50-year-old woman with ulnar-sided wrist pain
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A 50-year-old right-hand-dominant woman with a history of a left distal radius fracture presented to the orthopedic clinic 5 weeks after a ground-level fall. She was told at the time of her initial injury that she had sustained a distal radius fracture, but she did not feel an urgency to follow up because she had a low-demand occupation. At her initial visit, there was no gross motion at the fracture site and the patient was not interested in operative intervention. Subsequently, she was lost to follow-up until 3 months post-injury. At that time, she reported a pain-free period after her last visit followed by new onset ulnar-sided left wrist pain that occurred mostly during pushing and pulling activity. On exam, the patient was noted to have minimal radial- sided tenderness. On the ulnar side, there was significant tenderness over the extensor carpi ulnaris. Range of motion testing revealed 20° less wrist extension compared with the contralateral side.

Radiographs demonstrated a healed distal radius fracture with 3-mm shortening, 26° volar angulation and 9° greater radial inclination compared with the contralateral side . The patient had a positive ulnar variance of 2 mm vs. neutral ulnar variance in the uninjured wrist.

After radiographs revealed a distal radius malunion with positive ulnar variance, surgical options were discussed with the patient including distal radius osteotomy, ulnar shortening osteotomy and distal ulnar resection. The patient ultimately elected to have a distal radius osteotomy for correction of her malunion. Five months after injury, the patient underwent left distal radius volar opening wedge osteotomy with internal fixation using a volar locking plate. She was transitioned to a removable, short arm wrist brace with progressive range of motion at 6 weeks postoperatively and was allowed to begin weight-bearing 8 weeks after surgery. At final follow-up 20 weeks after surgery, the patient was pain free, non-tender, and had regained 50° wrist flexion and 50° wrist extension. Radiographs showed bony union, neutral tilt and radial inclination improved to 31°

Key points are as follows:

Distal radius fractures are a common injury and, when treated nonoperatively, can go on to malunion and cause significant disability;

The treatment for distal radius malunion involves varying osteotomy options with or without bone graft, but it is important to consider the 3D nature of this problem; and

The primary treatment option should be radial osteotomy to restore the native anatomy, but ulnar-sided procedures may be indicated in a subgroup of patients.

Source: https://www.healio.com/orthopedics/hand-wrist/news/print/orthopedics-today/{9be02300-e88b-44e9-93a6-8af13b05f9d0}/50-year-old-woman-with-ulnar-sided-wrist-pain