What's the next step after an X-ray reveals a fracture in a patient who fell on an outstretched hand with a swollen wrist, hand pain, and decreased sensation over the thumb and first three fingers?

Immediate Orthopedic Consultation for Suspected Acute Carpal Tunnel Syndrome

This patient requires urgent orthopedic or hand surgery consultation for suspected acute carpal tunnel syndrome secondary to the wrist fracture, as the decreased sensation over the thumb and first three fingers indicates median nerve compromise that may require emergent surgical decompression. 1

Critical Clinical Recognition

The combination of wrist fracture with decreased sensation in the median nerve distribution (thumb and first three fingers) represents a surgical emergency that demands immediate specialist evaluation. 2

• Distal radius fractures may be complicated by median nerve injury, which can progress to permanent nerve damage if not addressed promptly 2
• The swelling and sensory changes suggest compartment syndrome or direct nerve compression requiring urgent assessment 2

Immediate Management Steps

1. Urgent Specialist Referral

• Contact orthopedic surgery or hand surgery immediately for evaluation within hours, not days 1, 2
• Document the exact sensory distribution affected and any motor deficits (thumb opposition weakness) 1

2. Neurovascular Assessment

• Perform and document a complete neurovascular examination including:
  • Two-point discrimination in all digits 1
  • Motor function of the thenar muscles (thumb opposition) 1
  • Capillary refill and radial pulse 1
• Repeat this examination frequently (every 1-2 hours) while awaiting specialist evaluation 1

3. Immobilization Considerations

• Apply a well-padded sugar-tong splint with the wrist in neutral position 2
• Avoid circumferential casting in the acute setting due to risk of compartment syndrome with ongoing swelling 2
• Elevate the extremity above heart level 2

Advanced Imaging Considerations

While the fracture is already confirmed on X-ray, additional imaging may be needed for surgical planning:

CT Without IV Contrast

• CT is superior for detecting intra-articular extension of distal radius fractures and helps with preoperative planning for complex articular injuries 1
• Three-dimensional reconstructions are particularly helpful for surgical planning 1
• The orthopedic surgeon will determine if CT is needed before operative intervention 1

MRI Without IV Contrast

• MRI can identify concomitant ligament injuries (scapholunate ligament tears) that may affect surgical treatment 1
• Unlike CT, MRI shows soft tissue injuries including nerve compression 1
• However, MRI performed immediately at the time of injury has little added value for determining which patients require surgery compared to clinical examination 1

Common Pitfalls to Avoid

• Do not delay specialist consultation to obtain advanced imaging—the neurologic compromise takes priority over imaging 1, 2
• Do not apply a tight circumferential cast in the acute setting, as this can worsen compartment syndrome 2
• Do not assume sensory changes will resolve spontaneously—median nerve injuries with distal radius fractures require active intervention 2
• Do not discharge the patient home without clear neurovascular monitoring instructions and urgent follow-up arranged 1, 2

Surgical Indications

The orthopedic surgeon will assess for:

• Need for carpal tunnel release if acute carpal tunnel syndrome is confirmed 1, 2
• Fracture reduction and fixation, particularly if there is >2 mm articular step-off or significant displacement 1
• Timing of intervention (emergent vs. urgent) based on severity of nerve compromise 2