Figure 1. Anteroposterior radiograph of the right wrist.
Figure 2. Lateral radiograph of the right wrist.
A 64-year-old woman presents to the emergency department with right wrist pain following a fall. Anteroposterior and lateral radiographs of the right wrist (Figures 1 and 2) show a displaced distal radius fracture. She also complains of numbness and tingling in her thumb and index finger.
What is the next best step in treatment?
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Distal radius fractures are among the most common fractures seen in the emergency department.1 Acute carpal tunnel syndrome (ACTS) has been found to occur in more than 5% of displaced distal radius fractures that require fixation.2 ACTS can result from fracture hematoma formation and swelling or volar displacement of the distal radius, which compresses the median nerve. Treatment of ACTS after distal radius fracture involves closed reduction of the displaced fracture to relieve medial nerve compression. The wrist is then placed in a well-padded splint. Using local anesthetic for a hematoma block before reduction may increase wrist compartment pressures and should be avoided when patients have ACTS. Measurement of wrist compartment pressure with a wick catheter helps guide treatment when the patient has severe symptoms.
In most cases, treatment with closed reduction, splinting, ice, and elevation resolves symptoms. If symptoms of ACTS persist following discharge from the emergency department, early orthopedic follow-up within 1 to 2 days is recommended. Acute carpal tunnel release may be considered in patients with severe progressive wrist pain and progressive nerve dysfunction despite closed reduction of the displaced fracture. 2,3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Distal radius fractures in older versus younger patients. Mayo Clinic website. https://www.mayoclinic.org/medical-professionals/orthopedic-surgery/news/distal-radius-fractures-in-older-versus-younger-patients/MAC-20429805. Accessed December 6, 2018.
- Niver GE, Ilyas AM. Carpal tunnel syndrome after distal radius fracture. Orthop Clin North Am. 2012;43(4):521-527.
- Schnetzler KA. Acute carpal tunnel syndrome. J Am Acad Orthop Surg. 2008;16(5):276-282.