Question 1

Q: A 50-year-old manual laborer sustained a comminuted distal radius fracture treated with ORIF 3 months ago. Despite supervised hand therapy, he has persistent stiffness with 30-degree wrist extension (normal 70), weak grip strength at 40% of contralateral side, and visible muscle atrophy. He reports burning pain with light touch and keeps his hand wrapped in a sock. Skin appears mottled with decreased hair growth. He is applying for disability and has a pending lawsuit. Evaluate the clinical picture and appropriate next step.

Triple-phase bone scan and referral to pain management. ***Triple-phase bone scan and referral to pain management*** - The presence of **allodynia** (pain with light touch), **autonomic dysfunction** (mottled skin, hair changes), and **atrophy** following trauma is classic for **Complex Regional Pain Syndrome (CRPS)**. - A **triple-phase bone scan** typically shows increased periarticular uptake in the delayed phase, and multidisciplinary **pain management** is the gold standard for treatment. *EMG/NCS to evaluate for nerve injury* - While nerve injury can cause pain, it does not explain the **vasomotor changes** and skin/hair trophic changes seen in this patient. - This patient likely has **CRPS Type I** (reflex sympathetic dystrophy), which occurs in the absence of a defined nerve injury. *Psychiatric evaluation for malingering assessment* - Despite the **secondary gain** considerations (lawsuit/disability), the physical findings of **mottled skin** and decreased hair growth are objective clinical signs that cannot be faked. - Labeling the patient as malingering before ruling out organic conditions like **CRPS** is inappropriate and delays necessary care. *Repeat surgery for hardware removal and capsular release* - Additional surgery is often **contraindicated** in the acute/active phase of CRPS as it can significantly worsen the pain and inflammatory response. - Stiffness in CRPS is due to **neurogenic inflammation** and sympathetic overactivity rather than simple mechanical obstruction by hardware. *Independent functional capacity evaluation* - While useful for measuring work readiness, this is a **diagnostic tool** for disability status rather than a clinical management step for an active pathology. - The priority is to confirm the diagnosis of **CRPS** and initiate treatment to prevent permanent **joint contracture** and functional loss.

Question

A 50-year-old manual laborer sustained a comminuted distal radius fracture treated with ORIF 3 months ago. Despite supervised hand therapy, he has persistent stiffness with 30-degree wrist extension (normal 70), weak grip strength at 40% of contralateral side, and visible muscle atrophy. He reports burning pain with light touch and keeps his hand wrapped in a sock. Skin appears mottled with decreased hair growth. He is applying for disability and has a pending lawsuit. Evaluate the clinical picture and appropriate next step.

Accepted Answer

Triple-phase bone scan and referral to pain management

Answer

EMG/NCS to evaluate for nerve injury

Answer

Psychiatric evaluation for malingering assessment

Answer

Repeat surgery for hardware removal and capsular release

Answer

Independent functional capacity evaluation

Orthopedic Surgery Basics — MCQs

Orthopedic Surgery Basics — MCQs

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