What is the best course of action for a 61-year-old female patient with a history of Dupuytren's contracture who fell two weeks ago, resulting in bruising, mild swelling to the left wrist, and forearm, with pain when turning her arm supine and prone, loss of grip and strength in her left hand, and pre-existing Dupuytren's contracture in her left hand?

Immediate Management of Post-Traumatic Wrist and Forearm Injury in a 61-Year-Old

This patient requires immediate radiographic imaging with a standard 3-view wrist series (PA, lateral, and oblique) to evaluate for occult fracture, given the persistent pain with rotation, weakness, and ongoing symptoms two weeks post-injury. 1, 2

Initial Diagnostic Workup

Imaging Protocol

• Obtain 3-view radiographs of the wrist immediately (posteroanterior, lateral, and 45-degree semipronated oblique), as this is the standard initial imaging for suspected wrist trauma 1
• Consider adding a fourth semisupinated oblique projection to increase diagnostic yield for distal radius fractures 1, 2
• If radiographs are negative but clinical suspicion remains high (which it should given pain with supination/pronation and grip weakness), proceed to CT without IV contrast to evaluate for occult fractures, particularly involving the distal radius or carpal bones 1, 2
• MRI without IV contrast should be obtained if CT is negative or if there is concern for ligamentous injury (scapholunate ligament, triangular fibrocartilage complex), as pain with rotation suggests possible soft tissue involvement 1, 2

Critical Clinical Findings

The combination of:

• Pain with forearm rotation (supination/pronation) suggests distal radioulnar joint involvement or forearm fracture 1
• Loss of grip strength indicates either fracture, tendon injury, or nerve compromise 1
• Persistent symptoms at two weeks post-injury warrants aggressive investigation rather than continued observation 1, 2

Management Based on Findings

If Fracture is Identified

• Immobilize appropriately based on fracture pattern (splinting or casting for non-displaced fractures) 2
• Surgical consultation is indicated for displaced fractures with articular step-off >2mm, die-punch depression, or more than three articular fragments 2
• Early range-of-motion exercises should begin once stable fixation is achieved to prevent stiffness 1, 3

Special Considerations for This Patient

Age-Related Fragility Fracture Assessment

• At age 61, this wrist injury may represent a fragility fracture requiring osteoporosis evaluation, particularly given the mechanism (fall from standing height) 4, 2
• Implement systematic fracture risk assessment including DXA scan of spine and hip, vitamin D level, and secondary osteoporosis screening (TSH, calcium, albumin, creatinine) 1, 2
• Consider initiating anti-osteoporotic therapy with first-line bisphosphonates (alendronate or risedronate) even before DXA results if fracture is confirmed, as this represents a sentinel fragility fracture 1, 2
• Ensure calcium intake of 1000-1200 mg/day and vitamin D 800 IU/day 1

Dupuytren's Contracture Considerations

• The pre-existing Dupuytren's contracture is unlikely related to the acute injury but may complicate rehabilitation 5
• Do not attribute the current grip weakness solely to Dupuytren's disease, as this is an acute change following trauma 5
• Dupuytren's contracture itself does not require urgent intervention unless metacarpophalangeal or proximal interphalangeal joint contracture exceeds 30 degrees 5
• Post-injury rehabilitation may be more challenging due to the underlying fibrotic changes, requiring tailored hand therapy 5

Common Pitfalls to Avoid

• Do not dismiss "normal" initial radiographs in the setting of persistent symptoms - up to 55% of patients with negative initial radiographs have findings on MRI that change management 1
• Do not delay advanced imaging for 10-14 days with repeat radiographs - this outdated approach leads to functional impairment and delayed diagnosis 1, 2
• Do not attribute all symptoms to the known Dupuytren's contracture - acute loss of grip strength following trauma indicates new pathology 5
• Do not overlook this as a fragility fracture - wrist fractures in patients over 60 from ground-level falls warrant osteoporosis evaluation regardless of bone density 4, 2

Rehabilitation Considerations

Once Diagnosis is Established

• Initiate early finger motion immediately to prevent edema and stiffness, even while the wrist is immobilized 1, 3
• Begin aggressive range-of-motion exercises for fingers, hand, and wrist once immobilization is discontinued 1, 3
• Avoid overly aggressive therapy initially, as excessive force may compromise fracture healing or fixation 1, 3
• Plan for extended rehabilitation given the patient's age and pre-existing Dupuytren's contracture 5

Secondary Prevention

• Implement fall risk assessment as part of comprehensive fracture prevention 1, 2
• Coordinate with primary care or rheumatology for long-term osteoporosis management and monitoring 1, 2
• Ensure systematic follow-up to improve adherence to osteoporosis therapy, which is substantially higher when initiated in the fracture liaison service setting 1