Orthopedic injury, classification of the patient and the fracture

In this thesis clinical studies and literature research were presented to assist
physicians in the decision-making process for treatment of orthopaedic trauma
patients
Part 1 - Classification of the patient
Pain and disability are often associated with physical factors such as stiffness and
movement patterns, and behavioral or psychological factors (e.g. fear, beliefs, stress,
depression, physical inactivity). As a result, (conservative) interventions can be
broadly categorized into physical, psychological or combined interventions. Pain
and disability are often misinterpreted by patients but also by physicians. Since
psychological factors are often undervalued, although they are important or even
the most important predictors of symptom intensity and disability.
Physical interventions usually aim to improve physical capacity. Behavioral and
psychologically informed interventions aim to improve behaviors, cognitions or
mood (e.g. relaxation and cognitive behavioral therapy). Combined interventions
aim to improve physical and psychological factors, contributing to patients’ pain
and helping them understand the pathophysiology of the pain.
The studies presented in this thesis can assist physicians in the decision-making
process for treatment of orthopedic injuries. The focus thereby lies on the
classification of both disease and patient characteristics. In other words, we should
both treat the physical and the psychological aspects of the patients’ disease.
In chapter 2 a prognostic cohort was presented to measure factors correlated
with the patient’s expectations and if their expectations were met after the
appointment with the physician. Higher pre-visit expectations were associated
with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and
lower social economic status. Patients in the low and moderate met expectations
categories had significantly more symptoms of depression, and more disability
compared to those in the high-met expectations category.
Cognitive flexibility and psychological distress influence a patient’s expectations
and decision-making process. Cognitive flexibility is better known as a patient’s
mental ability to switch thinking between different concepts, adaptation and
resilience. In chapter 3 we showed that cognitive flexibility had no correlation with
patient disability or pain. However, there was a correlation between self-efficacy
and symptoms of depression and disability. This suggests that physicians should focus more on improving a patients coping strategies rather than encouraging
one’s open mindedness.
Prior research has described that psychosocial factors such as symptoms of
depression and low pain self-efficacy correlate with pain intensity and magnitude
of limitations in patients with some musculoskeletal disorders. In chapter 4 we
presented a prognostic cohort exploring the correlation between pain self-efficacy,
depression and disability in patients with an ankle sprain. This study showed
that these psychosocial and coping factors explain more about the variation in
symptoms and limitations after ankle sprain than the degree of pathophysiology
such as pain, swelling and grade of the sprain.
Chapter 5 described the validation of an abbreviated 2-item questionnaire of the
pain self-efficacy questionnaire. Reduction of the number of questions of the
original PSEQ for screening purposes for patient self-efficacy will result in more
efficient screening and less burden for the patient and physician, making this a
more applicable tool in daily clinical practice.

Part 2 - Classification of the injury
Ankle injuries are the most frequent encountered injuries in the emergency
department of the lower extremity. Besides a fracture, a broad variety of ankle
ligaments can be affected. Therefore, proper assessment of an injury is of the
utmost importance to choose the appropriate treatment, and for prognostic
purposes. In the second part of this thesis we emphasized on the classification
and epidemiology of ankle injuries and explored its possible consequences for
treatment and prognosis.
Ideally a system for classification of injuries is easy to use in daily clinical practice.
The best classification system for describing ankle fractures is the Lauge Hansen
classification. However, the reproducibility of the Lauge Hansen classification is
mediocre with poor intra- and inter-observer variability. In chapter 6 we introduced
a new, more reliable more descriptive classification system for ankle fractures.
This new descriptive classification system showed better intra- and interobserver
variation in novice, semi expert and even in expert observers. To improve clinical
handoffs and reduce the limitations of current classification systems this descriptive
system is a useful alternative and can be further developed and implemented.
In chapter 7 a retrospective cohort was described comparing ankle fractures in
mono and polytrauma patients. This study showed that polytrauma patients
suffer a different type of ankle fracture. Mono trauma patients predominantly had
supination external rotation or pronation external rotation whereas supination
adduction or pronation abduction injuries were mostly observed in polytrauma
patients. This implicates that mono and polytrauma patients experience different
fracture patterns, which could be directly linked to the differences in energy
transfer.
To further assess differences between patients, a large retrospective series of
patients with surgical fixation of an ankle fracture was described in chapter 8. We
described epidemiology and other factors such as fracture classification associated
with general and implant related complications. Complications are determined by
patient-, trauma- and treatment factors, not by the postoperative care regimen. Most
frequent encountered complications were wound infections (10.2%) and implant
failure (4.4%). Postoperative wound related complications were multifactorial and
depended on a combination of trauma-, patient- and treatment related factors. In
contrast, implant related complications occurred due to the interaction between
the type of fracture (classified according to the Lauge Hansen classification) and
subsequent surgical treatment, perhaps making this a more important quality
parameter.
In the systematic review and meta-analysis presented in chapter 9 of this thesis
the effectiveness and safety of currently used post-operative care regimens
after surgically fixed ankle fractures was presented. This meta-analysis showed
that 1) active exercises and 2) early weight bearing expedite return to work
and resumption of daily activities compared to immobilization and late weight
bearing. There was also preliminary evidence that immediate unprotected weight
bearing as tolerated was a safe post-operative care regimen resulting in quicker
recovery and return to work. This systematic review and meta-analysis resulted in
the study design presented in chapter 10. In this chapter we present the rationale
and design of a multicenter prospective randomized controlled trial comparing 1)
protected weight bearing, 2) unprotected non-weight bearing and 3) immediate
unprotected weight bearing as tolerated. Inclusion is based on both patient
and fracture characteristics, synergizing the work in the previous chapters, in an
attempt to tailor treatment.