Outcomes of Hand Fracture Treatments

Published:October 17, 2013DOI:https://doi.org/10.1016/j.hcl.2013.08.013

      Keywords

      Key points

      • Clinicians and researchers should use established and validated outcomes measures when assessing objective and subjective functional recovery.
      • The 36-Item Short Form Health Survey is designed to assess the general health of a population and is therefore not specific to the function of the extremity or the hand.
      • The Disabilities of the Shoulder, Arm, and Hand (DASH) questionnaire is a validated subjective outcomes measure of the upper extremity. Its use is well described in evaluating hand fracture outcomes, but concurrent injuries to the ipsilateral upper extremity as well as lower extremity injuries can negatively affect the reported DASH score.
      • The Patient-rated Wrist Hand Evaluation is a reliable and validated outcomes measure that has been used to assess patients with hand fractures. It has been shown to be more responsive than the DASH when specifically evaluating patients with hand and wrist injuries.
      • The Michigan Hand Questionnaire was specifically designed to subjectively evaluate the outcomes of patients with disorders of the hand. Although sensitive to detecting clinical changes in function, it has shown decreased correlation with overall patient disability.
      • The Jebsen-Taylor Hand Function Test is a validated, objective measure of hand functional capacity and its use is well established in the analysis of numerous disorders of the hand and fingers.
      • Physical examination is fundamental to predicting overall functional outcomes of the hand. However, normative values vary depending on age, gender, and hand dominance. Also, in certain situations the contralateral hand is not an accurate functional control.
      • Radiographic assessment is an important aspect of the overall outcome following hand fractures, although radiographic findings do not always correlate with functional recovery.
      • To date, a single, gold-standard outcomes assessment tool has yet to be identified. A combination of the currently established and validated outcome measurements may be required to comprehensively evaluate function, pain, disability, and treatment response.

      Introduction

      When evaluating outcome measures in medicine, the goal of any analysis should be to determine the beneficial or detrimental effect of a given intervention on a specific condition, disease, or injury. For an outcome measure to be helpful, it must be readily understood and administered and have been proved valid and consistent over a variety of demographic and cultural groups. The results of a reliable outcome measure should help predict the outcome of a treatment in a given patient population and guide future treatments for overall patient benefit.
      The bones of the hand are the most commonly injured part of the body, with fractures of the phalanges and metacarpals (Fig. 1, Fig. 2, Fig. 3, Fig. 4) accounting for up to 10% of all fractures of the axial skeletal system.
      • Emmett J.E.
      • Breck L.W.
      A review and analysis of 11,000 fractures seen in a private practice of orthopaedic surgery, 1937–1956.
      • Omokawa S.
      • Fujitani R.
      • Dohi Y.
      • et al.
      Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system.
      • Shimizu T.
      • Omokawa S.
      • Akahane M.
      • et al.
      Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate.
      • Egol K.A.
      • Koval K.J.
      • Zuckerman J.D.
      • et al.
      Handbook of fractures.
      Hand fractures are most commonly observed in men during the second and third decades of life, resulting from trauma or industry-related injuries in up to 50% of cases.
      • Egol K.A.
      • Koval K.J.
      • Zuckerman J.D.
      • et al.
      Handbook of fractures.
      Most phalangeal and metacarpal fractures can be treated nonoperatively; however, certain fracture types warrant surgical intervention.
      • Shimizu T.
      • Omokawa S.
      • Akahane M.
      • et al.
      Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate.
      • Pun W.K.
      • Chow S.P.
      • So Y.C.
      • et al.
      A prospective study on 284 digital fractures of the hand.
      • Freeland A.E.
      • Orbay J.L.
      Extraarticular hand fractures in adults: a review of new developments.
      Numerous surgical techniques have been described in the treatment of phalangeal and metacarpal fractures. The specific technique used depends on the characteristics of the fracture and the preferences of the surgeon. Possible surgical treatment options include
      • Freeland A.E.
      • Orbay J.L.
      Extraarticular hand fractures in adults: a review of new developments.
      :
      • Closed reduction and percutaneous pin fixation
      • External fixation
      • Open reduction with internal fixation
      Figure thumbnail gr1
      Fig. 1Posteroanterior (A), lateral (B), and oblique (C) views of the hand showing a displaced fracture of the base of the middle finger proximal phalanx.
      Figure thumbnail gr2
      Fig. 2Oblique (A) and lateral (B) radiographs showing a displaced fracture of the middle finger metacarpal mid-shaft.
      Figure thumbnail gr3
      Fig. 3Oblique (A) and lateral (B) radiographs demonstrating displaced spiral oblique fractures of the middle and ring metacarpals.
      Figure thumbnail gr4
      Fig. 4Posteroanterior radiograph showing fracture of the ring metacarpal neck.
      The commonly used implant types for fixation include
      • Freeland A.E.
      • Orbay J.L.
      Extraarticular hand fractures in adults: a review of new developments.
      :
      Several outcome measures have been used to evaluate the results of the various treatment modalities for hand fractures. These include:
      • Objective measures
      • Patient-based subjective measures
      • Radiographic assessments
      At present, no single outcome measure is widely accepted as the gold standard by which to accurately predict function after treatment. In this article, an evidence-based evaluation of the advantages and disadvantages for each outcome measure and their practicality for use in clinical practice is provided.

      General patient-reported subjective outcomes

       The 36-Item Short Form Health Survey

      The 36-Item Short Form Health Survey (SF-36) is a commonly used outcome measure used to evaluate the general health of a population. Originally developed in 1980 as a 108-item questionnaire for the insurance industry, it was designed for use in general population surveys, health population evaluations, research, and clinical practice.
      • Ware Jr., J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
      • Brazier J.E.
      • Harper R.
      • Jones N.M.
      • et al.
      Validating the SF-36 health survey questionnaire: new outcome measure for primary care.
      Because the original survey was lengthy and difficult to use in clinical practice, the abbreviated SF-36 was created.
      It focuses on 8 health concepts
      • Ware Jr., J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
      :
      • Limitations in physical activities because of health problems
      • Limitations in social activities because of physical or emotional problems
      • Limitations in usual role activities because of physical health problems
      • Bodily pain
      • General mental health (psychological distress and well-being)
      • Limitations in usual role activities because of emotional problems
      • Vitality (energy and fatigue)
      • General health perceptions
      The condensed version has proved to be highly reliable and reproducible in validation studies by Brazier and colleagues.
      • Brazier J.E.
      • Harper R.
      • Jones N.M.
      • et al.
      Validating the SF-36 health survey questionnaire: new outcome measure for primary care.
      Given its relative ease of use and established validity, the SF-36 has been translated and validated in multiple languages and is commonly used as a reference standard when developing new outcome measures.
      In the analysis of hand fracture treatment outcomes, Hornbach and Cohen
      • Hornbach E.E.
      • Cohen M.S.
      Closed reduction and percutaneous pinning of fractures of the proximal phalanx.
      used a subset analysis of the SF-36 in the postoperative evaluation of patients following closed reduction and percutaneous pinning (CRPP) of proximal phalanx fractures. In this study, analysis of the average SF-36 component scores showed no abnormalities, but individual subscales showed differences in patients with malrotation.
      A Swedish study prospectively analyzed patients with injuries to the hand and forearm and the associated effects of these injuries on general health, function, health care costs, and societal costs using the SF-36 and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores, with hand fractures representing 38% of all injuries in this study. Small to minimal differences were noted in physical and pain subsets and correlated with the results observed from the DASH scores.
      • Rosberg H.E.
      • Carlsson K.S.
      • Dahlin L.B.
      Prospective study of patients with injuries to the hand and forearm: costs, function, and general health.
      Although the SF-36 has proved to be a reliable and valid tool for outcome measures, it also has limitations. The SF-36, and its 108-item predecessor, were designed to assess the general health of a population and are therefore not specific to the extremity or the hand. As such, it has few questions that are affected by limitations of the upper extremity and is not ideal for analyzing local symptoms or function.
      • Rosberg H.E.
      • Carlsson K.S.
      • Dahlin L.B.
      Prospective study of patients with injuries to the hand and forearm: costs, function, and general health.
      • Schuind F.A.
      • Mouraux D.
      • Robert C.
      • et al.
      Functional and outcome evaluation of the hand and wrist.
      Medical, mental, and physical comorbidities that affect global health can negatively skew the overall SF-36 score of a patient with a hand injury.

      Extremity-specific patient-reported specific outcomes

       DASH Questionnaire

      Created in 1996 by Hudak and colleagues,
      • Hudak P.L.
      • Amadio P.C.
      • Bombardier C.
      Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
      the DASH questionnaire is a patient-rated outcomes measure that evaluates the upper extremity as a single functional unit.
      • Changulani M.
      • Okonkwo U.
      • Keswani T.
      • et al.
      Outcome evaluation measures for wrist and hand: which one to choose?.
      The developers’ goal was to provide a subjective means of evaluating patients’ upper extremity outcomes distinct from objective data measures such as radiographic and physical examination findings. The questionnaire consists of 30-items with 5 possible responses for each item. The DASH is scored from 0 to 100, with 0 being no disability and 100 being maximum disability. Two optional 4-item scales measure the ability to play sports or a musical instrument, and the ability to work.
      • Atroshi I.
      • Gummesson C.
      • Andersson B.
      • et al.
      The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients.
      Since its inception in 1996, the DASH assessment has been validated as an outcome measure in multiple languages.
      • Changulani M.
      • Okonkwo U.
      • Keswani T.
      • et al.
      Outcome evaluation measures for wrist and hand: which one to choose?.
      • Atroshi I.
      • Gummesson C.
      • Andersson B.
      • et al.
      The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients.
      • Gummesson C.
      • Atroshi I.
      • Ekdahl C.
      The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery.
      Gummesson and colleagues
      • Gummesson C.
      • Atroshi I.
      • Ekdahl C.
      The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery.
      performed a longitudinal study of treatment effects to determine a clinically significant change in DASH outcome after surgical treatment of upper extremity problems. A difference of 19 points on the DASH corresponded with a change of much better or much worse. A difference of 10 points corresponded with changes that were somewhat better or somewhat worse. Gummesson and colleagues
      • Gummesson C.
      • Atroshi I.
      • Ekdahl C.
      The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery.
      concluded that a 10-point difference in the preoperative to postoperative DASH score signifies the value needed to observe the minimally important change, most specifically when applied to subacromial impingement and carpal tunnel syndrome.
      The DASH questionnaire has been used extensively to measure patient-based outcomes after various hand injuries. Wong and colleagues
      • Wong J.Y.
      • Fung B.K.
      • Chu M.M.
      • et al.
      The use of Disabilities of the Arm, Shoulder, and Hand questionnaire in rehabilitation after acute traumatic hand injuries.
      prospectively evaluated 146 patients with acute hand trauma, 28% of whom had hand fractures, using the DASH score at initial and 10-week follow-up. There was a statistically significant improvement in the DASH during the course of treatment with improvement averaging 31 points, and the amount of change correlated with return to work. Dumont and colleagues
      • Dumont C.
      • Fuchs M.
      • Burchhardt H.
      • et al.
      Clinical results of absorbable plates for displaced metacarpal fractures.
      prospectively analyzed the clinical and functional outcomes of 12 patients with 14 displaced, unstable metacarpal fractures that were treated with open reduction with internal fixation using absorbable plate and screw constructs. Average postoperative DASH scores obtained at 6, 12, and 26 weeks were 30, 13, and 3, respectively. These scores correlated with an improvement in the visual analog score (VAS) for pain over the course of treatment.
      Ozer and colleagues
      • Ozer K.
      • Gillani S.
      • Williams A.
      • et al.
      Comparison of intramedullary nailing versus plate-screw fixation of extra-articular metacarpal fractures.
      used the DASH as a primary outcomes measure in a prospective comparison of internal fixation versus intramedullary nail fixation in 52 patients with extra-articular metacarpal fractures. The postoperative DASH for the plate-and-screw construct was slightly better than that of the intramedullary nail fixation group, but the difference did not reach statistical significance. In a prospective, randomized controlled trial by Zyluk and colleagues
      • Zyluk A.
      • Budzynski T.
      Conservative vs operative treatment of isolated fractures of phalanges: results of the prospective, randomized study.
      the DASH was used to analyze the functional outcomes of patients with phalangeal fractures. In this study, 22 patients were treated with either closed reduction and percutaneous K-wire pinning or closed reduction and immobilization, with 2-month and 6-month follow-up evaluations. For the operative group, the mean DASH scores at 2 months and 6 months were 25 and 7, respectively. The patients treated with closed reduction and immobilization showed mean DASH scores of 8 at 2 months and 3 at 6 months. Although a trend toward better DASH scores was observed for the nonoperative group at both follow-up evaluations, the difference between groups did not reach statistical significance.
      • Zyluk A.
      • Budzynski T.
      Conservative vs operative treatment of isolated fractures of phalanges: results of the prospective, randomized study.
      Functional outcomes following nonoperative treatment of hand fractures have also been evaluated using the DASH. In a prospective randomized trial, Hofmeister and colleagues
      • Hofmeister E.P.
      • Kim J.
      • Shin A.Y.
      Comparison of 2 methods of immobilization of fifth metacarpal neck fractures: a prospective randomized study.
      evaluated functional outcomes of patients with fifth metacarpal neck fractures who underwent treatment with closed reduction and immobilization using 2 different cast designs. Eighty-one active-duty military personnel received either a short-arm cast with volar outriggers (SAC-VOR) or a short-arm cast extended to the proximal interphalangeal (PIP) joint with a 3-point mold, placing the metacarpophalangeal (MCP) joints in extension (MCP-ext). Baseline DASH scores between the two groups were similar, as were all subsequent DASH scores over the following 3 months, although the DASH showed a trend toward less disability in the MCP-ext group compared with the SAC-VOR group.
      The DASH provides upper extremity surgeons with a more specific outcomes measures tool for function of the limb, compared with general questionnaires such as the SF-36, but its application to hand fractures has limitations. The DASH evaluates the upper extremity as a single functional unit and provides a regional evaluation of the limb and is thus not specifically geared to hand function. In the presence of ipsilateral shoulder, elbow, or wrist disorders, the DASH scores could reflect an increase in disability, even in the presence of a highly functional hand.
      • Schuind F.A.
      • Mouraux D.
      • Robert C.
      • et al.
      Functional and outcome evaluation of the hand and wrist.
      • MacDermid J.C.
      • Tottenham V.
      Responsiveness of the Disability of the Arm, Shoulder, and Hand (DASH) and Patient-rated Wrist/Hand Evaluation (PRWHE) in evaluating change after hand therapy.
      There is a paucity of literature examining the effect of comorbid upper extremity disorders on hand injury functional outcomes. In addition, disabling conditions of the lower extremity can negatively affect DASH scores in patients with comorbid upper extremity disorders. Dowrick and colleagues
      • Dowrick A.S.
      • Gabbe B.J.
      • Williamson O.D.
      • et al.
      Does the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system only measure disability due to injuries to the upper limb?.
      evaluated the DASH scores in 84 patients with upper extremity injuries, 73 patients with lower extremity injuries, and 49 control subjects, noting that patients with isolated upper and lower extremity injuries had statistically significantly higher DASH scores than the control group. It was concluded that any disability affecting the mobility and stability of the lower extremity can in turn cause limitations in upper extremity function and can be reflected in the DASH score.
      • Dowrick A.S.
      • Gabbe B.J.
      • Williamson O.D.
      • et al.
      Does the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system only measure disability due to injuries to the upper limb?.
      In addition, the general population normative DASH scores and the minimal numerical point value correlating with a clinically significant change in function may not apply to highly functioning individuals. In a study by Hsu and colleagues,
      • Hsu J.E.
      • Nacke E.
      • Park M.J.
      • et al.
      The Disabilities of the Arm, Shoulder, and Hand questionnaire in intercollegiate athletes: validity limited by ceiling effect.
      the validity of the DASH when applied to intercollegiate athletes was analyzed. The minimal numerical point value corresponding with a clinically significant change in the normal population could not be generalized to the athletes. Also, a ceiling effect pertained to the DASH scores in these athletes because they may obtain a normal DASH score before reaching their individual baseline physical function.

       Patient-rated Wrist Evaluation and Patient-rated Wrist Hand Evaluation

      The original Patient-rated Wrist Hand Evaluation (PRWE) was developed using a questionnaire in which physicians identified the factors they thought most indicative of patient recovery following wrist injury or surgery. These included pain intensity and frequency, frequently performed activities using either hand, and ability to perform activities of daily living.
      • Ritting A.W.
      • Wolf J.M.
      How to measure outcomes of distal radius fracture treatment.
      On average, a subject can complete the PRWE in 4 minutes.
      • Ritting A.W.
      • Wolf J.M.
      How to measure outcomes of distal radius fracture treatment.
      When used to evaluate patients with distal radius fractures and scaphoid nonunions, the PRWE showed excellent reliability. Validation of the survey was performed via comparison with specific components of the SF-36. A strong correlation between the SF-36 physical summary scores and PRWE scores was observed.
      • Changulani M.
      • Okonkwo U.
      • Keswani T.
      • et al.
      Outcome evaluation measures for wrist and hand: which one to choose?.
      Generated in 2004 as an offshoot of the PRWE, the Patient-rated Wrist Hand Evaluation (PRWHE) was developed as a more specific method of measuring functional outcomes in patients with hand disorders.
      • MacDermid J.C.
      • Tottenham V.
      Responsiveness of the Disability of the Arm, Shoulder, and Hand (DASH) and Patient-rated Wrist/Hand Evaluation (PRWHE) in evaluating change after hand therapy.
      MacDermid and colleagues
      • MacDermid J.C.
      • Tottenham V.
      Responsiveness of the Disability of the Arm, Shoulder, and Hand (DASH) and Patient-rated Wrist/Hand Evaluation (PRWHE) in evaluating change after hand therapy.
      compared it with the DASH, and the PRWHE was slightly more responsive for patients with wrist and hand injuries. In addition, with half as many items as the DASH, the PRWHE is shorter and more readily administered. A group of hand therapists supported this finding, stating that the PRWHE was simpler to use for both them and their patients. The PRWE is commonly used in the assessment of carpal tunnel syndrome, distal radius fractures, and other wrist based disorders, but the use of the more recently developed PRWHE has not been well described in evaluating hand fracture outcomes.
      • MacDermid J.C.
      • Tottenham V.
      Responsiveness of the Disability of the Arm, Shoulder, and Hand (DASH) and Patient-rated Wrist/Hand Evaluation (PRWHE) in evaluating change after hand therapy.

       The Michigan Hand Outcomes Questionnaire

      The Michigan Hand Outcomes Questionnaire (MHQ) was developed in 1998 to specifically evaluate the overall health and function in patients with hand disorders. Originally consisting of 100 items, the current MHQ assessment tool represents a more focused and user-friendly 37-item survey that encompasses 6 domains
      • Horng Y.S.
      • Lin M.C.
      • Feng C.T.
      • et al.
      Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire in patients with hand injury.
      • Naidu S.H.
      • Panchik D.
      • Chinchilli V.M.
      Development and validation of the hand assessment tool.
      :
      • Overall hand functioning
      • Activity of daily living
      • Pain
      • Work performance
      • Aesthetics
      • Patient satisfaction with hand functioning
      Cumulative scoring for the MHQ ranges from 0 to 100, with 0 representing minimal or worse function and 100 representing maximum function. The 37-item MHQ has undergone rigorous psychometric testing and showed high reliability and construct validity on each of the 6 domains, with the highest construct validity for activities of daily living. With high marks for reliability and validity, Chung and colleagues
      • Chung K.C.
      • Pillsbury M.S.
      • Walters M.R.
      • et al.
      Reliability and validity testing of the Michigan Hand Outcomes Questionnaire.
      reported the MHQ to be an excellent tool for assessing outcomes following hand surgery. Further testing of the MHQ by Chung and colleagues
      • Chung K.C.
      • Hamill J.B.
      • Walters M.R.
      • et al.
      The Michigan Hand Outcomes Questionnaire (MHQ): assessment of responsiveness to clinical change.
      showed that the instrument is responsive to the self-assessment of a patient’s clinical change.
      The MHQ has been used to analyze clinical outcomes following K-wire/traction device treatment of intra-articular PIP joint fractures. Theivendran and colleagues
      • Theivendran K.
      • Pollock J.
      • Rajaratnam V.
      Proximal interphalangeal joint fractures of the hand: treatment with an external dynamic traction device.
      reported that the average MHQ for 12 patients at mean follow-up of 24 weeks was 90, 6 points higher than the MHQ in another study of 7 patients with an average of 13.1 months’ follow-up treated with a similar construct.
      • Deshmukh S.C.
      • Kumar D.
      • Mathur K.
      • et al.
      Complex fracture-dislocation of the proximal interphalangeal joint of the hand. Results of a modified pins and rubbers traction system.
      • Suzuki Y.
      • Matsunaga T.
      • Sato S.
      • et al.
      The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracture-dislocations in the hand.
      They attributed the high MHQ score of 90 to the dynamic nature of their construct, allowing for early mobilization and preventing excessive arthrofibrosis.
      Although sensitive at detecting clinical changes in function, the MHQ has shown decreased correlation with overall patient disability compared with the DASH.
      • Horng Y.S.
      • Lin M.C.
      • Feng C.T.
      • et al.
      Responsiveness of the Michigan Hand Outcomes Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire in patients with hand injury.
      Other limitations of the MHQ include its length. At 37 items, it takes on average 15 minutes for a patient to complete the questionnaire.
      • Waljee J.F.
      • Kim H.M.
      • Burns P.B.
      • et al.
      Development of a brief, 12-item version of the Michigan Hand Questionnaire.

       Jebsen-Taylor Hand Function Test

      Developed in 1969, the Jebsen-Taylor Hand Function test (JTT) is a standardized and objective measure of hand function. It is composed of 7 subtests designed to provide a broad sampling of hand functional capacity
      • Jebsen R.H.
      • Taylor N.
      • Trieschmann R.B.
      • et al.
      An objective and standardized test of hand function.
      :
      • Writing
      • Simulation of page turning by turning over a 7.6 × 12.7 cm (3 × 5 inch) card
      • Picking up small common objects
      • Simulated feeding
      • Stacking checkers
      • Picking up large light objects
      • Picking up large heavy objects
      Over time, modifications of the JTT have been described. These modifications include eliminating the writing portion of the test, because this can depend on hand dominance, and administering the remaining 6 subtests with a strong enough correlation with activities of daily living and deformity to maintain the validity of the modified JTT.
      • Davis Sears E.
      • Chung K.C.
      Validity and responsiveness of the Jebsen-Taylor Hand Function Test.
      In a study by Hornbach and colleagues
      • Hornbach E.E.
      • Cohen M.S.
      Closed reduction and percutaneous pinning of fractures of the proximal phalanx.
      the JTT was used to evaluate the clinical and functional outcomes of 11 patients with proximal phalanx fractures treated with CRPP using K wires. Abnormal JTT scores were seen with increasing PIP flexion contractures. Subjective evaluation with the VAS was satisfactory and only minimal functional compromise was reported.
      • Hornbach E.E.
      • Cohen M.S.
      Closed reduction and percutaneous pinning of fractures of the proximal phalanx.
      Advantages of the JTT include its ease of administration and validation in the assessment of multiple hand disorders. It can also be readily modified to exclude the written subtest when deemed appropriate. However, Davis Sears and Chung
      • Davis Sears E.
      • Chung K.C.
      Validity and responsiveness of the Jebsen-Taylor Hand Function Test.
      found poor correlation between the JTT and patient-reported measures of disability, including patient satisfaction and domains that relate to activities of daily living, work, and function as assessed by the validated MHQ. In addition, the JTT was not as sensitive in detecting changes following hand surgery as the patient-reported responses obtained from the MHQ. They concluded that the JTT was a poor indicator of improvement and not a useful measure of the efficacy of treatments in hand surgery or of patient’s ability to perform activities of daily living.

      Physical examination measures of outcomes

      Physical examination of the hand includes the arc of motion through full flexion to full extension of each joint. In addition, grip, key, and pinch testing are frequently performed using a dynamometer and pinch meter. These measured values are often reported as a percentage of the control values obtained from the unaffected contralateral side. However, concurrent disorders of the upper extremity and cervical spine, as well as hand dominance, can distort the measured values. Other factors within a given population, such as gender and age, can also cause variation in the normative values.
      One way to measure digital range of motion is by calculation of the total active motion (TAM). TAM of a digit is defined as the sum of active flexion measurements at the MCP joint, PIP joint, and distal interphalangeal (DIP) joints minus the active extension deficits at the same three joints. Normal values for the TAM range from 260° to 270°.
      • Faruqui S.
      • Stern P.J.
      • Kiefhaber T.R.
      Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and outcomes.
      In a retrospective study by Faruqui and colleagues,
      • Faruqui S.
      • Stern P.J.
      • Kiefhaber T.R.
      Percutaneous pinning of fractures in the proximal third of the proximal phalanx: complications and outcomes.
      the postoperative TAM in patients undergoing percutaneous pinning of fractures in the proximal third of the proximal phalanx was analyzed. The proximal phalanx fractures were treated with either transarticular pinning or extra-articular cross-pinning fixation techniques. Mean postoperative TAM for the transarticular group and cross-pinning group were 201° and 198°, respectively. Motion at the PIP joint was most affected, with nearly half the patients from both groups losing greater than 20° of flexion.
      Horton and colleagues
      • Horton T.C.
      • Hatton M.
      • Davis T.R.
      A prospective randomized controlled study of fixation of long oblique and spiral shaft fractures of the proximal phalanx: closed reduction and percutaneous Kirschner wiring versus open reduction and lag screw fixation.
      prospectively analyzed the functional outcomes of patients treated surgically for long oblique or long spiral fractures of the proximal phalanx. In this trial, 32 patients were randomized to receive treatment with CRPP with K wires or open reduction internal fixation with lag screws. Of the 32 patients enrolled, 28 were available for evaluation at a mean follow-up of 40 months. At final follow-up there was no statistically significant difference in active range of motion between the two groups with respect to PIP motion, DIP motion, and fingertip-to-palm distance. However, 3 of the patients treated with lag screw fixation showed decreased interphalangeal (IP) joint flexion with the MCP joint extended, indicating intrinsic muscle tethering. In addition, 5 patients from both treatment groups showed weakness with abduction and adduction at final follow-up. In light of these minor findings, no statistically significant difference in hand grip and finger pinch strengths between the two groups was observed.
      In a study by Shimizu and colleagues,
      • Shimizu T.
      • Omokawa S.
      • Akahane M.
      • et al.
      Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate.
      predictors of postoperative range of motion for comminuted periarticular metacarpal and phalangeal fractures treated with titanium plates were analyzed. Using the percentage TAM compared with the unaffected contralateral digit, they identified fracture location, soft tissue injury, and age as predictors of postoperative motion. Phalangeal fractures, associated soft tissue injuries, and increased age were all correlated with decreased percent TAM after surgery.
      Grip and pinch values have been used for outcomes measurement, but normative means vary and depend on factors such as age, gender, fatigue, and hand dominance. Grip strength values vary from 5 kg for the nondominant hand in women more than 75 years of age to 73 kg for the dominant hand in men 24 to 34 years of age.
      • Massy-Westropp N.
      • Rankin W.
      • Ahern M.
      • et al.
      Measuring grip strength in normal adults: reference ranges and a comparison of electronic and hydraulic instruments.
      In an attempt to better define the observed variations across a given population, Walker and colleagues
      • Walker P.S.
      • Davidson W.
      • Erkman M.J.
      An apparatus to assess function of the hand.
      analyzed the normal range of motion, pinch strength, and grip strength. Although men and women had similar range-of-motion profiles, men had 40% stronger pinch strength and double the grip strength of women. Mathiowetz and colleagues
      • Mathiowetz V.
      • Kashman N.
      • Volland G.
      • et al.
      Grip and pinch strength: normative data for adults.
      reported that grip strengths were highest in the age range of 25 to 39 years, with a subsequent decline over time. Tip, key, and palmar pinch strength were stable from ages 20 to 59 years and then declined with age.
      Omokawa and colleagues
      • Omokawa S.
      • Fujitani R.
      • Dohi Y.
      • et al.
      Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system.
      prospectively analyzed the functional outcomes of patients treated for comminuted periarticular metacarpal and phalangeal fractures using a titanium plate system. Of the 51 patients enrolled, at the time of final follow-up postoperative TAM was excellent in 26 patients, good for 17, fair for 5, and poor for 3 patients. Average postoperative grip strength in these patients was 87% compared with the contralateral side. This study shows the direct correlation between grip strength and TAM and how, when possible, these measures should be combined to provide a complete objective function outcome analysis.

      Radiographic measurements of outcome of hand fractures

      Radiographic evaluation is critical in the assessment of hand fracture outcomes. Serial radiographs are used to evaluate the alignment, bony healing, and hardware positioning of both operative and nonoperatively treated fractures.
      Vahey and colleagues
      • Vahey J.W.
      • Wegner D.A.
      • Hastings 3rd, H.
      Effect of proximal phalangeal fracture deformity on extensor tendon function.
      evaluated radiographic alignment in a study of proximal phalanx fractures. Apex palmar angulated malunions resulted in skeletal shortening, extensor tendon lengthening, and PIP joint extensor lag. The radiographically measured apex palmar angulations of 16°, 27°, and 46° corresponded with extensor lags of 10°, 24°, and 66°, respectively. Other studies have substantiated this correlation, reporting a direct relationship between skeletal shortening and extensor lag.
      • Orbay J.L.
      • Touhami A.
      The treatment of unstable metacarpal and phalangeal shaft fractures with flexible nonlocking and locking intramedullary nails.
      In nonoperatively treated hand fractures, radiographs are used to assess outcomes of specific treatments. Tavassoli and colleagues
      • Tavassoli J.
      • Ruland R.T.
      • Hogan C.J.
      • et al.
      Three cast techniques for the treatment of extra-articular metacarpal fractures. Comparison of short-term outcomes and final fracture alignments.
      performed a retrospective analysis of 3 casting techniques following closed reduction of extra-articular metacarpal fractures in 263 patients. In group 1, patients were immobilized with the MCP joint flexed but allowing full range of motion of the IP joints. Group 2 patients were casted with the MCP joint in extension with full range of motion of the IP joints permitted, and group 3 patients were treated with the MCP joint flexed and IP joints in extension. Anteroposterior and lateral radiographs were completed immediately following reduction and casting, at the 5-week follow-up after cast removal, and at the final 9-week follow-up appointment. Comparison of the radiographs for all 3 groups showed no statically significant difference in fracture alignment at any time point. At final follow-up, all 263 patients had radiographic evidence of healing and had returned to preinjury functional capacity.

      Summary

      Numerous methods to evaluate outcome measures for hand fractures have been described and validated in the literature. These methods include patient-reported subjective measures, objective functional examination measures, a combination of both subjective and objective measures, and radiographic outcomes. There is no universally used outcome measure for hand fractures, although the optimal tool would be easily administered and comprehensive with regard to function, pain, disability, and responsive to surgery and over time. Unless a gold-standard outcomes assessment tool is identified, a combination of the currently established and validated outcome measurements may be required to obtain this information. The senior author has used the DASH score primarily in outcomes measurement, in addition to clinical and radiographic parameters. In addition, the SF-36 and Michigan hand questionnaire have been used to evaluate patient outcomes.

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