Six Weeks After Volar Plate Fixation: Complex Pain and Median Symptoms

The presentation raises complex regional pain syndrome and median nerve irritation or compression. The burning pain, allodynia, disproportionate swelling, skin color and temperature changes, and intolerance of light touch fit the Budapest criteria pattern for CRPS, although that diagnosis is clinical and requires other causes to be excluded. The median-distribution tingling also raises carpal tunnel syndrome or median nerve contusion related to the fracture or plate position. I would be more urgent because the pain is severe and constant, the sensory symptoms are progressive, and the patient cannot tolerate ordinary contact. I would not simply push range of motion through this pain. I would contact the hand surgeon the same day to report the sensory distribution, the allodynia, the color and temperature changes, and the marked strength loss. I would also check for red flags such as infection, hematoma, or compartment syndrome, although the healed wound and absence of fever make those less likely. The key judgment is that unexplained severe pain with sensory and autonomic changes is not routine stiffness.

I would keep the session gentle and pain-limited. I would avoid aggressive passive stretching, prolonged immobilization in a dependent position, tight wrapping, and any treatment that provokes allodynia. I would use elevation, light compression only if it does not increase pain, and gentle active-assisted range within a comfortable arc. Desensitization would start with very light, predictable touch on a tolerant area, not the most painful dorsum. I would teach pacing and pain-monitoring rules, because a flare that lasts hours after exercise suggests the dose was too high. I would also check the splint or brace for pressure over the median nerve and the distal forearm. If the patient has a resting hand position that increases pain, I would support the limb rather than let it hang. I would document baseline pain, sensory findings, edema, and active range so the surgeon can compare. I would not start a vigorous strengthening program or a high-dose passive stretch program during this diagnostic uncertainty.

The first stage is pain modulation and function preservation: gentle active range, edema control, protected positioning, and graded desensitization beginning well below the pain threshold. I would add mirror therapy or graded motor imagery if the patient can tolerate it, because these target cortical representation without loading the painful limb. I would coordinate medication and possible nerve evaluation with the surgeon. The second stage adds functional tasks with the affected hand, such as light dressing, writing, or kitchen setup, using short bouts and rest breaks. I would avoid a no-pain-no-gain approach. Strengthening would begin only after pain and autonomic signs stabilize, starting with isometrics and then light concentric work. I would monitor median nerve symptoms, especially if thumb abduction weakness or sensory loss progresses, because that may require a separate nerve decompression decision. The plan is contingent on the pain response: if allodynia spreads or pain persists hours after sessions, I would reduce the load and return to the surgeon rather than advance.