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Letter to the editor in response to the article of Dekkers and Søballe (Activities and impairments in the early stage of rehabilitation after Colles' fracture; Vol. 26, No. 11, June 3, 2004)

To the Editor We read the recent article by Dekkers and Søballe on early rehabilitation after Colles fracture with interest [1]. Of particular note is the relatively high rate of functional impairment which the authors documented 5 weeks after removal of plaster casts, with one-third of patients not able to perform all basic activities of daily living at 5 weeks after removal of plaster casts. The authors found that, in the short-term, functional impairment is correlated with pain with an improving tendency. Lately the influence of pain and analgesia on disease outcome is increasingly recognized [2,3]. However, until now it is not clear how acute pain at the time of fracture affects long-term outcome. We recently completed a questionnaire survey of all acute distal radius fractures treated between June 2000 and June 2002 at our institution. Patients were questioned about their pain at fracture and reduction, about pain and degree of functional recovery 6 months later, and their responses scored. (Pain: 0= none, 1= some, 2= severe; Function: 1= complete recovery, 2 =moderate recovery, 3 = some recovery, 4= no recovery). Sixty-three patients (mean 58, SD 17, range 20 – 88 years; 81% females) underwent closed reduction and plaster cast immobilisation for an acute distal radius fracture. We found that only 31 (49%) of these patients showed complete functional recovery 6 months after fracture, with nine (14%) reporting no recovery whatsoever at this time. Thirteen (21%) and 10 (16%), respectively, reported ‘moderate recovery’ or ‘some recovery’. The results for pain at 6 months were only marginally better, with 34 (54%) being completely pain free compared to eight (13%) still suffering from ‘severe pain’ and 21 (33%) still reporting some pain. Twelve (17%) of our group experienced severe pain during both fracture and reduction; in this group, four (25%) reported complete functional recovery 6 months after fracture and three (33%) reported none. Spearman correlation of the combined pain scores at fracture and reposition versus scored functional or pain outcomes was significant, with statistically significant (P5 0.05) Spearman R coefficients of 0.33 and 0.41, respectively. The results of our survey confirm the relatively poor outcome results of the study by Dekkers and Søballe [1]. Furthermore, we demonstrate that these outcome results also apply to other groups than women aged 50 years or more and that they also persist for up to 6 months after the fracture. Of interest is the fact that the acute pain surrounding fracture and reposition appears to have a significant detrimental impact on both functional and pain outcomes up to 6 months afterwards. The results of this survey suggest that pain and its prevention may play a significant role in outcomes after distal radius fracture. Thus, analgesia should be viewed not only in the context of the humanitarian obligation to relieve pain, but also as a therapeutic manoeuvre with the goal of facilitating early restoration of function [4,5]. We recommend that this factor be taken into account in future studies of outcome and rehabilitation after distal radius and other fractures.