Title: Fractured wrist; predictors of poor long-term clinical and socioeconomic outcomes (The FILTER Study)
Funder: Department of Health and Social Care

Abstract: Each year approximately 78,000 people in the UK aged over 50 experience a fragility-fracture of the wrist. Many of these fractures occur in individuals who are functionally independent, active, and with good health-related quality of life. Existing research has largely investigated consequences of wrist fractures in populations over 65, and often with a narrow focus or single outcome of pain or hand disability, falls or future fractures. Yet, an estimated 20% of patients with wrist fracture are thought to develop broader functional decline, and frailty, with consequent increased healthcare use. Understanding the extent and burden of these long-term consequences and the prognostic factors that identify those at high risk is essential to select subgroups likely to benefit from early, targeted interventions. A recent national priority setting survey highlighted the need to prioritise the impact on functional outcomes and long-term health post fracture for future research Research question In patients over 50 years of age, what are the long term functional and socio-economic consequences of a fragility fracture of the wrist and what are the factors that will identify patients at risk of poor long-term outcomes. The objectives are to; Describe outcomes of overall function and participation which are important to patients, Identify long-term consequences in all patients over 50 years and in particular, in younger individuals (&ge;50-65 years), who are often still working at the time of fracture, Analyse and describe trajectories towards frailty and increased healthcare use which are essential to inform the long-term primary care management of patients post fracture, and Identify prognostic factors associated with unfavourable functional outcomes. Plan of investigation 1) In a systematic review, synthesise available evidence from studies and trials regarding long-term patient-reported outcomes following wrist fracture (pain, functional decline, complications, quality of life) and socio-economic (healthcare utilisation, work absence). potential prognostic factors, associated with risk of poor long-term outcomes 2) Using medical record data from a national primary care database Describe the long-term clinical outcomes of wrist fracture, compared to an age and sex matched control sample: i) functional decline (frailty trajectories). ii) healthcare utilisation (primary care clinical encounters, medication prescriptions, referrals, unplanned hospital admission). iii) time to complications (neuropathies, complex regional pain syndrome), first non-wrist fracture, and death. Describe patient characteristics associated with outcomes above (including age, gender, comorbidities, deprivation, lifestyle factors at the time of fracture) Benefits to patients/NHS The results of this study will provide unique and novel data regarding; estimates of the long-term impact and burden of fragility wrist fractures relevant to patients and the NHS in terms of function, participation, quality of life and subsequent healthcare use trajectories of frailty and healthcare use over the very long term (up to 30 years) in a large (~n=110,000) representative sample of people &ge;50 years experiencing wrist fracture prognostic factors likely to identify patients at high risk of poor outcome. Findings from this study may lead to better patient/public awareness of the potential long-term effects of wrist fractures and promote the need for better bone health. Equally an increased awareness of the impact to the NHS may also inspire new resourcing and rehabilitation approaches. Results will directly inform the design of a brief screening tool to assess patients after diagnosis of fracture. The tool will be rapidly evaluated across local clinical sites for face validity, acceptability, and practical value and in other national datasets for predictive performance. The screening tool alone could improve clinical decisions for onward referral of patients to existing pathways of care. Ultimately, we plan a randomised trial evaluating the clinical/cost-effectiveness of targeted interventions for those identified by the screening tool as at risk of poor long-term outcome.

Lay abstract: Broken wrists (wrist fractures) in people over 50 years old are very common, especially in women and there are approximately 78,000 each year in the UK. Many patients recover well from a wrist fracture. However, over half may continue to have pain, and 1 in 5 will develop long-term disability. Wrist fractures may affect the person s ability to work, look after themselves, prepare meals and move about confidently. Some patients risk losing their independence, becoming frail and even dying early. We want to be able to predict who will not recover well after a wrist fracture, so that those people can be offered more support and rehabilitation. We plan two pieces of work. Firstly, we will review existing research to assess long-term consequences of wrist fractures that are of importance to patients, such as impact on work and independence. Secondly, we plan to analyse data from a large national database of anonymised GP records. This will allow us to look at clinical outcomes in a very large number people (about 110,000) over a period of up to 30 years. We will investigate whether people become frail after their wrist fracture, and need more healthcare. Both pieces of work will assist us to highlight the features or characteristics of patients who did not recover well. Results will increase awareness of the burden and impact of the condition to patients and the NHS and will be utilised to design a screening tool (for use at diagnosis of wrist fracture) to identify patients who will need rehabilitation or extra treatment. In the future, we aim to test the screening tool and targeted rehabilitation packages in a randomised trial to determine whether better results for patients with wrist fracture can be achieved alongside reduced long-term costs to the NHS.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: INJURIES AND ACCIDENTS