Comparison of volar-flexion, ulnar-deviation and functional position cast immobilization in the non-operative treatment of distal radius fracture in elderly patients : a pragmatic randomized controlled trial study protocol

STUDY PROTOCOL Open Access Compa ison o ola - lexion, ulna -de ia ion and unc ional posi ion cas immobiliza ion in he non-ope a i e ea men o dis al adius ac u e in elde ly pa ien s: a p agma ic andomized con olled ial s udy p o ocol Lau i Rai io 1* , An i Launonen 2 , Teemu He onko pi 1 , Toni Luokkala 3 , Juha Kukkonen 4 , Aleksi Rei o 3 , Baki Sum ein 2 , Minna Lai inen 2 and Ville M. Ma ila 1,2 Abs ac Backg ound: Dis al adius ac u es (DRFs) a e he second mos common ac u es, a e hip ac u es, seen in clinical p ac ice. The high incidence o low-ene gy auma DRFs in elde ly pa ien s aises ques ions abou he bes ea men me hod in e ms o unc ion, pain, and quali y o li e. Al hough he majo i y o hese ac u es a e ea ed non-ope a i ely wi h cas immobiliza ion, alid scien i ic e idence o he op imal cas immobiliza ion is lacking. In addi ion, se e al publica ions, including Coch ane e iew ha e ou lined he need o mo e e idence o de e mine he mos app op ia e me hod o cas immobiliza ion. Me hods: This s udy is a p agma ic, p ospec i e, andomized, mul i-cen e ial. The ial is designed o compa e wo widely used cas posi ions ( ola lexion-ulna de ia ion posi ion and unc ional posi ion) o he non-ope a i e ea men o DRF in pa ien s o e 64 yea s o age. The main hypo hesis o he ial is ha unc ion posi ion yields co esponding unc ional ou come, pain elie and quali y o li e when compa ed o he ola lexion-ulna de ia ion posi ion. The p ima y ou come measu e is Pa ien Ra ed W is E alua ion (PRWE) sco e and he seconda y ou come measu es will be he Disabili ies o he A m, Shoulde and Hand (DASH) sco e, Visual Analogue Scale (VAS), 15-dimensional (15D) alue and a e o su gical in e en ions. The esul s o he ial will be analysed a e 1 and 2-yea s. Discussion: This publica ion p esen s a p ospec i e, p agma ic, andomized, na ional mul i-cen e ial s udy p o ocol. I p o ides de ails o pa ien low, andomiza ion, ollow-up and me hods o analysis o he ma e ial as well as publica ion plan. T ial egis a ion: ClinicalT ials.go iden i ie : NCT02894983 22 Augus 2016. Keywo ds: Colles’ ac u e, Rehabili a ion, Conse a i e ea men , T ea men ou come, P ospec i e s udies, Pain, Clinical p o ocols * Co espondence: [email p o ec ed] 1 Uni e si y o Tampe e, School o Medicine, 33014 Tampe e, Finland Full lis o au ho in o ma ion is a ailable a he end o he a icle © The Au ho (s). 2017 Open Access This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion 4.0 In e na ional License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons license, and indica e i changes we e made. The C ea i e Commons Public Domain Dedica ion wai e (h p://c ea i ecommons.o g/publicdomain/ze o/1.0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed. Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 DOI 10.1186/s12891-017-1759-y Backg ound Dis al adius ac u es (DRFs) a e p e alen in he gen- e al popula ion, and in pa ien s o e 60 yea s o age hey a e he second mos common ac u es a e hip ac- u es. [1]. In elde ly pa ien s, DRFs a e ypically caused by a all om a s anding heigh o e an ou s e ched hand, whe eas in younge pa ien s he ac u e is mainly caused by high-ene gy auma such as mo o ehicle collisions [2, 3]. The popula ion-based ac u e inci- dence a ies be ween na ions. In No he n Eu ope, he o e all incidence is 200–320/100,000 pe son yea s and 550/100,000 pe son yea s in pa ien s o e 60 yea s o age [4–7]. The o e all ac u e incidence o DRFs in he No dic coun ies seems o ha e le elled o in he las wo decades [8]. The majo i y o DRFs a e ea ed wi h cas immobiliza ion. The heo e ical pu pose o he cas is o s abilize he ac u e, and hus o allow he bone o heal. Du ing cas immobiliza ion, he s abilized ac u e main- ains alignmen . Howe e , a signi ican p opo ion o ac u es will lose alignmen du ing cas immobiliza ion, >especially in olde pa ien s wi h os eopo o ic bone. The alignmen o hese uns able ac u es is o en accep able a e closed educ ion and a he beginning o cas immobiliza ion, bu is los du ing he pe iod he cas is wo n [9]. Se e al di e en immobiliza ion me hods o he non- ope a i e ea men o DRFs ha e been desc ibed [10–15]. These me hods o immobiliza ion include unc ional b a- cing, he immobiliza ion o he w is in neu al and sligh ly ex ended posi ion o in p ona ion o in supina ion. The o iginal educ ion in o ola lexion- was i s de- sc ibed by F ede ic J. Co on in 1910 [16]. The sligh lexion-ulna de ia ion- posi ion was popula ized by Cha nley in his seminal wo k [17]. I has been hough ha a sligh lexion-ulna de ia ion posi ion would induce so issue a ound he ac u e and he pull p oduced by adioca pal ligamen s (i.e. ligamen o axis) would esis he disloca ing o ces gene a ed o e he ac u e line [18, 19]. In clinical p ac ice, he lexion-ulna de ia ion pos- i ion can cause he common ex enso endons o igh en and p oduce inapp op ia e inge lexion du - ing ea men . Thus, he posi ion en ails p oblems wi h degene a i e join s ha a e ulne able o he s i ness p oduced by immobiliza ion, which is a common p ob- lem in elde ly people. In addi ion, a ise in ca pal un- nel p essu e om 18 mmHg o neu al posi ion o 47 mmHg o lexion posi ion has been de ec ed, [20] median ne e comp ession being he mos common complica ion o DRF [21, 22]. E alua ion o ea men T ea men ou comes o DRFs can be measu ed wi h a a ie y o ools. Pa ien - epo ed ou come measu es (PROMs) desc ibe a pa ien ’s iew o hei symp oms combined wi h unc ional s a us. The ools used in he e alua ion measu e he mobili y and usabili y o he o ea m and w is and include he Pa ien Ra ed W is E alua ion (PRWE) ques ionnai e, he Disabili ies o he A m, Shoulde and Hand (DASH) ques ionnai e, he Ga land-We ley ques ionnai e and he Visual Analogue Scale (VAS). A commonly used objec i e measu e is g ip s eng h. In addi ion, he 15D ques ion- nai emeasu es hepa ien ’s gene al quali y o li e h ough di e en ques ions and akes in o accoun di- e sea easo li e[23].Theou comesa eindexedand compa able wi h a e e ence popula ion and he pa- ien ’s own esul s a di e en s ages o he ea men [24]. In addi ion o PROM’s, pa ien cha ac e is ics ha e been shown o be associa ed wi h ea men ou - come [25]. The se e i y o acu e pain, ca as ophic hinking and auma- ela ed anxie y expe ienced by he pa ien a e measu ed using he pain ca as ophizing scale (PCS) [26]. The scale has been shown o be asso- cia ed wi h inge s i ness a e DRF [27], and i is one o he mos commonly used ools o measu ing he ca as ophic hinking ela ed o pain [26]. P e ious s udies The li e a u e on he non-ope a i e ea men o DRFs is ex ensi e. Howe e , p e ious s udies ha ha e examined he mos alid me hod o cas immobiliza ion ha e been mainly case s udies wi hou con ol g oups. The exis ing compa a i e ials lack uni o m and pa ien - a ed ou - come measu es, and su e om inadequa e andomizing and sho ollow-up pe iods [10–13]. In e es ingly, he e ha e been no p e ious s udies ha ha e compa ed he lexion-ulna de ia ion posi ion wi h he unc ional cas posi ion in elde ly pa ien s. Consequen ly, he Coch ane e iew has concluded he e is no enough e idence based on andomized con olled ials o conclude which me hod o cas immobiliza ion is he bes o he com- mon ypes o DRFs in he elde ly [28]. I has been shown ha he unc ional ou come o DRF in elde ly people (o e 64 yea s) is poo ly co ela ed o he adiog aphic ou come [29–35]. Mo eo e , i has been sugges ed ha unc ional ou come a e DRFs in elde ly pa ien s may be a ec ed by mo e han ac u e-speci ic ac o s. Pain ca as ophizing hough s and a ea o using he inju ed limb a e ela ed o disabili y, inc eased pain and muscle weakness in all uppe ex emi y aumas in- cluding DRF pa ien s [36–39]. Pain ca as ophizing as a p edic o o unc ional ou come has been mos ly s udied among pa ien s diagnosed wi h ch onic musculoskele al pain such as os eoa h i is, lowe back pain o acu e whiplash inju ies [40–42]. Pain ca as ophizing has no , howe e , been p e iously s udied in elde ly pa ien s wi h non-ope a i ely ea ed DRF. Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 Page 2 o 7 The aim o his p agma ic, andomized con olled s udy is o compa e unc ional ou come measu ed wi h PRWE sco e a e DRF ea ed wi h ola lexion-ulna de ia ion cas immobiliza ion o unc ional cas immobiliza ion in elde ly pa ien s o e 64 yea s o age. Fu he , we aim o assess whe he PCS and unc ional ou come a e DRFs a e associa ed. Me hods and design The p esen s udy is a p agma ic, p ospec i e, andom- ized con olled, mul i-cen e ial. The ial cen es a e Tampe e Uni e si y Hospi al, Cen al Finland Cen al Hospi al and Sa akun a Cen al Hospi al. The s udy aims o compa e wo di e en cas immobiliza ion posi ions. The wo cas posi ions compa ed a e sligh ola lexion-ulna de ia ion immobiliza ion (widely used glo- bally) and unc ional immobiliza ion (also commonly used in se e al coun ies). See Addi ional iles 1, 2, 3 and 4 o he pic u es o he cas posi ions. The p ima y ou come in his s udy is he PRWE sco e measu ed a e one and 2 yea s. The seconda y ou - comes measu ed a e Quick-DASH sco e, pain in isual analogue scale (VAS), quali y o li e (15D), g ip s eng h, complica ions and numbe o su gical in e en ions and cas changes. Subg oup analysis will be pe o med o iden i y pa ien -speci ic ea u es indica ing good o poo ou comes and he associa ion o he ea u es wi h PCS. F ac u es will be classi ied wi h AO-classi ica ion. Hypo heses Ou p ima y hypo heses in he s udy a e as ollows: (i) The ola - lexion, ulna de ia ion cas and he unc ional cas ea men s will yield simila unc ional ou comes measu ed wi h PRWE (ii)The ola - lexion, ulna de ia ion cas and he unc- ional cas ea men s will esul in co esponding ou comes wi h ega d o quali y o li e and g ip s eng h. Func ional cas ea men will esul in lowe a es o complica ions and numbe o cas changes. (iii)High PCS will be associa ed wi h poo unc ional ou come on he PRWE scale despi e he adiog aphic pa ame e s. (i )The high g ip s eng h o he uninju ed limb (ie. pa ien gene al physiological s eng h) will no p edic he poo unc ional ou come on he PRWE despi e he adiog aphic pa ame e s. Pa ien selec ion and me hods The eligible s udy popula ion comp ises conse a i ely ea ed elde ly pa ien s (o e 64 yea s o age) wi h a DRF iden i ied in he public o e e al eme gency depa - men s (ER) o pa icipa ing hospi als. The ollowing c i e ia we e used in pa ien selec ion: Inclusion c i e ia low ene gy in a- o ex a-a icula do sal p ima ily s able, educible DRF wi hin 3 cm o he adioca pal join diagnosed wi h la e al and pos e io -an e io adiog aphs in ER physician on-call (gene al p ac i ione , acu e phys- ician, o hopaedic esiden , o hopaedic consul an ) hinks pa ien would be sui able o non-ope a i e ea men Exclusion c i e ia Ope a i e ea men Re used o pa icipa e in he s udy Open ac u e mo e han Gus ilo 1 g adus Unde 65 yea s o age Chau eu e’s o Ba on’s ac u e Smi h’s ac u e ( ola angula ion o he ac u e) Does no unde s and w i en and spoken guidance in local languages Pa hological ac u e o p e ious ac u e in he same w is , o ea m o elbow Randomiza ion All pa ien s will be andomized a e diagnosis, bu be- o e ea men , o ei he unc ional cas o ola lexion- ulna de ia ion cas using a andom numbe ma ix in block alloca ion ashion. The blocks will be dependen on age, cen e and in a-ex a a icula ac u e because, based on he li e a u e, unc ional ou come is a ec ed by age and p esence o in a-a icula ac u e [43, 44]. The ea men alloca ions om he ma ix will be sealed in en elopes and si ua ed in he eme gency oom. A e pa ien en olmen has been con i med and in- o med consen ob ained, he pa ien will be asked o ill in he PCS ques ionnai e and a medical o de ly will open he andomiza ion en elope. The physician on-call will be esponsible o he educ ion, i needed. The medical o de lies esponsible o he cas ing will no pa icipa e in he s udy in any o he way. The esea ch coo dina o moni o s he s udy low and an independen moni o ing commi ee will be es ablished o he s udy. In e en ion I he ac u e is well aligned, closed educ ion will no be pe o med. The ea ing physician will pe o m closed educ ion when necessa y, bu speci ic h esh- olds (sho ening, do sal angula ion, adial inclina ion) is no se . Closed educ ion akes place unde local an- aes hesia by means o a local in il a ion commonly used in Finland. The echnique o closed educ ion is Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 Page 3 o 7 no limi ed o some speci ic echnique. Fluo oscopy may be used i i is a ailable in he pa icipa ing cen e. Since DRFs a e usually ea ed by heal hca e cen e physicians, expe ienced acu e physicians and auma su geons, we do no see any eason o limi he numbe , educa ion o expe ience o he on-call physicians in his p agma ic ial. The bookle showing cas posi ion examples will be deli e ed o he pa icipa ing cen es and adequa e ain- ing will be gi en o ensu e a uni o m posi ion o cas ing in he s udy. The ini ial ma e ial o he cas is plas e . A e educ ion, a se o adiog aphs will be aken o e i y he posi ion o he ac u e. Should he physician on-call accep ha he ac u e will be ea ed non- ope a i ely, he cas alloca ed will be used o 5 weeks. Follow-up Follow-up isi s in his s udy will be conduc ed in p i- ma y heal hca e cen es, as seen necessa y by he phys- ician on-call. We expec ha ollow-ups will be a anged acco ding o egional guidelines, no mally a e 1 and 2 weeks wi h adiog aphs. Due o he p agma ic na u e o he ial, we will no se any angula ion deg ees o sho ening limi s o indica e ope a i e ea men . In case seconda y displacemen o he ac u e occu s du ing he ollow-up, he ea ing physicians will use hei dis- c e ion o consul a local o hopaedic su geon o hand su geon who will pe o m he necessa y ope a i e ea - men . Since pa ien s will be andomized in blocks by he hospi al, we assume ha andomiza ion will ake ca e o any possible di e ences be ween cen es. Figu e 1 cas immobiliza ion ime is es ima ed o be 5 weeks, acco ding o cu en guidelines in Finland. The inal isi o a gene al p ac i ione (GP) will be a he ime o cas emo al. All pa ien s will unde go an x- ay p io o cas emo al. The decision o e e pa ien s o a physio he apis a e cas emo al will be le o he dis- c e ion o he ea ing GP. The i s esea ch isi will occu a e 3 mon hs a he o hopaedic ou pa ien clinic in he hospi al whe e he ea men was ini ially s a ed. This isi is speci ically pa o he s udy p o ocol. Du ing his isi , di ec la e al and an e opos e io adiog aphs will be aken. PRWE, PCS, Quick-DASH, 15D, pain in VAS and g ip s eng h (bo h hands) will all be assessed. In o ma ion on he numbe o cas changes du ing ea men will be acqui ed om he pa ien . P ima y ou come, PRWE a 1- and 2-yea ollow-up will be measu ed by using an In e ne -based sys em. Pa ien s no using he In e ne will be con ac ed by phone o egula mail by a s udy nu se. Complica ions and he numbe o su gical in e en ions will be eco ded on he pa ien ’s medical iles a e 1 and 2 yea s (Table 1). Powe analysis In his ial, a alida ed w is speci ic PRWE sco e will be used as he main ou come measu e. The minimal clinically impo an di e ence (MCID) in PRWE is 11 poin s and s anda d de ia ion (SD) is 14 poin s [45]. In powe calcula ions, we de e mined he equi ed sample size pe g oup o be 40 pa ien s wi h 95% con idence in e al, powe o 0.95 and SD o 14. Thus, in o de o ha e enough s a is ical powe , 40 pa ien s in bo h g oups ha e o comple e 1 yea ollow-up. Assuming a d op-ou a e o 30%, g oup size would be 57 (114 in o al). Analysis o he ma e ial All anonymised in o ma ion ga he ed in he s udy will be s o ed in a s udy cloud- egis y a Tampe e Uni e si y Hospi al. The egis y is p o ec ed wi h passwo ds and he da a will be dele ed 15 yea s a e he end o he s udy. S a is ical analysis Cha ac e is ics o he pa icipan s will be desc ibed using mean and s anda d de ia ion, median and qua iles (con inuous a iables) o p opo ion (ca ego ical a i- ables). The pa ien s will be analysed acco ding o he in en ion- o- ea p inciple, i he pa ien changes o a di e en ea men g oup. G oups a baseline will hen be compa ed using - es , Mann-Whi ney U o Fishe ’s exac es . P ima y (PRWE) and seconda y ou comes (Quick-DASH sco e, VAS, 15D, g ip s eng h, complica- ions and numbe o su gical in e en ions and cas changes) will be compa ed be ween he g oups a 12 mon hs and 24 mon hs using he Mann-Whi ney U es . The esul s a e p esen ed wi h 95% con idence in- e als. Two-way- ables wi h he chi-squa e es will be used o dicho omous a iables. In subg oup analysis, he e ec o age, sex, ac u e g oup, smoking and o he diseases will be e alua ed agains he sco es and o e all quali y o li e a e ac u e. Analysis o co a iance will be used o assess he e ec o PCS on he ou come o cas ea men . PRWE will be used as a dependen a i- able, cas as independen and PCS as co a ia e. The e - ec o cas ea men on he PRWE is also in es iga ed in mul i a iable analysis by pe o ming linea eg ession analysis since he dependen a iable, PRWE, is no mally dis ibu ed. The main explana o y a iables a e belie ed o be cas , age, sex, ac u e g oup, smoking and o he diseases. O he au ho s, AR is esponsible o he s a is ics. E hics The ial p o ocol and addi ional pape s, including con- sen o m, pa ien in o ma ion shee and ques ionnai es ha e been app o ed by he Regional E hics Commi ee o Tampe e Uni e si y Hospi al (App o al numbe : R16035). Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 Page 4 o 7 Fig. 1 The low cha o he s udy Table 1 The assessmen s and p ocedu es o he ial Medical his o y Radiog aph PRWE PCS Pain G ip Quick-DASH 15D ROM Baseline x x x 1–2 weeks (x) (x) 5–6 weeks (x) x 3 mon hs x x x x x x x x x 1 yea x x x x x x 2 yea s x x x x x x Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 Page 5 o 7 Time schedule The ec ui men o he s udy began in Augus o 2016 and he esul s will be analysed a e he 1 and 2-yea ollow-up pe iod. The inal epo will be published by he end o 2019. Discussion This publica ion p esen s a p ospec i e, andomized, na- ional mul i-cen e ial o he non-ope a i e ea men o DRF. I depic s de ails o he pa ien low, andomiza ion, in e en ion, ollow-up and analysis o he ma e ial. The limi a ions o his s udy a e he lack o pa ien ’s blinding o ea men and he exclusion o pa ien s wi h o he han do sally displaced DRFs. The blinding o ea men is no easible o p ac ical easons and by excluding all pa ien s o he han do sally displaced DRF pa ien s om he s udy enables us o compa e ou esul s o o he ials. The s eng hs o he s udy a e he p agma ic na u e o he s udy, he comp ehensi eness o Finnish egis e s wi h pe sonal iden i ica ion numbe and he excellen co e age o ou s udy hospi als. The p agma ic na u e o he s udy, including no p e-se h esholds o su gical ea men in case o seconda y displacemen , e eals he eal impac o he ea men o DRFs in he elde ly popula ion. The egis e s allow us o ollow-up pa ien s du ing he s udy, and he e o e educes he p obabili y o pa ien s being los in ollow-up. All su gical in e en- ions, o example, a e eco ded o egis e s ega dless o he hospi al. O he s eng hs o he s udy a e he ali- da ed p ima y ou come measu e (PRWE) and he aking in o accoun o pain ca as ophizing endency in explaining he esul s o he ea men . Addi ional iles Addi ional ile 1: Figu e S1. The i s pic u e o lexion-ulna de ia ion cas . (TIFF 35156 kb) Addi ional ile 2: Figu e S2. The second pic u e o lexion-ulna de ia ion cas . (TIFF 35156 kb) Addi ional ile 3: Figu e S3. The i s pic u e o unc ional cas . (TIFF 35156 kb) Addi ional ile 4: Figu e S4. The second pic u e o unc ional cas . (TIFF 35156 kb) Abb e ia ions 15-D: 15 dimensional heal h- ela ed quali y o li e indica o ; DRF: dis al adius ac u e; GP: gene al p ac i ione ; PA: pos e io -an e io ; PCS: Pain Ca as ophizing Scale; PRWE: Pa ien Ra ed W is E alua ion; Quick-Dash: Quick Disabili y o A m, Shoulde and Hand; VAS: isual analog scale Acknowledgemen s The au ho s o NITEP g oup a e Lau i Rai io 1 , An i Launonen 2 , Teemu He onko pi 1 , Toni Luokkala 3 , Juha Kukkonen 4 , Aleksi Rei o 3 , Baki Sum ein 2 , Minna Lai inen 2 , Ville M. Ma ila 1,2 . Funding No ex e nal unding. A ailabili y o da a and ma e ials No applicable. Au ho s’con ibu ions AL, TL, JK and VM a e esponsible o de eloping he ial. AL, TL, JK, VM, AR, TH, LR and ML d a ed he p o ocol. AL will moni o and ad ise on he me hodological aspec s o he ial. AL pe o med he powe calcula ions and he de e mina ion o s udy g oup size. LR will pe o m he s a is ical analyses and be a majo con ibu o in w i ing he manusc ip . All au ho s ha e ead and app o ed he inal manusc ip . Au ho s’in o ma ion No applicable. E hics app o al and consen o pa icipa e The Regional E hics Commi ee o Tampe e Uni e si y Hospi al has app o ed he p o ocol o he ial and addi ional pape s, including consen o m, pa ien in o ma ion shee and ques ionnai es. (App o al numbe : R16035). The pa ien s ha e o gi e hei in o med consen in o de o pa icipa e o he s udy. Consen o publica ion No applicable. Compe ing in e es s The au ho s decla e ha hey ha e no compe ing in e es s. Publishe ’sNo e Sp inge Na u e emains neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a ilia ions. Au ho de ails 1 Uni e si y o Tampe e, School o Medicine, 33014 Tampe e, Finland. 2 Depa men o O hopaedics, Uni o Musculoskele al Su ge y, Tampe e Uni e si y Hospi al, Teiskon ie 35, PL2000, 33521 Tampe e, Finland. 3 Cen al Finland Cen al Hospi al, Keskussai aalan ie 19, 40620 Jy äskylä, Finland. 4 Sa akun a Cen al Hospi al, Sai aalan ie 3, 28500 Po i, Finland. Recei ed: 10 Feb ua y 2017 Accep ed: 11 Sep embe 2017 Re e ences 1. Cou -B own CM, Caesa B. Epidemiology o adul ac u es: a e iew. Inju y. 2006;37(8):691–7. 2. O’neill T, Coope C, Finn J, Lun M, Pu die D, Reid D, Rowe R, Wool A, Wallace W. Incidence o dis al o ea m ac u e in B i ish men and women. Os eopo osis In . 2001;12(7):555–8. 3. Solgaa d S, Pe e sen VS. Epidemiology o dis al adius ac u es. Ac a O hop Scand. 1985;56(5):391–3. 4. Flinkkilä T, Si niö K, Hippi M, Ha onen S, Ruuhela R, Oh onen P, Hy önen P, Leppilah i J. Epidemiology and seasonal a ia ion o dis al adius ac u es in Oulu, Finland. 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Radiologic and pa ien - epo ed unc ional ou comes in an elde ly coho wi h conse a i ely ea ed dis al adius ac u es. J Hand Su g. 2004;29(6):1121–7. 45. Walenkamp MM, de Muinck KR, Goslings JC, Vos LM, Rosenwasse MP, Schep NW. The minimum clinically impo an di e ence o he pa ien - a ed w is e alua ion sco e o pa ien s wi h dis al adius ac u es. Clin O hop Rela Res®. 2015;473(10):3235–41. • We accep p e-submission inqui ies • Ou selec o ool helps you o ind he mos ele an jou nal • We p o ide ound he clock cus ome suppo • Con enien online submission • Tho ough pee e iew • Inclusion in PubMed and all majo indexing se ices • Maximum isibili y o you esea ch Submi you manusc ip a www.biomedcen al.com/submi Submi you nex manusc ip o BioMed Cen al and we will help you a e e y s ep: Rai io e al. BMC Musculoskele al Diso de s (2017) 18:401 Page 7 o 7