Thesis (M. Phil.)--University of Hong Kong, 2002. / Includes bibliographical references.

Distal radius fracture is a common injury. The majority of people recover well but a proportion have ongoing pain, stiffness, deformity and functional limitation. Associations between these outcomes, injury characteristics and treatment methods are inconsistent, for example a deformed wrist is not always painful, stiff and functionally limiting. The psychological response to fracture and the role that psychological factors play in recovery are complex and poorly understood. Identification and treatment of those psychological factors that might influence disability and symptom intensity could improve outcomes in this large group of patients. The aim of this thesis is to explore the influence of psychological factors on outcome following fracture of the distal radius. To investigate these relationships further a literature review was carried out looking at the association between psychological factors and outcomes in distal radius fracture patients. Prospective studies were then performed in order to identify associations between demographic factors, injury severity, treatment and psychosocial factors and symptom intensity and disability after fracture and to identify predictors of psychological response to injury. A prospective randomised controlled trail (RCT) was then carried out to compare the impact of an additional psychological workbook intervention versus an information workbook in the otherwise routine management of distal radius fracture. The literature review identified evidence to support the association between psychological factors and outcome after acute injury in general but limited evidence specifically pertaining to distal radius fracture. The first prospective study of 216 patients found psychosocial factors to be more strongly associated with disability (Disability of Arm Shoulder and Hand score, DASH) and pain intensity after distal radius fracture than any injury or treatment factor. The second prospective study of 153 patients found that psychological traits are relatively stable in this cohort and that no demographic, injury or treatment factors were associated with the small changes in psychological scores up to 10 weeks following injury. The RCT demonstrated that use of a psychological workbook did not significantly improve disability six weeks after injury compared to an information workbook in a cohort of patients with distal radius fracture (DASH 38 vs 35, p = 0.949). The importance of psychosocial factors in recovery from distal radius fracture has been demonstrated. Following this injury, psychological factors remain stable over time or fluctuate to a small degree with distinct trends. In cohorts with stable psychological responses to fracture, the individual psychological response cannot be reliably predicted by demographic, injury or treatment factors. Use of a psychological workbook intervention does not improve outcomes in patients with a good initial psychological response to injury. Future work should investigate less psychologically stable and well adapted cohorts, establish how best to identify patients at risk of poor outcome and whether, indeed, these specific groups are amenable to treatment and if so what form this intervention should take. It should address limitations identified in this work, primarily, reduce questionnaire fatigue with more focused psychological questionnaires. Ultimately, it should work towards creating a structure where patients can be screened with a recognised psychological scoring system at initial presentation to fracture clinic and allow a sub-group of psychologically mal-adpted patients to be referred on to a dedicated psychology service, that would work to optimise the psychological conditions for recovery.

Den nuvarande metoden för att behandla handledsfrakturer, specifikt reponeringen (återföring till rätt position) av enklare frakturer, kräver idag två till tre personer med en behandlingstid på cirka 20 minuter. 25 000 personer drabbas av handledsfrakturer varje år i Sverige, där majoriteten är just av den enklare sorten som inte kräver operation. Denna metod ansågs för tidskrävande och dessutom för smärtsam för patienten enligt Rami Elias, ortopedisk kirurg på Specialistcenter Scandinavia. Ett hjälpmedel utvecklades utifrån dessa problem och krav från uppdragsgivaren. En funktionell prototyp byggdes och blev testad. Det nya hjälpmedlet gav prov på en minskad tidsåtgång och skonsammare behandling för patienten. / The current method for treating wrist fractures, specifically reduction (repositioning the bones) of simple fractures, require two to three people with a treatment time of about 20 minutes. 25,000 people are affected by wrist fractures each year in Sweden, where the majority of these are of the simpler variety that does not require surgery. This method was considered too time consuming and also too painful for the patients according to Rami Elias, orthopedic surgeon at Specialistcenter Scandinavia. An assistance tool was developed based on these issues and demands of the client. A functional prototype was built and tested. The new tool showed evidence of providing reduced treatment time and being less harmful to the patients.

[Truncated abstract] The aim of the research was to explore the association between wrist guard use and wrist fracture risk in snowboarders in Australia. During the study, the opportunity was also taken to examine the relationship between wearing wrist guards and the severity of wrist and elbow injury. A case-control study was conducted at the Mount Buller Medical Centre, Victoria, Australia. A total of 494 participants was recruited during the 2004 and 2005 ski seasons. Cases were defined as any snowboarder seen at the Clinic with a fractured wrist (N = 119), and controls as any snowboarder seen at the clinic for any reasons other than a fractured wrist (N = 375). Severity of forearm injuries were defined and analysed separately. Study participants completed a questionnaire consisting of: basic demographics (age and sex only); wrist guard use on the day of presentation; normal use of protective equipment; the number of days spent snowboarding that season; the ability of the snowboarder; and ski run difficulty. Risk taking behaviour was assessed by a history of any previous fracture or joint injury and psychometric questions. Clinic medical staff recorded site and severity of fractures and soft tissue injuries. Logistic regression was used to obtain adjusted odds ratios for these risk factors against the main outcome measure. Presence of wrist fracture and injury in snowboarders with and without wrist guards. ... There was a significant association between wrist guard use and soft tissue elbow injuries (adjusted odds ratio = 17.6, p = 0.011, 95% CI: 1.93 – 160.2), but no significant association with elbow fractures (adjusted odds ratio = 1.84, p = 0.385, 95% CI: 0.46 – 7.30). There was thus no evidence in this study that wrist guards increase the occurrence of other severe injuries in the forearm by transferring the impact force away from the protected wrist up the arm. No evidence was found for compensatory risk taking behaviour in participants wearing protective equipment. A local injury prevention strategy was implemented in schools in the Mt Buller district during the course of this study. Education about the protective effects of wrist guards enabled a policy change in the local secondary college so that wrist guard use is now mandatory for all snowboarders in the school ski programme: That policy states:

Patient reported outcome (PRO) measurement of disability is integral to a patient-centered approach to health care and gauging the biopsychosocial impact of health conditions from the patient's perspective. This thesis investigates disability after proximal humerus, elbow and distal radius fractures; conditions that constitute a major burden in musculoskeletal health care and a substantial impact on health-related quality of life (HrQoL). Disability is defined by the World Health Organisation (WHO) International Classification of Disability, Functioning and Health (ICF) as ‘a multi-dimensional construct involving a dynamic interaction between impairment, activity limitations and participation restrictions, that are influenced by contextual factors'. This international, consensus-based framework acts as a guide for the application of outcome measures in performing scientific research. The WHO ICF also considers other patient perspectives on health and health care systems, including patient experience and patient activation within the contextual factors component. Patient experience encompasses aspects such as satisfaction, expectation management and confidence with care, and is measured using a variety of scales and questionnaires. Patient activation relates to 'the knowledge, skills and confidence a person has in managing their own health and health care'. This concept is quantified using patient activation measures (PAMs). The overarching goal of this thesis is to identify the most influential factors predicting disability after proximal humerus, elbow and distal radius fractures. This work also aimed to define the relationship between disability, experience and activation to inform the development of a patient-centred approach to managing these challenging injuries. The first systematic review highlights the dominance of psychosocial factors in influencing disability associated with a range of upper extremity conditions. Few studies have assessed this relationship in specific trauma populations. The second review underlines the paucity of upper extremity PRO measures incorporating fracture populations in their original development. It also reports the highly variable quality of initial studies introducing these measures. The final review demonstrates the superior measurement properties of computer adaptive tests (CATs), a contemporary form of PRO measurement, over fixed-scale instruments. Few studies apply CATs in trauma and few have been performed outside the U.S. These reviews collectively informed the selection of PRO measures for the experimental studies in this thesis. Firstly, a pilot study establishes a methodology for addressing the key objectives and the feasibility of using a web-based platform for measuring patient outcomes. Strong correlation between PROMIS Physical function CAT, a computer adaptive measure of physical function, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), a region-specific, fixed scale is observed. The core experiment (n=734) expands upon this work and demonstrates correlations between a range of generic and region-specific measures in an upper extremity trauma population. Disability is shown to correlate with satisfaction, and the strength of this correlation increases over time. Applying PRO measures of disability in populations with shoulder, elbow and wrist fractures show that self-efficacy (i.e. coping ability) within 6 weeks of injury was the strongest predictor of medium-term disability at 6-9 months. In proximal humerus and elbow fractures, kinesiophobia (i.e. fear of movement) within a week of injury was also a strong predictor of disability. The final study concludes that greater patient activation is associated with greater health-related and experiential outcomes. However, psychosocial factors including self-efficacy, superseded activation in predicting disability and satisfaction. This thesis contributes evidence for musculoskeletal health care professionals (HCPs) to consider specific psychosocial factors, such as coping abilities, and patient activation early in the recovery process to improve disability following these injuries.