Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Outcomes Following Plate Fixation of Fractures of Both Bones of the Forearm in Adults"
by Kurt P. Droll, MD, FRCS(C), et al.

Commentary & Perspective by
Jesse B. Jupiter, MD*,
Massachusetts General Hospital, Boston, Massachusetts

Posted December 2007

Droll and colleagues at St. Michael's hospital have produced an insightful retrospective study in which they evaluated objective measures of strength, investigated patient-based functional outcomes, and determined variables associated with upper-extremity and general health status.

The study supports the concept that the success of management of these fractures with internal fixation should be judged not only by rates of union but by functional outcomes as well. While it is very well accepted that stable internal fixation of forearm fractures offers a far better chance at a good functional outcome than alternative methods do, there still remain residual problems from any fracture, in part reflecting the reality that {these injuries also affect soft tissue and skeletal tissue.

While contemporary patient-rated outcomes leave much to be desired with regard to identifying specific issues (e.g., task-related difficulties, which may vary from patient to patient), the authors did clearly find that pain represents a major confounding variable with regard to patient-rated outcome evaluations and should be scored higher than it is currently scored in some outcome tools.

I do have some concerns regarding certain limitations of this study:

1. The cohort of patients in this study was relatively small and heterogeneous. The age range was very large, and some patients worked at labor-demanding jobs whereas others had less vigorous lifestyles.

2. The Baltimore Therapeutic Equipment Work Simulator (BTE) effectively tests strength to the maximum but may or may not reflect the strength required either for activities of daily living or the specific job requirements of the patients.

3. The authors do not address limb dominance, which can be a factor in younger individuals in their job or recreational requirements.

4. The manuscript text does not clearly stratify the data according to more complex skeletal lesions, soft-tissue lesions, neural lesions, or associated limb trauma. Certainly, major open fractures with soft-tissue trauma of the surrounding musculature will influence strength.

5. Some patients had transient nerve injuries; it would be useful to know if these patients had residual pain.

6. Subjective outcome tools such as the Short Form-36 (SF-36) may not adequately reflect the specific issues of the traumatic limb injury to warrant giving that tool much weight in the determination of outcome.

Despite these limitations, I agree in general with the observations and conclusions of the authors.

*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.