dimension of personal factors to learn from individuals who expressed incongruence between their QDASH and GROC scores; how they described their perceived change in therapy. The third purpose was to explore the MAM dimension of therapy-related factors to examine the effect of patient-therapist collaborative goal setting on patient adherence to treatment and QDASH outcomes. Results demonstrated in the first study that diagnosis specific MCID’s differed from the global MCID using multiple diagnoses. In the second study results demonstrated that patients expect to have a dedicated therapist who they can trust to work collaboratively with them to establish goals and spend time with them to achieve these goals. In the third study, our first hypothesis was not supported for all three measures of adherence. The median for home exercise program diary adherence was found to trend towards significance by 8.7 percent favoring the experimental group Mann-Whitney U (p < .100). Our second hypothesis was not supported. The experimental group receiving collaborative goal setting intervention had similar QDASH mean change scores 45.9±27.6 compared to the control group 46.1±23.8, Mann-Whitney U (p < .859).

A alta frequência das fraturas da extremidade distal do rádio estimula o contínuo estudo e desenvolvimento dos métodos de tratamento, buscando melhor qualidade de vida com menos sequelas e limitações. A placa volar bloqueada tem se tornado o método de escolha no tratamento nos últimos anos. Menos morbidade e a reabilitação mais precoce têm aumentado muito a utilização dessas placas. Esse método, contudo, não é isento de complicações. As mais frequentes estão relacionadas aos tendões extensores. Tendinites e rupturas têm sido relatadas. Com o objetivo de se proteger os tendões extensores, estudos têm sugerido a utilização de parafusos unicorticais na parte distal da placa e recomendam que os mesmos tenham pelo menos 75% do comprimento do parafuso bicortical. Esses estudos são restritos a fraturas extra-articulares. Esta pesquisa objetivou estudar e comparar as propriedades mecânicas dos modelos fixados com placas volares utilizando parafusos unicorticais e bicorticais em fraturas intra-articulares da extremidade distal do rádio classificadas como AO 23C3 sob cargas fisiológicas e a possibilidade de recomendar o parafuso unicortical na prática clínica. Objetivou também comparar, pelo método dos elementos finitos, as tensões geradas nos modelos após diferentes carregamentos com validações realizadas com os resultados dos ensaios mecânicos. Foram avaliados 42 modelos divididos em seis grupos de sete modelos, três com parafusos unicorticais e três com parafusos bicorticais. Cada grupo foi submetido a um único tipo de ensaio: compressão axial, flexão dorsal e flexão volar. Foram feitos dois ensaios estáticos intercalados por um carregamento cíclico e por último um ensaio até a falência. Os resultados demonstraram similaridade entre os respectivos grupos e confirmaram nossas hipóteses de que: a) o comportamento mecânico do modelo utilizando parafusos unicorticais é equivalente ao modelo usando parafusos bicorticais; b) o carregamento cíclico afeta o comportamento mecânico dos modelos das fixações das placas volares bloqueadas na extremidade distal do rádio. A análise por elementos finitos mostrou que as fixações unicortical e bicortical não resultaram em qualquer região de concentração de tensão crítica, sendo as duas indicadas para a estabilização de fraturas do rádio. / The high frequency of distal radius fractures stimulates the continuous study and development of treatment methods seeking a better quality of life and fewer sequels and limitations. The volar locking plate has become the chosen method for the treatment in recent years. The lower morbidity and earlier rehabilitation have greatly increased the use of these plates. This method, however, is not free from complications, the most common being related to extensor tendons. Tendinitis and rupture have been reported. In order to protect the extensor tendons, studies have suggested the use of unicortical screws in the distal part of the plate, and recommended that they be at least 75% of the length of the bicortical screw. These studies are restricted to extra articular fractures. This study aimed at studying and comparing the mechanical properties of the models fixed with volar plates using unicortical and bicortical screws in intra-articular fractures of the distal radius classified as AO 23C3 under physiological loads and the possibility of recommending the unicortical screw in clinical practice. The tensions generated in the models after different loads with validations performed with the results of the mechanical tests were also compared. We studied 42 models divided into six groups of seven models, three with unicortical screws and three with bicortical screws. Each group underwent a single type of test: axial compression, dorsiflexion and volar flexion. Two static tests were performed, intercalated by a cyclic loading, and finally a test until bankruptcy. Our results demonstrated a similarity between the respective groups and confirmed both our hypotheses that: a) the mechanical behavior of the model using unicortical screws is equivalent to the model using bicortical screws, and b) that the cyclic loading affects the mechanical behavior of the models of the fixations of the volar locked plates in the distal radius. The finite element analysis showed that the unicortical and bicortical fixations did not result in any regions of critical stress concentration, so they are both indicated for the stabilization of radius fractures.

Abstract Distal radius fractures (DRFs) are the most commonly encountered fall-related fracture in clinical practice. Recognised as a typical fragility fractures, the ageing of the population may increase the occurrence of DRFs in the near future. The aims of this thesis were (I) to describe the epidemiology of DRFs in a cohort of adult patients in the city of Oulu during the year 2008 and to study changes in the incidence of DRFs during the last decades in Finland and other northern countries and the relationship between slippery conditions during the winter and the incidence of DRFs, (II) to compare the results of primary nonoperative treatment and early palmar plating of primarily dislocated DRFs in 80 patients &#8805; 50 years old in an randomised controlled study and (III) to investigate the rate and risk factors for plate-related complications after palmar plate fixation of 881 DRFs. The crude incidence rate of DRFs was 258/100 000 person-years in Oulu in 2008, and the age-specific incidence rate in the female population aged &#8805; 70 years was increased compared to previous studies in Finland and in Norway. A clear seasonal variation was observed in fall-related DRFs. The number of DRFs was 2.5 times higher on slippery winter days compared to non-winter days. Early palmar plating of DRFs showed favourable DASH (disabilities of the arm, shoulder and hand) scores at two years compared to primary nonoperative treatment. Delayed surgery in the primary nonoperative treatment group did not provide comparable DASH scores to early plating. The overall complication rate in the cohort of 881 plate-fixated DRFs was 15%. These could be regarded as plate-related in 7% of cases. Operations performed by low-volume surgeons and patient ages &#60; 40 years were independent predictors of plate-related complications. In conclusion, the incidence of DRFs has increased during the last decades in Finland in elderly females, and slippery winter conditions increase the risk of DRFs. Early palmar plating of DRFs produces more consistent results compared to primary nonoperative treatment in patients &#8805; 50 years old. The complication rate after palmar plating of DRFs is significantly influenced by surgeon experience and patient age. / Tiivistelmä Värttinäluun alaosan murtuma (rannemurtuma) on yleisin kaatumistapaturman aiheuttama luunmurtuma, jonka taustalla on monesti ikääntymisestä johtuva luun hauraus. Väestön edelleen ikääntyessä rannemurtumien ilmaantuvuus todennäköisesti lisääntyy. Tämän väitöskirjan tavoitteina oli (1) kuvata rannemurtumien epidemiologiaa ja ilmaantuvuuden muutosta Suomessa ja muissa Pohjoismaissa viimeisten vuosikymmenien aikana, sekä tutkia liukkaiden talvikelien yhteyttä rannemurtumien ilmaantuvuuteen. Lisäksi tavoitteena oli (2) verrata kahden eri hoitokäytännön — varhaisen levykiinnityksen ja ensisijaisen konservatiivisen hoidon — kliinisiä tuloksia ≥ 50-vuotiailla rannemurtumapotilailla. Lopuksi tavoitteena oli (3) selvittää rannemurtuman levytykseen liittyvien komplikaatioiden yleisyys sekä riskitekijät. Rannemurtumien ilmaantuvuus oli oululaisessa aikuisväestössä 258/100 000 henkilövuotta vuonna 2008. Ikä-spesifinen ilmaantuvuus lisääntyi aiempaan suomalaistutkimukseen verrattuna etenkin &#62; 70 vuotiailla naispotilailla ja sama suuntaus todettiin myös aiemmassa norjalaistutkimuksessa. Rannemurtumien ilmaantuvuudessa todettiin selkeä vuodenaikavaihtelu, ja liukkaalla talvikelillä rannemurtuman riski oli 2.5-kertainen verrattuna ei-talvikelin murtumariskiin. Varhaisella rannemurtuman levykiinnityksellä saavutettiin paremmat DASH (Disabilities of the Arm, Shoulder, and Hand) – pisteet kahden vuoden seurannassa verrattuna ensisijaiseen konservatiiviseen hoitoon. Murtuman asennon heikentyessä seurannassa ei myöhäisleikkauksella saavutettu kliinistä hyötyä ensisijaisessa konservatiivisen hoidon ryhmässä. Komplikaatioprosentti 881 levykiinnityksellä hoidetun rannemurtumapotilaan aineistossa oli 15 %. Levytyskomplikaatioita todettiin 7 %:lla potilaista. Itsenäisiä levytyskomplikaatioille altistavia riskitekijöitä olivat kirurgin vähäinen leikkauskokemus ja potilaan matala ikä (&#60; 40 vuotta). Yhteenvetona voidaan todeta, että rannemurtumien ilmaantuvuus on lisääntynyt Suomessa iäkkäillä naispotilailla viimeisten vuosikymmenten aikana ja liukkaudella on selkeä yhteys rannemurtumien ilmaantuvuuteen. Varhaisella leikkaushoidolla saavutetaan yhtenäisemmät hoitotulokset verrattuna ensisijaiseen konservatiiviseen hoitoon ≥ 50-vuotialla rannemurtumapotilailla. Kirurgin leikkauskokemus ja potilaan ikä ovat yhteydessä rannemurtuman levytyskomplikaatioiden riskiin.

A alta frequência das fraturas da extremidade distal do rádio estimula o contínuo estudo e desenvolvimento dos métodos de tratamento, buscando melhor qualidade de vida com menos sequelas e limitações. A placa volar bloqueada tem se tornado o método de escolha no tratamento nos últimos anos. Menos morbidade e a reabilitação mais precoce têm aumentado muito a utilização dessas placas. Esse método, contudo, não é isento de complicações. As mais frequentes estão relacionadas aos tendões extensores. Tendinites e rupturas têm sido relatadas. Com o objetivo de se proteger os tendões extensores, estudos têm sugerido a utilização de parafusos unicorticais na parte distal da placa e recomendam que os mesmos tenham pelo menos 75% do comprimento do parafuso bicortical. Esses estudos são restritos a fraturas extra-articulares. Esta pesquisa objetivou estudar e comparar as propriedades mecânicas dos modelos fixados com placas volares utilizando parafusos unicorticais e bicorticais em fraturas intra-articulares da extremidade distal do rádio classificadas como AO 23C3 sob cargas fisiológicas e a possibilidade de recomendar o parafuso unicortical na prática clínica. Objetivou também comparar, pelo método dos elementos finitos, as tensões geradas nos modelos após diferentes carregamentos com validações realizadas com os resultados dos ensaios mecânicos. Foram avaliados 42 modelos divididos em seis grupos de sete modelos, três com parafusos unicorticais e três com parafusos bicorticais. Cada grupo foi submetido a um único tipo de ensaio: compressão axial, flexão dorsal e flexão volar. Foram feitos dois ensaios estáticos intercalados por um carregamento cíclico e por último um ensaio até a falência. Os resultados demonstraram similaridade entre os respectivos grupos e confirmaram nossas hipóteses de que: a) o comportamento mecânico do modelo utilizando parafusos unicorticais é equivalente ao modelo usando parafusos bicorticais; b) o carregamento cíclico afeta o comportamento mecânico dos modelos das fixações das placas volares bloqueadas na extremidade distal do rádio. A análise por elementos finitos mostrou que as fixações unicortical e bicortical não resultaram em qualquer região de concentração de tensão crítica, sendo as duas indicadas para a estabilização de fraturas do rádio. / The high frequency of distal radius fractures stimulates the continuous study and development of treatment methods seeking a better quality of life and fewer sequels and limitations. The volar locking plate has become the chosen method for the treatment in recent years. The lower morbidity and earlier rehabilitation have greatly increased the use of these plates. This method, however, is not free from complications, the most common being related to extensor tendons. Tendinitis and rupture have been reported. In order to protect the extensor tendons, studies have suggested the use of unicortical screws in the distal part of the plate, and recommended that they be at least 75% of the length of the bicortical screw. These studies are restricted to extra articular fractures. This study aimed at studying and comparing the mechanical properties of the models fixed with volar plates using unicortical and bicortical screws in intra-articular fractures of the distal radius classified as AO 23C3 under physiological loads and the possibility of recommending the unicortical screw in clinical practice. The tensions generated in the models after different loads with validations performed with the results of the mechanical tests were also compared. We studied 42 models divided into six groups of seven models, three with unicortical screws and three with bicortical screws. Each group underwent a single type of test: axial compression, dorsiflexion and volar flexion. Two static tests were performed, intercalated by a cyclic loading, and finally a test until bankruptcy. Our results demonstrated a similarity between the respective groups and confirmed both our hypotheses that: a) the mechanical behavior of the model using unicortical screws is equivalent to the model using bicortical screws, and b) that the cyclic loading affects the mechanical behavior of the models of the fixations of the volar locked plates in the distal radius. The finite element analysis showed that the unicortical and bicortical fixations did not result in any regions of critical stress concentration, so they are both indicated for the stabilization of radius fractures.

Syftet med studien var att utvärdera patientens upplevelse av den postoperativa smärtan och behandlingen av denna när den perifera nervblockadens effekt avtagit efter operation av distal radiusfraktur. Metoden som använts är en empirisk kvantitativ deskriptiv enkätstudie. Tjugo patienter deltog i denna pilotstudie. Demografin stämde väl överens med de statistiska data, som visar att distrala radiusfrakturer är vanligt förekommande hos kvinnor i åldern 55 år och äldre. Resultatet av studien har påvisat att många patienter har upplevt mer smärta än vad de själva varit beredda på. Slutsatsen utifrån visuell analog skala, VAS, visar att smärtan har varit svår för patienterna att behandla hemma trots att de haft tillgång till smärtbehandlade läkemedel. Informationen som patienten erhållit har varit otillräcklig och kan vara en källa till den svårbemästrade smärtan. / The aim of the study was to evaluate patient´s experience of the postoperative pain and its treatment after peripheral nerve blockade for operation of a distal radius fracture had ceased. The method used was an empiric, quantitative, descriptive study using enquiries. Twenty patients participated in this pilot study. Demography was according to statistical data, that distal radius fractures are common in women aged 55 or more. The results showed that many patients experienced more severe pain than expected. The conclusion from visual analogue scale, VAS, shows that the pain was difficult to treat at home in spite of prescription of pain killers. The information given to the patient was insufficient, which may have contributed to the difficulty to control pain.

Bakgrund: Distal radiusfraktur är den vanligaste frakturen i Sverige där kvinnor drab-bas oftare än män. Majoriteten av de patienter som opereras vårdas på en dagkirurgisk enhet och sköter sin egenvård i hemmet. Kvinnor upplever smärta annorlunda än män vilket kan ha betydelse i valet av smärtlindringsstrategi. Inför operationen erhåller patienten antingen en plexusblockad eller generell anestesi med infiltrationsanestesi i smärtlindrande syfte. I anestesisjuksköterskans kompetensbeskrivning ingår det att ansvara för planering och övervakning vid dessa olika anestesimetoder. Vilken av de två anestesimetoder som används varierar på sjukhusen runt om i Sverige. Det finns ett begränsat forskningsunderlag på vilken anestesimetod som är att föredra. Syfte: Syftet var att undersöka smärtupplevelsen hos kvinnor efter dagkirurgisk operation av distal radiusfraktur. En jämförelse mellan anestesimetoderna plexusblockad och infiltrationsanestesi med Ropivacain. Metod: En kvantitativ enkätundersökning. Data har samlats in genom ett bekvämlighetsurval där enkäten bestående av strukturerade frågor har delats ut av personal på sju postoperativa avdelningar. Resultat: Inga statistiskt signifikanta skillnader har hittats mellan grupperna som erhållit antingen plexusblockad eller infiltrationsanestesi med Ropivacain. Dock visade sig en betydande andel uppleva svår eller värsta tänkbara smärta kvällen eller natten efter operation. Båda grupperna uppvisar även problem med sömn och vila postoperativt. Slutsatser: Resultatet från magisteruppsatsen antyder att det finns förbättringspotential postoperativt för kvinnor med radiusfraktur som upplever smärta. Dessutom bör grundläggande behov, särskilt vila, sömn och aptit, tas i beaktande. / Background: Distal radius fracture is the most common fracture in Sweden and women are affected more often than men. The majority of the patients who require surgery are cared for in a day surgery unit. They are then responsible for their own care at home. Women experience pain differently than men and this can be important when deciding upon a pain relief strategy. Prior to surgery, the patient receives either a plexus blockade or general anesthesia with infiltration anesthesia for pain relief purposes. The nurse anesthetist´s (CRNA) competence description includes being responsible for planning and monitoring of these different anesthesia methods. The choice of anesthesia method used varies in hospitals around Sweden. There is a limited amount of research on which anesthesia method is preferable. Method: A quantitative survey. Data has been collected using convenience sampling where a questionnaire consisting of structured questions was distributed by hospital staff in seven postoperative departments. Results: No statistically significant differences were found between the groups that received either plexus block or ropivacaine infiltration anesthesia. However, a significant proportion were found to experience either severe pain or the worst possible pain in the evening or night after surgery. Both groups show problems with sleep and rest postoperatively, while the infiltration group tends to be more inconvenienced by decreased appetite than the patients in the plexus group. Conclusions: The results of the master's thesis suggest that there is potential for improvement for postoperative female patients with a radius fracture experiencing pain. Additionally basic needs, in particular rest, sleep and appetite, should be taken into account.