Distal radius fractures (DRF) are the most common type of acute wrist trauma [
Baseline characteristics such as pre reduction radial shortening, education, injury compensation, and the presence of other medical comorbidities have been shown to predict patient-reported pain and disability 1-year following DRF [
The importance of social support in improved health outcomes is well validated in patients with a variety of medical conditions including coronary atherosclerosis [
This study was a prospective cohort study evaluating the role of social support in patient-reported pain and disability at 1 year after DRF.
Skeletally mature patients were recruited from the practices of nine fellowship-trained hand surgeons at a single tertiary referral center between January 2002 and January 2010. Inclusion criteria included any individual older than 18 years, with an extra- or intra-articular DRF. Exclusion criteria included patients who did not have a complete Medical Outcomes Study (MOS) Social Support Survey at baseline. All participants provided informed written consent and the study was approved by the local Health Sciences Research Ethics Board.
At the baseline visit, patient demographic and injury characteristics were recorded. Demographic data included age and gender. Injury characteristics included whether the dominant or nondominant hand was injured, the overall energy of the injury (low (e.g., fall from standing height), intermediate (e.g., fall or trauma from a low velocity activity such as rollerblading), and high (e.g., trauma from high velocity such as a motor vehicle collision)), open versus closed fracture, the mechanism of injury (fall on ice or snow, fall on outstretched hand, or other), presence of injury compensation, and treatment of the fracture (nonoperative versus operative). In addition, DRF complications were documented at baseline, 3, 6, and 12 months.
The outcome variable was the PRWE [
The Medical Outcomes Study (MOS) Social Support Survey [
General health related quality of life (HRQoL) was assessed using the SF-12 Health Survey (version 2). The total score of the SF-12 v.2 can range from 0 (lowest possible health) to 100 (maximal possible health). The SF-12 v.2 physical (PCS-12) and mental (MCS-12) summary scores were used to represent these two components of health status in the current study; scores are based on population norms with higher scores representing a better health status [
Pre- and posttreatment and final radiographic results were evaluated. The overall severity of the fracture was assessed according to the AO classification system [
The demographics, injury characteristics, treatment, and complications were analyzed using descriptive statistics. A paired
Two hundred and ninety-one patients met the eligibility criteria to be included in this study. Participants ranged in age from 18 to 84 years, with a mean age of
Approximately half the cohort (46.0%) injured their dominant hand. The mechanism of fracture varied between participants. Twenty-four percent reported a fall on ice or snow, 56.6% reported a fall from standing height, and the remaining 20.0% stated another mechanism of injury such as a motor vehicle collision, rollerblading accident, or a fall from a raised platform. Accordingly, the majority of fractures were low energy (68.0%) and only a minority were high energy (11.0%). For the study cohort, only a minority of patients were involved in a claim for injury for injury compensation (16/271, 5.9%). Table
AO fracture classification and treatment.
AO type | |
A (extraarticular) | 34.4% |
B (partial articular) | 17.3% |
C (complete articular) | 48.2% |
Treatment | |
Cast (undisplaced) | 34.4% |
Cast, CR | 37.5% |
CR, percutaneous pinning, ±Exfix | 8.2% |
Open reduction, Exfix | 1.0% |
ORIF | 18.9% |
CR: closed reduction, Exfix: external fixation, ORIF: open reduction internal fixation.
Half the cohort (52.9%) did not have an acceptable alignment on their final radiograph. Of the participants lacking an acceptable reduction, the majority (78.7%) had been managed nonoperatively. The overall complication rate over the one-year followup was 20.0%. Almost half of the complications (8.0%) were mild with symptoms only and no specific treatment required. Overall, 45 patients had a complication at some point during their followup, with 15 of these patients reporting complications at the one-year followup.
The first model (Model 1) included only the total MOS social support score in the stepwise regression. The total MOS social support score was found to be predictive of the 1-year PRWE score, explaining 4.3% of the variability. The next model (Model 2) included the total value of each of the MOS subscales including emotional/informational support, tangible support, affectionate support and positive social interaction, and the additional item (“someone to do things with to help you get your mind off things”). The Durbin Watson test statistic for the second regression model was 1.80, indicating that the residuals are not correlated. Only emotional/informational support was found to be predictive of the 1-year PRWE score, explaining 4.7% of the variability seen in the 1-year PRWE score (Tables
Social support and 1-year PRWE scores (model summary).
Model |
|
|
Adjusted |
Std. error of the estimate | Change statistics | ||||
---|---|---|---|---|---|---|---|---|---|
|
|
df1 | df2 | Sig. |
|||||
1 | 0.221a | 0.049 | 0.043 | 19.034 | 0.049 | 9.271 | 1 | 181 | 0.003 |
2 | 0.229b | 0.052 | 0.047 | 18.998 | 0.052 | 9.975 | 1 | 181 | 0.002 |
Dependent variable: 1-year PRWE.
aPredictors (constant), MOS SSS-overall score transformed to a 0 to 100 scale.
bPredictors (constant), MOS SSS-total subscale score for emotional/informational support.
MOS SSS: Medical Outcomes Study Social Support Survey.
Social support and 1-year PRWE scores (coefficients).
Model | Unstandardized coefficients | Standardized coefficients beta |
|
Sig. | |
---|---|---|---|---|---|
|
Std. error | ||||
1 | |||||
Constant | 36.132 | 6.601 | 5.474 | 0.000 | |
MOS SSS-total score | −0.252 | 0.083 | −0.221 | −3.05 | 0.003 |
2 | |||||
Constant | 35.159 | 6.074 | 5.788 | 0.000 | |
MOS SSS-total subscale score for emotional/informational support | −0.564 | 0.178 | −0.229 | −3.16 | 0.002 |
Dependent variable: 1-year PRWE.
MOS SSS: Medical Outcomes Study Social Support Survey.
In order to determine if any other variables were confounding the relationship between social support and outcome, a subsequent regression analysis was performed to evaluate the following potential confounders: age, gender, malunion, and treatment complications. Age, gender, presence of complications, and radiographic alignment were not identified as confounders as they did not influence the role emotional/informational support played in predicting 1-year PRWE scores. This further supports the importance of emotional/informational support in all patients independent of the radiographic alignment and presence of malunion.
This study identified that fracture outcomes fit within a biopsychosocial paradigm, since baseline emotional/informational support contributes to 4.7% of the variability of the pain and disability outcome scores of distal radius fractures at one year, regardless of age, gender, and final radiographic alignment. The remaining MOS Social Support subscales including tangible support, affectionate support, positive social interaction, and “someone to help you get your mind off things” were not predictive of 1-year PRWE scores.
The benefit of improved social support, in particular emotional support, early in the course of treatment of an elderly cohort of individuals with hip fractures is well established. Shyu et al. [
The current investigation extends the relationship of emotional/informational support to improved patient-reported outcomes in the distal radius fracture population. One cannot necessarily assume that the relationship observed in hip fracture would also be present for distal radius fractures since hip fracture impairs mobility, whereas upper extremity fractures may not necessarily do so. However, since upper extremity function is important to tasks of daily life there is a theoretical rationale to assume the relationship could be similar. However, the studies examining social support in hip fractures use predominantly elderly cohorts who have received operative intervention. In the current study we included a broader cross-section of age, inclusion of both intra- and extra-articular DRF, and the primarily nonoperative treatment of patients in the current study. One might expect that younger patients would be less in need of social support. Despite the differences in composition of the study cohorts, the benefit of emotional/informational support is preserved. Further neither agen or gender was a significant moderator of this effect in multivariate analysis.
We do not know the mechanism by which social support impacts outcome in the DRF population. For example, social support might empower people to participate more actively in their recovery, or it might be that instrumental help allows people to focus on healthy habits like optimal nutrition and participation in regular therapy sessions. Another potential explanation is that positive perceptions of having social support are related to an optimistic personality trait that also influences self-reported assessment of function.
Previous studies of social support vary slightly depending on whether social support is quantified according to social network structures or assessed according to the patient’s perception of the quality of social support received. A study by Queenan et al. [
The role of social support has also been established in other pathologies. A prospective study including hospitalized patients with hip fractures (
Other research has also studied which factors are predictive of pain and disability according to the PRWE following DRF [
One of the limitations to the study was that only a minority (58/291, 19%) of participants reported having social support available “little” or “none of the time.” Thus, participant inclusion in the study was independent of the results of their baseline MOS social support scores.
Future investigations are required to further inform our understanding of when and how social support affects outcomes and potentially whether interventions designed to maximize emotional/informational support at baseline can result in improved outcomes. The additional variance of 4.7% explained by emotional support may appear small statistically; however the finding that baseline emotional support has a measureable impact one year after DRF pain and disability indicates a long-term effect deserving of clinical attention. Qualitative research will be needed to inform how social support affects patients with DRF and what social supports may be of value if an intervention was designed. Future studies in the DRF population are needed to characterize the role of interventions, including both formal and informal methods, to maximize social support on reduced pain and disability as an outcome measure.
Using a biopsychosocial approach to DRF, the current investigation examined the relationship between social support and patient-reported pain and disability 1 year after fracture. Of all of the MOS Social Support subscales examined, emotional/informational support was found to explain 4.7% of the variance in patient-reported pain and disability at 1 year. At the initial visit following a distal radius fracture, surgeons should consider counseling their patient on the potential rehabilitative benefits of improved social support.
This study was funded by an operating grant received from the Canadian Institute of Health Research (CIHR).