Orthopedics

Feature Article 

A Qualitative Study Assessing Information on the Internet Compared With AAOS Guidelines for the Treatment of Distal Radius Fractures

Sarah M. Lamont, MD; Andrew M. Steffensmeier, MD; Timothy W. Harman, MD; David W. Martineau, MD

Abstract

The goal of this study was to compare information available on the Internet about the treatment of distal radius fractures with the guidelines established by the American Academy of Orthopaedic Surgeons (AAOS) in a qualitative observational study. A scoring system was used to compare the top 20 websites, excluding advertisements, from Google, Bing, and Yahoo with the AAOS guidelines. In addition, the results of the advertising content and the social media content were discussed. Of the 32 unique websites included in the study, 22 (68.75%) suggested operative fixation for fractures with unacceptable postreduction alignment (radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm) as opposed to cast fixation. Of the 32 sites, 26 (81.25%) were unable to recommend for or against any 1 specific operative method for fixation of distal radius fractures. Only 2 of 32 (6.25%) sites mentioned age-specific recommendations, and 6 of 32 (18.75%) mentioned accurate activity protocols. Because the AAOS cannot recommend for or against immobilization of the elbow in patients treated with cast immobilization, it is reasonable that 7 of 32 (21.88%) sites discussed these options. The websites common to all 3 search engines also scored very well, with 84.89% of their recommendations being consistent with the AAOS recommendations. Most websites contain appropriate recommendations for the treatment of distal radius fractures. However, there is a significant amount of misinformation as well. The available information may be difficult for patients to interpret and may affect their expectations about care. [Orthopedics. 2020;43(2):e79–e86.]

Abstract

The goal of this study was to compare information available on the Internet about the treatment of distal radius fractures with the guidelines established by the American Academy of Orthopaedic Surgeons (AAOS) in a qualitative observational study. A scoring system was used to compare the top 20 websites, excluding advertisements, from Google, Bing, and Yahoo with the AAOS guidelines. In addition, the results of the advertising content and the social media content were discussed. Of the 32 unique websites included in the study, 22 (68.75%) suggested operative fixation for fractures with unacceptable postreduction alignment (radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm) as opposed to cast fixation. Of the 32 sites, 26 (81.25%) were unable to recommend for or against any 1 specific operative method for fixation of distal radius fractures. Only 2 of 32 (6.25%) sites mentioned age-specific recommendations, and 6 of 32 (18.75%) mentioned accurate activity protocols. Because the AAOS cannot recommend for or against immobilization of the elbow in patients treated with cast immobilization, it is reasonable that 7 of 32 (21.88%) sites discussed these options. The websites common to all 3 search engines also scored very well, with 84.89% of their recommendations being consistent with the AAOS recommendations. Most websites contain appropriate recommendations for the treatment of distal radius fractures. However, there is a significant amount of misinformation as well. The available information may be difficult for patients to interpret and may affect their expectations about care. [Orthopedics. 2020;43(2):e79–e86.]

Distal radius fractures are among the most common fractures seen in the overall population. A substantially higher frequency of distal radius fractures has been observed in patients older than 50 years (25% for patients older than 50 years and 18% for patients younger than 50 years).1 Factors that predispose people to these fractures include increased fall risk, osteoporosis, glucocorticoid use, and obesity.2,3 The range of patient populations affected by these fractures suggests that specific, independent considerations are needed for the management of each group.4 Although complications from distal radius fractures are infrequent in the pediatric population, posttraumatic arthritis has been noted in young adults, and a decline in functionality and independence has been seen in the elderly.1 Reduced wrist range of motion and sensorimotor deficits also have been observed after treatment.5,6

The course of treatment should be determined on a case-by-case basis. There are several acceptable methods for the treatment of distal radius fractures, and it is suggested that physicians rank the potential treatments that are considered appropriate and select a treatment option based on physician comfort with the procedure and patient opinion.7 Factors that must be considered include the patient's age, activity level, bone quality or strength, occupation, previous or current injuries, joint involvement, extent of fracture displacement, and involvement of the joint surface.8

Rhee et al9 suggested that the best surgical treatment of distal radius fractures is achieved when surgeons are familiar with multiple treatment strategies and are willing to alter their approach on a case-by-case basis. Physicians also must use an evidence-based approach and consult the literature when devising an action plan.10 Although treatment methods vary, as shown by Okoroafor and Cannada,11 it is universally accepted that detailed imaging should be performed before the mode of treatment is chosen.12 Trispiral tomography, computed tomography, and reconstructed sagittal and coronal cross-sections are most useful in evaluating complex distal radius fractures.13

With a growing number of patients seeking health information online, it is important for the available information to be accurate and to show the multivariable nature of treating distal radius fractures. Although more than half of surveyed Americans reported consulting social media for health advice, they were still more likely to consult a “professional health site” for their information.14 This study evaluated which Internet sources are most commonly cited by the population for health information and compared the information found on these sites regarding the treatment of distal radius fractures with the guidelines established by the American Academy of Orthopaedic Surgeons (AAOS).

Materials and Methods

A qualitative observational study was performed to compare the overall accuracy and validity of content available from 3 of the most frequently visited search engines and social media websites with the AAOS clinical practice guidelines for the treatment of distal radius fractures. This study identified the top 20 websites or content listings, excluding advertisements, from Google, Bing, and Yahoo and compared the information they provided with the AAOS guidelines. Advertisements within each site were analyzed, but were excluded from the comparison. Content found within social media sites, including Facebook, Twitter, and LinkedIn, also were analyzed.

A scoring system was used for analysis and comparison of the results from each of the searches with the AAOS clinical practice guidelines. An abbreviated version of the AAOS clinical practice guidelines15 for treatment includes the following:

  • Suggest operative fixation as opposed to cast fixation for fractures with post-reduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm. (Moderate)

  • Suggest rigid immobilization in preference to removable splints when using nonoperative treatment for the management of displaced distal radius fractures. (Moderate)

  • Suggest that patients do not need to begin early wrist motion routinely after stable fracture fixation. (Moderate)

  • Suggest adjuvant treatment of distal radius fractures with vitamin C to prevent disproportionate pain. (Moderate)

  • Arthroscopy is an option for patients with distal radius intra-articular fractures to improve diagnostic accuracy for wrist ligament injuries, and computed tomography is an option to improve diagnostic accuracy for patterns of intra-articular fractures. (Limited)

  • Unable to recommend for or against performing nerve decompression when nerve dysfunction persists after reduction. (Inconclusive)

  • Unable to recommend for or against casting as definitive treatment for unstable fractures that are adequately reduced initially. (Inconclusive)

  • Unable to recommend for or against any 1 specific operative method for fixation of distal radius fractures. (Inconclusive)

  • Unable to recommend for or against operative treatment for patients older than 55 years with distal radius fractures. (Inconclusive)

  • Unable to recommend for or against immobilization of the elbow in patients treated with cast immobilization. (Inconclusive)

The data from each website were tracked and organized with a collection tool to correlate the number of recommendations that matched the AAOS guidelines. The scoring system for each website was made by calculating the ratio of the total grade A (moderate), B (limited), and C (inconclusive) recommendations to the total number of recommendations suggested to obtain a percentage. The percentages for each search engine were compared using this scoring system. For each search engine, the authors also compared the score of the first 10 websites that appeared on the search with that of its next 10 websites to determine the accuracy of information in relation to its position in the listings.

Results

For Google, Bing, and Yahoo, the first 20 listings for the search term “distal radius fracture” were reviewed and 8 websites were common to all 3 search engines. Google and Yahoo had 2 additional sites in common. Google and Bing had 1 additional site in common, and Yahoo and Bing had 9 additional sites in common. Google had 9 unique sites. Yahoo and Bing had 1 and 2 unique sites, respectively. In total, 32 unique sites were listed among the 60 listings from the 3 search engines (Table 1).

Website Listings Breakdown

Table 1:

Website Listings Breakdown

Of the 32 unique websites included in the study, 22 (68.75%) suggested operative fixation for fractures with unacceptable postreduction alignment (radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm) as opposed to cast fixation (Table 2). Of the 32 sites, 26 (81.25%) were unable to recommend for or against any 1 specific operative method for fixation of distal radius fractures. Only 2 of 32 (6.25%) sites mentioned age-specific recommendations, and 6 of 32 (18.75%) sites mentioned accurate activity protocols. Because the AAOS is unable to recommend for or against immobilization of the elbow in patients treated with cast immobilization, it is reasonable that 7 of 32 (21.88%) sites discussed these options. The most common websites within the 3 search engines scored the highest in agreement with AAOS recommendations.

Treatment Recommendations of Site Listings Compared With AAOS Recommendations

Table 2:

Treatment Recommendations of Site Listings Compared With AAOS Recommendations

The percentage of the number of grade A, B, and C recommendations mentioned for each site was calculated (Table 3), and the average of the percentage of all unique listings was 74.86%. Sites exclusive to Google scored the highest, with 81.67% of treatment recommendations. As a whole, the websites common to all 3 search engines scored very well, and 84.89% of their recommendations were consistent with AAOS recommendations.

Number of Grade A, B, and C Recommendations of Total Recommendations MentionedNumber of Grade A, B, and C Recommendations of Total Recommendations MentionedNumber of Grade A, B, and C Recommendations of Total Recommendations Mentioned

Table 3:

Number of Grade A, B, and C Recommendations of Total Recommendations Mentioned

Next, the sites identified by each search engine and the sum of their grade A, B, and C recommendations divided by total recommendations were compared, starting with sites 1 to 10 vs 11 to 20 (Figure 1). For example, the average percentage of grade A, B, or C recommendations for the first 10 Yahoo listings was 73.34% compared with 75.47% for the next 10 listings.

Bar graph representation of the percentages of grade A, B, and C recommendations for each search engines' first and next 10 search results.

Figure 1:

Bar graph representation of the percentages of grade A, B, and C recommendations for each search engines' first and next 10 search results.

Advertisements found by searching “distal radius fracture” on Google, Yahoo, and Bing had findings that were variable or irrelevant. Postings included site-specific advertisements and promotions, links to physician group web pages, and insurance listings. Also included were pharmaceutical advertisements for gels, injections, and medications, none of which included AAOS recommendations for treatment and could be misleading. No banner advertisements were found on the social media search with Facebook, LinkedIn, and Twitter; however, industry-sponsored “articles” on bracing options and fracture fixation appeared on Facebook.

Discussion

Smartphones continue to dominate society, and medical information is available at most patients' fingertips. Unfortunately, inaccurate information can lead to erroneous preconceptions. Effective management of distal radius fractures considers multiple factors and requires the expertise and training of a physician. This study compared the information available on the Internet with established practice guidelines outlined by the AAOS to gain a better understanding of what information is available to patients.

Overall, the information available within 3 search engines often provided appropriate treatment recommendations, and at least two-thirds of the sites suggested operative fixation for appropriate radiographic postreduction parameters. More than half of the sites mentioned rigid immobilization in preference to removable splints for nonoperative treatment of displaced distal radius fractures. Both of these recommendations were graded as moderate by the AAOS. Unfortunately, sites became less consistent with other moderate listings, and fewer than one-fifth of sites recommended that patients did not need to begin early wrist motion after fracture fixation or adjuvant treatment with vitamin C to prevent pain.

More than 80% of sites provided inconclusive information, such as inability to recommend for or against casting as definitive treatment for adequately reduced unstable fractures and inability to recommend for or against any 1 specific operative fixation method. Inconclusive elements create confusion for patients. When using a search engine, the expectation may be that the higher-ranked listings would contain more reliable recommendations. However, this was not the case for Yahoo or Bing, and there was only a 3.3% difference in recommendations that closely followed the AAOS guidelines (grades A–C) in the first 10 listings compared with listings 11 to 20. In addition, information found on social media was biased toward specific manufacturers and industry-sponsored studies. Advertisements for ineffective or irrelevant modalities also were mentioned and could lead to physician–patient skepticism.

This study had limitations, including performance of the search in 1 location (Dayton, Ohio). Regional factors can affect the results of any Internet search. In addition, information on social media can be affected by location as well as the characteristics of the user performing the search. A resident and a medical student reviewed the 32 sites individually to check for statistical agreement; however, site information is continuously being updated and may not reflect the current status of the site.

Conclusion

Although the sources that patients consult cannot be controlled, physicians can be aware of misleading information. Posting up-to-date guidelines for the general public is important, and this practice should become more consistent with time.

References

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  3. Acosta-Olivo C, Gonzalez-Saldivar JC, Villarreal-Villarreal G, et al. Correlation between obesity and severity of distal radius fractures. Orthop Traumatol Surg Res. 2017;103(2):199–202. https://doi.org/10.1016/j.otsr.2016.12.007 PMID: doi:10.1016/j.otsr.2016.12.007 [CrossRef]28089796
  4. Levin LS, Rozell JC, Pulos N. Distal radius fractures in the elderly. J Am Acad Orthop Surg. 2017;25(3):179–187. https://doi.org/10.5435/JAAOS-D-15-00676 PMID: doi:10.5435/JAAOS-D-15-00676 [CrossRef]28199291
  5. Dillingham C, Horodyski M, Struk AM, Wright T. Rate of improvement following volar plate open reduction and internal fixation of distal radius fractures. Adv Orthop. 2011;2011:565642. https://doi.org/10.4061/2011/565642 PMID: doi:10.4061/2011/565642 [CrossRef]21991417
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Website Listings Breakdown

SourceNo. of Sites Common to All 3 Sources (of 20)No. of Sites Common to 1 Other Source (of 20)No. of Sites Exclusive to That Source (of 20)Total No. of Separate Sites (of the 60 Visited)
Google83 (2 with Yahoo, 1 with Bing)932
Yahoo811 (2 with Google, 9 with Bing)1
Bing810 (1 with Google, 9 with Yahoo)2

Treatment Recommendations of Site Listings Compared With AAOS Recommendations

SourceNo./Total No.

Operative Fixation for Fractures With Radial Shortening >3 mm, Dorsal Tilt >10°, or Intra-articular Displacement >2 mm (Grade A)Rigid Immobilization vs Removable Splints for Displaced Distal Radius Fractures (Grade A)No Need to Begin Early Wrist Motion (Grade A)Adjuvant Treatment With Vitamin C (Grade A)Arthroscopy and CT as an Option to Improve Diagnostics (Grade B)Nerve Decompression When Nerve Dysfunction Persists After Reduction (Grade C)Casting as Definitive Treatment for Unstable Fractures (Grade C)Specific Operative Method for Fixation (Grade C)Operative Treatment for Patients Older Than 55 Years (Grade C)Immobilization of the Elbow (Grade C)
Google exclusive8/94/91/90/93/90/97/96/91/91/9
Yahoo exclusive1/11/10/10/11/10/10/11/10/10/1
Bing exclusive0/22/20/21/20/20/21/21/20/21/2
Google + Yahoo2/22/21/20/21/20/22/22/20/21/2
Google + Bing1/10/10/11/11/11/11/10/10/11/1
Yahoo + Bing5/99/93/91/92/91/99/99/91/91/9
Google + Bing + Yahoo5/83/81/81/84/81/88/87/80/82/8
Total from all 32 sites22/3221/326/324/3212/323/3228/3226/322/327/32

Number of Grade A, B, and C Recommendations of Total Recommendations Mentioned

WebsiteNo.

Grade A: SurgeryGrade A: Rigid ImmobilizationGrade A: No Early Wrist MotionGrade A: Vitamin C TherapyGrade B: CT and ArthroscopyGrade C: Nerve DecompressionGrade C: CastGrade C: Specific SurgeryGrade C: Operative Treatment for Patients Older Than 55 YearsGrade C: Elbow ImmobilizationInconclusiveTotal Grade A, B, and C RecommendationsTotal Website Recommendations% of Total Website Recommendations
AAOS11111Ice, elevation, NSAIDs: 35862.50
Wikipedia111111N/A: 066100.00
Orthobullets111111N/A: 066100.00
Radiopaedia1N/A: 011100.00
Medscape1111NSAIDs: 14580.00
HSS11111Biologic agents: 15683.33
ASSH11Hand therapy: 12366.66
YouTube11111Ice, NSAIDs: 25771.43
wheeless online.com1N/A: 011100.00
PubMed11111N/A: 055100.00
aofoundation.org111111Hand therapy: 16785.71
central jerseyhand.com11Occupational therapy: 12366.66
slideshare.net1111Hand therapy, ice: 24666.66
miamihand-center.com1111N/A: 044100.00
vumedi.com111111N/A: 066100.00
philly.com111N/A: 033100.00
physiopedia.com11111Ice, heat, elevation, NSAIDs, therapy: 551050.00
reboundmd.com1111N/A: 044100.00
healio.com11111Hand therapy: 15683.33
Merck Manuals1N/A: 011100.00
WebMD111Elevation, ice, NSAIDs, therapy: 43742.86
UpToDate1111111Elevation, ice, NSAIDs: 371070.00
handctr.com1111Elevation, ice, NSAIDs: 34757.14
boneand-joint.com111111Occupational therapy: 16785.71
erickson-handsurgery.com1111Rest, elevation, ice, NSAIDs, therapy: 54944.44
patient.info1111Therapy: 14580.00
foreonline.org111111Hand therapy: 16785.71
advanced orthopedic-specialists.com1111Therapy, NSAIDs: 24666.66
rearm yourself-texas.com1111N/A: 044100.00
atlantic ortho.com1111NSAIDs, elevation, therapy: 34757.14
togct.com111NSAIDs: 13475.00
orthoassociates.com11NSAIDs, elevation: 22450.00
Total:13117574.86
Google total:809881.63
Yahoo total:8711774.36
Bing total:8110775.70
Sites common to all 3 search engines total:293680.56
Authors

The authors are from the Department of Orthopedics (SML) and the Boonshoft School of Medicine (AMS), Wright State University, Dayton; the University of Cincinnati Medical Center (AMS), Cincinnati; and the Department of Orthopedics (TWH, DWM), Grandview Medical Center, Dayton, Ohio.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Sarah M. Lamont, MD, 30 E Apple St, Ste 2200, Dayton, OH 45409 ( sarahmlamont@gmail.com).

Received: December 17, 2018
Accepted: February 04, 2019
Posted Online: January 13, 2020

10.3928/01477447-20200107-01

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