Osteoporotic fractures, such as vertebral and hip fractures, cause a considerable loss of quality of life, both acute loss, immediately after the fracture, and chronic loss because of recurrent fractures and disability due to incomplete recovery [5–9]. Several instruments have been developed for the assessment of quality of life after vertebral fractures. The European Foundation for Osteoporosis, now merged with the International Osteoporosis Foundation, developed a specific questionnaire for quality of life in patients with vertebral fractures. This questionnaire Qualeffo-41 (spine) has been validated and translated into many languages ([10], www.osteofound.org). It showed that quality of life decreased with increasing number of vertebral fractures and that lumbar fractures had more impact on quality of life than thoracic fractures [11]. A shorter version has also been developed [12].

The 12 questions of the IOF-wrist fracture questionnaire were arranged in four domains: pain, upper limb symptoms, physical function and general health. The total score was calculated by adding up individual answers and normalising the total score to a 100-scale, 0 representing the best and 100 the worst quality of life. As expected, the frequency distribution of responses for each score differed between patients and control subjects. The median domain scores with interquartile range for the IOF-wrist fracture questionnaire, Qualeffo-41 (spine) and the EQ-5D are shown in Table 2. The discriminatory capacity of the 12 questions of the IOF-wrist questionnaire is shown in Table 3. Odds ratios for being in the patient group rather than in the control group were high and significant. The discriminatory capacity of the IOF-wrist and Qualeffo-41 domain scores is shown in Table 4 and Fig. 1. The discriminatory capacity was high except for the pain domain of Qualeffo-41.

Spearman rank correlations between similar domains of the three questionnaires were calculated. Most correlations between corresponding domains of the three questionnaires were highly significant. The highest correlations were observed between the physical function domains of the IOF-wrist fracture questionnaire and Qualeffo-41 (R=0.81, P<0.001) and between the total scores of the IOF-wrist fracture questionnaire and Qualeffo-41 (R=0.77, P<0.001) and the total scores of the IOF-wrist fracture questionnaire and the EQ-5D (R=−0.72, P<0.001).

The patients with wrist fracture were followed up for 1 year after the fracture. Median scores and interquartile range for each time point and the significance versus baseline are shown in Table 5. Median domain scores for the IOF-wrist questionnaire during 1 year are shown in Fig. 2. The median domain scores of the IOF-wrist fracture questionnaire had significantly improved at 3 months. Improvement continued up to 6 months for upper limb symptoms, physical function, general health perception and overall score. The physical function improved a little more at 12 months. The scores on Qualeffo-41 and EQ-5D also improved up until 6 months, but the differences were smaller and some domains did not improve at all. Similar observations were made for the total score of these questionnaires (Fig. 3). Patients with a fracture on the right side had significantly higher scores immediately after the fracture for the IOF physical function domain [right vs left, median (interquartile range, IQR): 89 (75, 96) vs 71 (61, 86), P=0.002]. A fracture on the dominant side was associated with higher scores than a fracture on the non-dominant side with regard to physical function [89 (75, 96) vs 70 (59, 82), P<0.001] and overall score [67 (54, 79) vs 56 (47, 67), P=0.016]. The latter is shown in Fig. 4. Patients undergoing surgical treatment had lower scores of Qualeffo-41, indicating better quality of life, on general health (P=0.013) and mental health (P=0.004) than patients with non-surgical treatment. Patients using analgesics had a higher scores of the IOF-wrist fracture questionnaire on pain (P=0.009), on physical function (P=0.001) and a higher overall score (P=0.002) than patients not using analgesics.

The IOF questionnaire on distal radius fracture discriminated well between patients with distal radius fracture and controls, as can be concluded from the high odds ratios. Similar data have been obtained with Qualeffo-41 [10]. The 12 questions discriminated to a similar degree between patients and control subjects, as should be expected, because the items were identified in a focus group of patients with wrist fracture. The discrimination was excellent on all questions, regarding upper limb symptoms, physical function and general health.

The 1-year follow-up in the patients with wrist fracture showed adequate responsiveness to change, since the median score of the IOF-wrist questionnaire decreased from 60 to 25 after 3 months and to less than 10 (on a scale of 100) within a year. The improvement was very rapid in the first 3 months after the fracture followed by a slower improvement up to 1 year. Whether improvement may still continue to occur after 1 year cannot be answered by this study. A similar course of improvement, i.e. fast improvement during the first 3 months, followed by a slower improvement to (almost) complete recovery at 1 year after the fracture, has been observed with other questionnaires and physical assessment, i.e. handgrip strength [13, 15]. As can be expected, fractures on the right side had a higher impact on quality of life than fractures on the left side. This effect was even more marked for the dominant versus non-dominant side. This confirms the face validity of the IOF-wrist fracture questionnaire.

Quality of life could not be measured before the fracture, but it is likely that it is similar or better than the estimate at 12 months after the fracture. The major decrease in quality of life was present during the first 6 months after the fracture. The loss of quality of life after wrist fracture may have been somewhat underestimated due to the exclusion criteria, since patients with comminuted fractures were excluded as well as patients with recent clinical vertebral fracture or other osteoporotic fracture. There was some loss to follow-up, which may also have influenced the results a little.

The utility loss after distal radius fracture was 0.14 during the first 3 months and 0.03 during the second 3 months assuming that utility was 0.80 at baseline similar to the value at 12 months. It indicates loss of QALY of about 0.09 during the first half year and 0.02 during the second half year. The total loss after wrist fracture adds up to 0.055 QALY. This result is similar to a previous study on quality of life after distal radius fracture [13]. In the previous study, the total quality of life lost was 0.05 QALY. An expert panel of the National Osteoporosis Foundation (NOF) estimated the quality of life loss after wrist fracture at 0.0464 in the first and 0.0006 in the second year after the fracture [16]. However, the QALY loss in the second year could increase to 0.30 in the case of dependency after the fracture according to the panel [16]. Thus, the QALY loss may depend on the age of the patient, the type of fracture and complications such as complex regional pain syndrome, all causing dependency of the patient on others. A similar variation was reported by the panel of the NOF regarding quality of life loss in the first year after vertebral fracture, ranging from 0.05 in a vertebral deformation to 0.50 QALY in a clinical fracture with severe pain [16]. Classification of vertebral fractures at diagnosis and a follow-up study on quality of life should be performed to better define the utility losses. The problem is that the onset of a vertebral deformity is often not known, as it may be asymptomatic.

Besides the new IOF instrument and the EQ-5D, other instruments have been used to assess recovery after wrist fracture. The disability of the arm, shoulder and hand (DASH) questionnaire, the patient-rated wrist evaluation (PRWE) and the short form 36 (SF-36) were combined with physical response measures in 59 patients with distal radius fracture [15]. In this study, the questionnaires were highly responsive in the first 3 months after the fracture when physical testing was not possible. The PRWE was more responsive than the DASH, and these two were more responsive than the SF-36, which is a generic quality of life instrument. The PRWE is a specific wrist questionnaire and the DASH is an upper limb questionnaire. Another analysis came to similar conclusions [17]. In our study, the specific IOF instrument was more responsive than the generic EQ-5D and the Qualeffo-41, which is a specific vertebral fracture questionnaire.

Strengths of our study include the design of our questionnaire after focus group interviews, the comparison with a generic instrument generating utility values and the longitudinal multicenter design. A limitation of our study is that the follow-up time points were not always strictly adhered at. However, when restricting the analysis to the subjects whose follow-up was within a strict time frame (e.g., 5–7 weeks for the 6-week time point), this did not change the results. Another weakness of our study is the fact that we did not compare our questionnaire with existing instruments such as DASH and PRWE. In addition, physical assessments such as handgrip strength were not done in our study.