A huge number of short-term follow-up articles are visualized in the literature on distal radius fracture. In contrast, very few reports which evaluate on long-term outcomes ^[1]. With the treatment of this fracture during recovery, there will be an initial decline period in function followed by improvement stage up to 1 year ^[2]. Functional recovery is known to occur even after 1-year post-treatment, despite very scanty reports focusing on beyond 1-year follow-up results ^[3]. The clinical and radiological outcome measures with objective criteria were more stressed in the past in distal radius fracture than in the functional results ^[4]. However, these clinico radiological outcome measures do not represent patient perspective and seem less relevant functionally ^[5]. Hence, in this decade, many published reports are based on functional outcomes with patient-reported evaluation and on quality of life in daily living activities ^[6]. The long-term results include a return to the original job and the ability to perform daily living activities with wrist–hand function ^[7]. The primary objective of this study is to investigate the association between different treatment modalities and its impact on patient-reported long-term functional evaluation and daily living activities. The secondary aim is to find out the relationship of age at the time of fracture, sex, and Frykman classification methodology impact over subjective evaluation as reported by the patient at a mean of 10-year follow-up.

Sindhudurg residents who were treated by the author for distal radius fracture between January 01^st, 2008, to December 31^st, 2011, at Government District Hospital are enrolled in this prospective study. Only unilateral, closed distal radius fractures in elderly above the age of 50 years with regular follow-up for 2 years are only included in this study. All patients who met these inclusion criteria were called upon physically to be present at a special review clinic attended by the author for examination by sending postcards. This follow-up clinic was conducted in the orthopedic department from January 01^st, 2022, to May 31^st, 2022, with a long-term follow of 10–14 years after this original study period of 2008–2011. To increase more number of respondents, patients were additionally contacted by public relations officers through telephonic messages. The original study and this long-term follow-up study were approved by the Ethical Review Board of Government District Hospital, Sindhudurg. A detailed physical examination was done by the author along with wrist radiographs. The range of motion of the wrist and forearm was measured with a goniometer. Data analyzed in the original study of 2008–2011 were obtained from clinical records of the Government District Hospital, which is the only free public hospital in this region, which is estimated to cover more than 90% of the Sindhudurg population ^[8]. The selection of distal radius fracture patients in this report was based solely on the final diagnosis mentioned in the case paper as well as the fracture treatment registered by the treating doctor. Radiography confirmed each diagnosis of distal radius fracture. Fractures were classified according to the Frykman classification system. The patients in the study period of 2008–2011 were treated by five different treatment methods, both operative and conservative ^[9]. Among responders, 82 (51.9%) were treated conservatively. In this, 51 (62.2%) with below elbow cast with the forearm in pronation, and 31 (37.8%) managed with above elbow cast with the forearm in supination. Surgical intervention with three operative modalities was performed in 28 (36.8%) with pins and plaster, 34 (44.7%) with external fixation, and 14 (18.4%) by open reduction and internal fixation. The patient-reported functional outcome was measured using a patient-rated wrist evaluation score, which is a 15-item questionnaire on wrist pain and disability in daily living activities as perceived by the patient. Scores on two subscales of pain and function combined to a total score ranging from 0 (no pain or disability) to 100 (severe pain and disability). The total patient-rated wrist evaluation score was calculated using a published algorithm. The patient’s perceived health-related quality of life was measured utilizing EQ-5D questionnaire. This has five questions regarding mobility, self-care, daily activities, discomfort, and anxiety. The results are converted to a utility score that ranges from −0.33 to 1; a lower score reflects a poorer quality of life. The valid and reliable patient-rated hand–wrist functional outcomes and results with the sequential change in the quality of life proposed by the author are also measured.

Statistical analysis

Data analysis was completed using statistical software (Statistical Analysis System version 8.2). Categorical data were described using frequencies and percentages. The patient characteristics were described using summary statistics and compared with conservative and surgical intervention groups. The patient-rated wrist evaluation score, Visual Analog Scale (VAS), EQ-5D, and functional outcome measures proposed by the author were compared between patient groups with respect to age, sex, dominant hand, treatment method, Frykman classification using Student’s t-test and I-way analysis of variance. Multiple linear regression analysis was conducted to identify which treatment type was associated with a quantum of score. All statistical analyses were performed using Statistical Packages for the Social Sciences statistics. P < 0.05 were considered statistically significant.

A total of 218 patients who qualified with inclusion criteria became eligible for long-term follow-up and were called for clinical examination and interrogation at a special review examination clinic chaired by the author. Twenty-two patients died, and 38 could not come. Finally, 158 patients came for follow-up clinical radiological examination. Of these, 103 (65.2%) were men, and 55 (34.8%) women. The mean age at follow-up was for men 68 ± 9 years (range 51–92 years) and for women 64 ± 8 years (range 52–96 years). The mean follow-up time with standard deviation (SD) was 10.2 ± 2.6 years (range 9.9–14.1 years). The dominant wrist side was fractured in 105 (66.5%). The mean patient-rated wrist evaluation score was 12 (SD = 17, range 0–96). There was no statistically significant difference in patient-rated wrist evaluation scores regarding sex. (P = 0.2, P = 0.3) and also as regards Frykman classification type (P = 0.2, P = 0.3). There were no statistically significant differences in functional outcomes between fracture types. This indicates function did not correlate with fracture type in this study report. The patient-rated wrist evaluation scores also did not statistically differ much between age groups of 10 years each, right from 50 years onwards (P = 0.4) (Table 1). The patients who were treated conservatively with plaster cast had lower scores, indicating less pain and better wrist function, as compared with the surgical intervention treatment group (P < 0.01). The mean EQ-5D score after long-term follow-up was 0.86. The mean EQ-5D score for patients aged between 50 and 70 years was lower than that of patients above 70 years. (P = 0.04). The mean EuroQol-VAS (EQ-VAS) was 81.2 (range 25–100, 95% CI 76–84). With these EQ-VAS scores, there were no significant differences between age and sex subgroups. The scores were lower in patients treated conservatively compared to three subgroups of surgical intervention (P = 0.03). The patient self-rated outcomes at long-term follow-up with mean ± SD values were for the surgical intervention group, pins and plaster 13.5 ± 29.6, external fixator 14.6 ± 32.1, open reduction, and internal fixation 6.3 ± 22.3. Similar values for conservatively treated patients were for below elbow cast 7.3 ± 12.5 and for above elbow cast with forearm in supination 7.2 ± 13.3, respectively. Overall, patients treated with the surgical intervention group were not happy with the patient-reported outcome and satisfaction score. These differences were statistically significant (P > 0.001). The conservatively treated patient group (mean ± SD, 11.5 ± 28.0 vs. 7.3 ± 12.9; P = 0.5) had better functional outcomes and greater satisfaction (P = 0.5) for the difference. Overall 36 (43.9%) elderly patients treated by the conservative method were very much satisfied with the eventual long-term outcome of their distal radius fracture as against 27 (35.5%) treated by surgical intervention (Table 2). Similarly, 4 (4.8%) were very much dissatisfied in the conservatively treated group as against 10 (15.7%) from the surgical intervention group (P > 0.001). Both values are statistically highly significant.

Elderly patients in this study were more satisfied with much better overall functional outcomes treated conservatively than with surgical intervention for long-term follow-up at 10 years. A similar better patient-reported functional outcome in non-operative groups than operated patients at a 4-year follow-up study was reported contrary to our 10-year long-term review analysis ^[10]. This Netherlands study reports that the mean difference of patient-rated wrist evaluation scores for patients varies from 12 to 18, compared to our study 13–39, which could indicate a clinically relevant difference. In the sub-group analysis, this functional benefit was most obvious in the Frykman type VIII fracture group. To the best of our knowledge, very few studies have been reported in the literature on long-term follow-up with patient-reported outcomes in favor of conservatively treated patients than with surgical intervention ^[11]. In this study, the EQ-5D showed no statistically significant differences in outcome as regards to age and sex group. The earlier short-term outcome of patient-reported functional results implied that EQ-5D values might normalize to fracture status ^[12]. With these contradictory opinions, it is felt that EQ-5D may not be the most discriminating and appropriate instrument in long-term evaluations ^[13]. That is how higher scores for quality of life as measured by EQ-5D did not go hand in hand with better wrist function. The patient reported unsatisfactory wrist function at prolonged follow-up in the surgical intervention group in this study, which could be possibly due to complications after the operative procedure. This may be implant-related and can occur even at a longer time ^[14]. Another reason for the difference between non-operative and operative groups could be that patients who were treated surgically have different expectations than the conservatively treated group. Hence, expectation management plays a crucial role in satisfaction with the final functional outcome ^[15]. Many reports from the literature suggest very few clinical differences between surgical intervention and conservative treatment, contrary to our long-term 10 years subjective follow-up study ^[16]. The functional results were compared in this study at 2-year and 10-year follow-up examinations. Significant differences were identified. As per inclusion criteria, only the patients who had regular 2-year follow-up after distal radius fracture were only called upon for long-term review examination. The functional differences and changes in daily living activities between 2 and 10 years follow-up examinations show significant improvement in disability and functionality. Contrary to the findings of this study, it leads to the assumption that longer follow-up may demonstrate the deterioration of function, possibly with the progression of radio carpal arthritis ^[17]. In a study of 15-year follow-up, this hypothesis was rebelled, further reported that wrist function did not correlate with the degree of radio carpal arthritis ^[18]. In this study, only one mode of treatment of internal fixation was studied. Overall it appears from our results at long-term follow-up at 10 years that degenerative changes at the wrist may very well affect the objective clinical and radiological findings. The patient’s subjective well-being and quality of life in previous research work by the author have shown that many objective parameters do not reflect functional outcomes of importance to the patient ^[19]. The majority of the authors present mean values with SD for patient-rated wrist evaluation score, EQ-5D. Comparisons with data from the literature have to be evaluated carefully, as the results are most likely to appear in non-parametric distribution ^[20]. Due to the lack of longer follow-up studies involving patient-rated wrist evaluation scores, EQ-5D it cannot be contrasted for our study of 10-year follow-up results with those of other investigations ^[21]. Patient rating scales were developed by the author way back in 2004 and are believed to be a comprehensive assessment of functional outcomes ^[22]. This has been shown to be highly sensitive in detecting variations in the clinical and functional outcome as it reflects important aspects of physical performance ^[23]. This reliable and valid tool for patient-rated assessment of wrist and hand function was used by the author for the last 18 years ^[24]. The present study is unique in that distal radius fractures are evaluated at a very long-term duration of 10 years, treated by five different treatment modalities, using validated reliable measures such as patient-rated wrist evaluation score, EQ-5D, EQ-VAS, and by authors method. This allows surgeons to assess outcomes from their patient’s prospectives in a valid and reliable way ^[25]. Another strength of this study is the large number of elderly patients who participated in a 10-year follow-up review. This provided considerable statistical power for analysis. This study has limitations, such as the traditional physical outcome measures were not assessed. However, this was beyond the scope of this study. Another limitation is a greater population of conservatively treated patients in the response group, which introduces a potential bias. This over-representation may indicate satisfactory results in non-operative patients.

After a mean follow-up of 10 years, patients treated conservatively perceived much better functional outcomes with good quality of daily living activities than with the surgical intervention group, independent of age and sex. Patients treated surgically had worse subjective long-term outcomes including activity limitations and pain.

In this long-term study, very good similar clinical outcomes have been documented in elderly patients with unstable distal radius fractures who were treated both conservatively and by surgical intervention. It has been demonstrated that malalignment does not necessarily correlate with poor functional outcomes following distal radius fractures in elderly patients. There was no significant difference found in the functional result despite the worst radiographic result in the conservative treatment group. There is no evidence for the superiority of one of the different treatment methods we can choose, particularly in elderly patients. Conservative treatment is the best treatment for distal radius fractures in the elderly.