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Figure 1. Anteroposterior radiographic view of displaced distal radius fracture.
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Figure 2. Lateral view of wrist.
A 35-year-old woman presents with severe left wrist pain after a fall that occurred 4 days ago. On physical examination, the patient has significant swelling to the wrist and pain to palpation over the distal radius. She also complains of pain and paresthesia in her thumb, index, and middle fingers that seem to be getting worse over the last day. Assessment of her light tough sensation shows diminished feeling in the medial nerve distribution compared with the contralateral hand. Radiographic imaging anteroposterior and lateral views (Figures 1 and 2) show a displaced distal radius fracture.
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Acute carpal tunnel syndrome (ACTS) can occur after a distal radius fracture because of elevated compartment pressure in the wrist from swelling and compression from a displaced fracture. A carpal tunnel contusion can be differentiated from ACTS by worsening symptoms over time (ie, ACTS). Generally, symptoms are watched over a few days to follow symptom progression and wait for the swelling to subside prior to surgery. Failing to recognize ACTS can lead to permanent injury to the median nerve.1,2
Acute carpal tunnel syndrome is diagnosed clinically with pain and paresthesia in the median nerve distribution or in the thumb, index, and middle fingers. Patients with fracture translation greater than 35% and female patients younger than 48 years of age are at higher risk of developing persistent carpal tunnel syndrome.2 Patients with persistent or worsening ACTS symptoms should have a prophylactic carpal tunnel release at the time of open reduction and internal fixation (ORIF). A closed reduction of a displaced fracture and splinting may also help ACTS symptoms before definitive surgery.1,2
The incidence of ACTS after a distal radius fracture is around 9% and the symptoms are severe enough in 5% of patients to require a carpal tunnel release. A carpal tunnel release can be performed with a separate incision at the time of ORIF of a distal radius fracture.1,2
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.
References
1. Leow JM, Clement ND, McQueen MM, Duckworth AD. The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius. Eur J Orthop Surg Traumatol. 2021;31(5):981-987. doi:10.1007/s00590-021-02975-5
2. Dyer G, Lozano-Calderon S, Gannon C, Baratz M, Ring D. Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. Hand Surg Am. 2008;33(8):1309-1313. doi:10.1016/j.jhsa.2008.04.012
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