Seven Weeks After Volar Plating: Sorting Out Stiffness, Strength, and Nocturnal Tingling
Mrs. R is a 58-year-old right-dominant cashier, 7 weeks after volar plate fixation of a right distal radius fracture. She wore a short arm cast for 4 weeks and has had no formal therapy. Today: wrist flexion 25°, extension 30° with a firm end-feel, supination 40°, pronation 55°. Grip is 8 kg on the right and 24 kg on the left; lateral pinch 3 kg versus 7 kg. She reports intermittent tingling in the thumb and index finger that wakes her at night. Phalen's test reproduces the tingling at 25 seconds. Tinel's over the carpal tunnel is negative, but percussion 3 cm proximal to the plate is uncomfortable. Pain is 3/10 at rest, 6/10 at end range. She must return to 8-hour cashier shifts in 3 weeks.
1. Organize the findings into impairment-level problems, then state which problem you would address first this visit and why.
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Impairments: (1) limited wrist and forearm ROM, extension and supination most restricted; (2) strength deficit (grip 33% of the uninvolved side, pinch 43%); (3) sensory symptoms with a mixed provocation picture; (4) moderate pain, present only at end range.
Reasoning about the tingling: nocturnal symptoms plus a Phalen's response at 25 seconds suggest a nerve component, but the negative carpal tunnel Tinel and the tenderness to percussion proximal to the plate keep two alternatives live: swelling/positional compression that resolves with edema control and neutral night positioning, and soft-tissue irritation from the plate or pronator over the proximal edge.
What to treat first: edema and ROM, using low-irritability techniques (elevation/retrograde massage, tendon gliding, gentle sustained end-range holds, supination emphasis). The end-feel is firm rather than capsular-hard and pain appears only at end range, so irritability is moderate and controlled mobilization is appropriate. Supination and extension are the priority because they drive scanning, reaching, and lifting at a register, and her 3-week return-to-work date sets the timeline. Strengthening is introduced once pain at end range falls and ROM plateaus, not before.
2. Select two patient-reported outcomes and one performance-based measure, and justify each against her return-to-work goal.
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PRWE: region-specific for distal radius fracture, captures both pain and specific function, and has a published minimal clinically important difference of roughly 11 points, so serial scores tell you whether change is real rather than perceived. It is short enough to repeat biweekly.
QuickDASH: adds work-role and general upper-limb items, which matters because the discharge question is not "can she move her wrist" but "can she do an 8-hour register shift." Use it at baseline and at return to work.
Grip and pinch dynamometry (Jamar, position 2, mean of three trials, expressed as percent of the uninvolved side): the strongest single correlator of loaded hand function here, and her 8 kg value gives a concrete target against her 24 kg uninvolved side. Pair it with goniometry, particularly supination, which predicts functional rotation more than flexion does.
Rationale for the mix: patient-reported measures catch the work-role limitation that goniometry misses, while dynamometry and ROM anchor the objective progress needed for documentation and for any payer review.
3. She asks whether the tingling means she needs carpal tunnel surgery. How do you reason through this with her, and what findings over the next two weeks would change your referral decision?
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What to tell her: the symptoms are real but the picture is not yet typical structural carpal tunnel syndrome - the carpal tunnel Tinel is negative, the provocation is at 25 seconds rather than immediate, and there is a separate tender spot proximal to the plate. The most likely contributors are postoperative edema, wrist positioning at night, and soft-tissue irritation near the plate. A neutral wrist night orthosis plus edema control and tendon gliding is a reasonable two-week trial, and it costs her nothing diagnostically.
Findings that would trigger referral: persistent nocturnal symptoms despite neutral night splinting and edema control; constant (not intermittent) numbness; thenar atrophy or weakness of thumb abduction; static two-point discrimination worse than 6 mm in the thumb or index; or symptoms spreading proximally. Any of these shifts the balance from irritability toward nerve compromise and warrants EMG/NCS and a surgical opinion.
Reasoning stance: the decision is not "does she have carpal tunnel syndrome" but "how likely is this to be a compression neuropathy that will progress without intervention." Two weeks of documented response to conservative measures answers that more cheaply than immediate electrodiagnostics, and it also gives her a clear benchmark to watch.