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Scientific Articles   |    
Ethnic Disparities in Recovery Following Distal Radial Fracture
Michael Walsh, PhD1; Roy I. Davidovitch, MD1; Kenneth A. Egol, MD1
1 NYU Hospital for Joint Diseases, 301 East 17th Street, Suite 1402, New York, NY 10003. E-mail address for K.A. Egol: kenneth.egol@nyumc.org
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at NYU Hospital for Joint Diseases, New York, NY

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 May 01;92(5):1082-1087. doi: 10.2106/JBJS.H.01329
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Abstract

Background: 

Ethnic disparities have been demonstrated in the treatment of chronic diseases, such as diabetes and heart disease. It is unclear if similar ethnic disparities appear with respect to recovery following fracture care.

Methods: 

We retrospectively reviewed 496 individuals (253 whites, 100 blacks, and 143 Latinos) with a fracture of the distal part of the radius. Assessment of physical function and pain was conducted at three, six, and twelve months following treatment. The Disabilities of the Arm, Shoulder and Hand (DASH) score was used to assess physical function, and a visual analog scale was used to assess pain. Multiple linear regression was used to model physical function and pain across ethnicity while controlling for age, sex, mechanism of injury, level of education, type of fracture, type of treatment (operative or nonoperative), and Workers’ Compensation status.

Results: 

Both blacks and Latinos exhibited poorer physical function and greater pain than whites did at most follow-up points. Latinos reported more pain at each follow-up point in comparison with blacks and whites (p < 0.001 at three, six, and twelve months). These significant differences remained after controlling for Workers’ Compensation status, which was also strongly associated with both pain and function.

Conclusions: 

These findings suggest that recovery is different between ethnic groups following a fracture of the distal part of the radius. These ethnic disparities may result from multifactorial sociodemographic factors that are present both before and after fracture treatment.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Kenneth A. Egol, MD
    Posted on July 31, 2010
    Dr. Egol and colleagues respond to Ms. Ali and Dr. Peters
    NYU Hospital for Joint Diseases, New York, New York

    We appreciate the interest in our paper. The purpose of this study was to draw attention to the differential rate of recovery following distal radius fractures between ethnic subpopulations in our urban patient population. This was a retrospective review of prospectively collected data and as such has several limitations, which are described within the discussion section of our paper. Ms. Ali’s assumption that our study is incomplete because it lacks 2-year follow up is incorrect. Most studies that look at functional outcome after fracture regard one year as adequate follow up. The reference used by Ms. Ali is an informational pamphlet from the AAOS, meant to guide patient expectations, not scientific literature. The vast majority of outcome research in orthopaedic fracture care focuses on one year outcomes. Moreover, the authors of this report have published similar one-year follow-up data on ankle fracture in this same journal.

    Regarding poor compliance with physical therapy, the authors do recognize that this can contribute to differential outcomes. We did not have sufficient data to adequately define occupation across ethnicity and so could not adjust for job type in our analyses. We recognize the possibility that more physically demanding jobs may delay functional recovery in distal radius fracture patients. We further recognize that if such jobs are distributed unequally across ethnicity that this may contribute to the differential recovery rates observed in our patient population. However, as mentioned above, we lacked the necessary data to assess this. We would like to point out that our paper identifies an ethnic disparity in functional recovery, our paper does not, and cannot, explain why this exists because we did not measure the factors that contribute to it. This is pointed out in the discussion section of the paper and highlights the need for further investigation that explores the potential causes of disparity in orthopaedic trauma outcomes. Additionally, we feel the observation that states, “...it would be reasonable to assume that Latinos of particular professional backgrounds are more prone to distal radial fractures” is flawed. There is no reason that a Latino in a service industry job is more prone to a distal radius fracture than an African American or Caucasian in the same industry.

    Osteoporosis screening was not a part of this study; therefore we could not adjust for bone mineral density as the author suggests. As is clearly described in the paper, there were no differences between patients with respect to mechanism of injury as the majority of patients sustained low energy falls. Distal radius fractures are fractures of osteoporosis, which is most common in older Caucasian women. Again our purpose is not to identify causative factors for fracture, but the differential response to treatment. Regardless of the underlying cause, our data does show a differential response to treatment that physicians need to recognize and understand. As acknowledged in our original publication, our findings indicate the need for future efforts to focus on identifying the factors contributing to outcome disparities so that they can be eliminated.

    Amber Ali
    Posted on July 01, 2010
    Recovery of Latinos From Distal Radial Fracture
    Department of Health Disparities Research, MD Anderson Cancer Center, Houston, Texas

    To the Editor:

    In the recent study published in The Journal of Bone and Joint Surgery entitled, "Ethnic Disparities in Recovery Following Distal Radial Fracture" (1), Walsh, Davidovitch and Egol explain that Latinos significantly differ from Whites in regard to recovery after a distal radial fracture. Readers are led to believe that “these ethnic disparities may result from multifactorial sociodemographic factors”; however, the study clearly states that controls have been set for age sex, level of education, and workers’ compensation status. Although this research makes a great contributor to medical literature, a clear conclusion was not stated in order to make a valid reasoning from the data and results.

    Improvement in movement and function following a distal radial fracture, or a Colles fracture, requires at least two years, according to the American Academy of Orthopedic Surgeons (2). This study is incomplete because it observed only half of the recovery time necessary for this particular fracture. Each individual takes a different amount of time to return to normal functioning. Therefore, the study does not consider the time that may be needed for other patients that may need a longer recovery period. It is also important to note that the type of injury, the type of treatment received, and the individual body’s response are all determining factors in recovery. The Latino patients may have had more potential for recovery in the 13 to 24 months that followed the researchers’ data collection period. A discovery can be made stating that Latinos may just have a slower rate of improvement in terms of fractures instead of reaching the generalization that “multifactorial sociodemographic factors” were the cause of the disparities.

    This study also failed to collect several important pieces of data from the observed patients. After the recommended treatment was performed, therapy sessions began to be conducted. Since the quality of care was not a control, as stated by the authors as a limitation, readers are not aware of the kind of after-care received by the patients. After-care of the wrist or of any sort of injury is crucial for a successful recovery. Reports from this research, however, do show that Latinos attended an average of only 68% of the physical therapy sessions that Whites attended in the time span of one year. Not having a measure of the quality of health care the patients received makes it difficult to understand exactly why Latinos suffered more pain and had a harder time in regaining wrist function. Knowing how the patients themselves treated their fractures is also substantial information that can lead to an explanation of results. The jobs held by the subjects are unknown, therefore one also cannot assume that repeated physical stress at work was irritating the fracture and delaying recovery. If, for instance, the majority of the Latinos that were surveyed held an office position, then this information would serve as insight to understanding why there was a disparity in the recovery of the Latinos. Because corporate jobs that require employees to work on the computer for a majority of the time puts stress on the workers’ wrists, injuries such as the Colles fracture become common. This scenario also applies to the Latinos working in fields or construction sites all day since “nearly one in four (24%) work in service occupations; 22% in sales and office jobs; 17% in construction, extraction, and maintenance jobs; 18% in production, transportation, and material moving occupations; and 2% in farming, fishing, and forestry occupations” (3). Consequently, it would be reasonable to assume that Latinos of particular professional backgrounds are more prone to distal radial fractures.

    Screening for bone density amongst the patients would have also been warranted in the methodology used to conduct this study. According to the National Osteoporosis Foundation (4), “ten percent of Hispanic women aged 50 and older are estimated to have osteoporosis, and 49 percent are estimated to have low bone mass”. Without awareness of the patients’ medical histories, it is impossible to reach a definite conclusion from this study.

    The reason as to why the patients fractured their wrists is very crucial because if it is indeed due to osteoporosis and weakened bones and joints, then this would explain the disparity. Several future bone-related injuries can also be prevented by screening the patients and raising awareness in bone health. The average person is still unaware how vital vitamin D is for the strengthening of our bones (5). Despite the valuable information that has not been included, the article addressing the disparities amongst Latinos with distal radial fractures shed light upon a very serious problem. This topic is very current and in need of additional attention by these and other researchers. It is hopeful that this editorial may add to comprehension of the study conducted by Walsh, Davidovitch and Egol and that researchers will continue to address this issue of health concern, recognizing a coherent reasoning for the disparity.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Walsh M, Davidovitch RI, Egol KA. Ethnic disparities in recovery following distal radial fracture. J Bone Joint Surg Am. 2010;92:1082-7.

    2. AAOS. Your orthopaedic connection: distal radius fracture. http://orthoinfo.aaos.org/topic.cfm?topic=a00412. Accessed 2010 Jun 28.

    3. National Council of La Raza. Twenty of the most frequently asked questions about Hispanics in the U.S. 30 June 2010. http://www.nclr.org/content/faqs/detail/396. Accessed 2010 Jun 30.

    4. National Osteoporosis Foundation. Fast facts on osteoporosis. http://www.nof.org/osteoporosis/diseasefacts.htm. Accessed 2010 Jun 28.

    5. Stumpf T. Bone health and vitamins D and K. 2007 Dec 17. http://www.chiroeco.com/article/edit-series/DL ESeries iss20BG07.pdf. Accessed 2010 Jun 30.

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