Surgery is iatrogenic harm. To justify surgery, the subsequent change in pathophysiology needs to outweigh its harm. With respect to distal radial fractures, surgical fracture reduction and fixation need to result in a noticeable improvement in upper-extremity capability compared with that associated with forgoing surgery, while accounting for any potential adverse events. Distal radial fractures come in all shapes and sizes, and so do the patients who have such fractures. This factor complicates counseling patients about whether any potential benefits outweigh the iatrogenic harm resulting from surgery.Several national guidelines provide thresholds for fracture displacement to assist with this decision-making process. As mentioned in the study by Schmidt et al., >10°of dorsal angulation seems to be a popular threshold. These thresholds are based on studies suggesting worse capability beyond a specific amount of displacement. However, these thresholds do not account for the uncertainty surrounding measurements of displacement or for the limited effect of pathophysiology on health. Slight changes in the angle of the xray beam and interobserver variability could cause alignment recorded on a lateral radiograph to change from, for instance, 8°of dorsal angulation (sometimes referred to as "acceptable" alignment) to 12°("unacceptable" alignment) without actually changing the expected upper-extremity recovery. For example, in a previous study, my colleagues and I found only low moderate agreement when a large group of surgeons were asked whether a fracture was more or less than 5°dorsally angulated 1 . Most physicians will agree that recovery from injury-and health in general-is determined by the biopsychosocial model. This model includes pathophysiology, such as fracture alignment, but also unhelpful thoughts and feelings (mental health) and role fulfillment (social health). The variation in capability accounted for by pathophysiology is surprisingly limited. Instead, unhelpful thoughts and feelings, not fracture severity, accounted for a large proportion of the variation in upper-extremity capability after distal radius fracture 2 .It is in this light that we need to view the study by Schmidt et al. The authors found a significant association between increased dorsal tilt and the QuickDASH score, grip strength, and wrist range of motion starting before 10°of dorsal angulation. However, the reduction in capability was below a noticeable clinical level. At 20°of dorsal tilt, the probability of a reduction in the QuickDASH score of greater than the noticeable relevant level of 10 points was about 50% (assuming a Bayesian analysis with uninformative prior), and even at 30°there was a small chance that the difference in QuickDASH was below a level that patients generally qualify as relevant. In addition, dorsal angulation only accounts for a small proportion of capability, and other studies have suggested that unhelpful thoughts and feelings are more important 2 .We can use these data to counsel patients with "unacceptab...
