Distal Radius Fracture, ABOS Oral Boards Preparation

This is a 58-year-old right-hand-dominant retired schoolteacher who fell from standing while walking her dog and landed on her outstretched right hand. She presented to the emergency department with pain and visible dorsal deformity of the right wrist. She has well-controlled hypertension and osteopenia diagnosed two years ago. Her neurovascular exam was intact, full digital motion, intact sensation in the median, ulnar, and radial distributions, and symmetric radial pulses. Skin was intact with no compartmental tightness.

AP and lateral radiographs showed a dorsally displaced, comminuted intra-articular distal radius fracture with 20 degrees of dorsal tilt, 3mm of radial shortening, and a 2mm articular step-off involving the lunate fossa. The DRUJ was congruent and there was no ulnar styloid fracture.

We placed her in a sugar-tong splint and brought her back at one week. Repeat films showed maintained displacement. Given the articular incongruity, the dorsal tilt beyond acceptable parameters, and the radial shortening, combined with her desire to remain active and independent, we discussed operative and non-operative options. She understood that non-operative management risked malunion with loss of grip strength and forearm rotation. After shared decision-making, she elected for surgical fixation.

I performed ORIF through a volar FCR approach with a variable-angle volar locking plate. The DRUJ was stable after fixation. Post-operative films confirmed restoration of radial inclination, volar tilt, and articular congruity.

She was placed in a removable volar splint. At two weeks, sutures were removed, wound was healing well, and we started gentle range of motion. At six weeks, X-rays showed early healing with maintained alignment. However, at the six-week visit she reported worsening nighttime numbness and tingling in the thumb, index, and middle fingers. Phalen test was positive at 20 seconds and she had a positive Durkan compression test. I diagnosed acute carpal tunnel syndrome, likely from a combination of post-operative swelling, hematoma, and the plate sitting close to the carpal tunnel. I placed her in a night splint and followed her weekly. By eight weeks the symptoms were improving. At three months, the carpal tunnel symptoms had resolved, she had 55 degrees of flexion and 60 degrees of extension, and grip strength was about 70% of the contralateral side. I referred her for a DEXA scan and started her on calcium and vitamin D given the fragility fracture. At six months, she had near-full range of motion, was back to all her activities, and reported minimal discomfort and no numbness.

At final follow-up, she was satisfied, she was walking her dog again, gardening, and had no significant functional limitations. Looking back, I would have obtained a CT scan preoperatively. The articular comminution was more complex than the plain films suggested, and having that three-dimensional understanding before I was in the operating room would have improved my pre-operative plan and plate selection. The carpal tunnel symptoms were likely related to post-surgical swelling, and I had a low threshold for carpal tunnel release if they had not resolved by three months.