David Nelson , MD
Private Practice, San Francisco
Webmaster, eRadius
Associate Editor, J Hand Surgery
Director, San Francisco Bay Area Hand Club

Although I might decrease the distraction 2 mm, I think that the reduction of the radius has dramatically improved the alignment. However, mainly due to the intraarticular stepoffs seen on the lateral and another one on the PA, I think further surgery is required for the radius. In addition, the ulnar fracture is not the typical styloid-only fracture, but is a head fracture. These have been shown by Jupiter to have a higher incidence of radial nonunion if not stabilized. They represent a much greater soft tissue and bony injury and need to be treated more aggressively. Therefore, both the radius and the ulna need further reduction and stabilization. This will have to be done open.

The options for the radius include many options, but a fixed-angle volar plate would be my first choice. My choice for the ulna would be a fixed-angle plate, but it will be difficult due to the distal location of the fracture.

The median nerve numbness is a matter for concern. While one cannot rule out direct injury as the sole cause of numbness, it is probably a combination of direct injury and ischemia due to swelling in the wrist. This is the reason it is often wise in cases of high energy trauma to release the median nerve at the same time as the treatment of the distal radius. Delayed decompression of the median nerve has a reasonable incidence of permanent or delayed recovery and a high incidence of RSD. Now the median nerve needs to be released as soon as the patient is stable again for surgery. I think that even a delay of 24 hours is contraindicated.

The treating surgeon decided to place a fixed-angle volar plate on the radius and plate on the ulna. In addition, a median nerve decompression was done at the same time in both the palm and the distal forearm.

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