Psychological distress during the first 12 months post-upper limb fracture: systematic review and meta-analysis

Background and purpose Upper limb fractures cause substantial disability and loss of independence, creating a growing burden in an ageing population. The purpose was to systematically review the evidence to determine how psychological distress may change during the initial 12 months following post-upper limb fracture. Methods A systematic review of published and unpublished literature databases was performed to 25th August 2026. Studies presenting data on psychological distress were eligible. Data were appraised using the Downs and Black Appraisal tool, with analysis through meta-analysis comparing scores from fracture to early- (two to six weeks) and longer-term (six to 12 months) follow-up. Results 28 studies ( n = 5,638 people) were eligible and included. There was a significant decrease in depression from early recovery to up to 12 months (Standardised Mean Difference (SMD): 0.65; 95% confidence intervals (CI): 0.43–0.86; N = 2,230), and anxiety (SMD: 0.51; 95% CI: 0.43–0.59; N = 1229). Overall, methodological quality was moderate, with inadequate adjustment for confounding (24 studies) and limited accounting for loss to follow-up (26 studies) identified as common limitations. Kinesiophobia scores were lower at six- to 12-month follow-up compared with the initial fracture assessment (MD: 8.32; 95% CI: 7.26–9.38; N = 1,072). Pain catastrophising scores were lower at six- to 12-month follow-up compared with the initial fracture assessment (MD: 2.05; 95% CI: 1.66–2.43; N = 1,803), although the difference in effect estimates between shorter- and longer-term follow-up was not statistically significant ( p = 0.26). Conclusion Psychological distress was reported following upper-limb fracture, at a population level, anxiety, depression, kinesiophobia and pain catastrophising generally decreased during the first 12 months following fracture. However, kinesiophobia and pain-catastrophising scores did not reach clinically important levels. Further research is required to determine the prevalence and trajectories of clinically important distress and to identify individuals at greatest risk. Clinicians should remain alert to symptoms of anxiety, depression, fear of movement and fear of falling, particularly where recovery is delayed. They should consider further assessment or referral where clinically indicated. Evidence is currently insufficient to recommend universal screening or a specific psychological intervention. Clinical trial number Not applicable.