Pain on dorsal hand post radius fracture

I'm seeing this patient who fractured his L radius 4/7/08 which has been treated with an ORIF. First appt reported no pain so we started ROM exercises. When he came in for his 2nd appt he c/o pain of the dorsal aspect of his hand over II, III metacarpals when in wrist flexion (7/10). Palpation of the area and mobilisation of all carpal and metacarpal joints did not reproduce pain, neither did movement in any of the other directions.

We continued with ROM exercises and I advised that the pain is probably due to stretching the structures but it should subside with time.

Saw him for the 4th time today and still no improvement in range or pain (range most likely because he is afraid to push further because of the pain). I assessed extensor indicis because it was the only structure in the area that we hadn't ruled out yet and resisted extension reproduced the pain (yay! I found something!).

All I can think of now is that this tendon is passing directly over the plates and screws in his wrist, but I still can't explain why he is getting this pain.

I'm hoping to get advice on
1) what the cause of this pain is
2) how can I manage it
3) how can I convince the patient that his exercises will be beneficial (yellow flags are flying in the wind now!!!)

If you can shed some light on any of this it would be greatly appreciated!!

have you ruled out neural involvement,expecially ULTT radial nerve bias.neural mobility restriction can also cause the pain.
is there associated systemic problems
please mention the fracture wass at which level
individual carpal mobility??
carpal instability tests??
distal radio-ulnar joint diastasis ???

He hasn't shown any neural signs so haven't performed ULTT but will give that a go next time he is in. Tested all the carpal joint mobility and stability of ligaments, all negative.

Fracture is distal radius, can't remember exact location.

Hi

pain over the dorsal aspect after this operation at this stage is very normal. If yellow flags are flying try to keep hands off, gentle ROM is best. Keep your patient positive, these can take a long time before pain subsides. There will also be some reduced range, this is normal. take it easy, their body hasnt even healed yet

Hello,

The most common cause of dorsal wrist pain is TFCC central tear. This occurs in 50% of wrist fractures. The way to examine and test it is quite variable and unreliable. The interrater reliability for TFCC diagnosis is huge. The test to perform is the weight bearing test. Simply have your patient place the palm on a bathroom scale with the elbow straight and push to the point of pain. This may recapture the pain. You may also see a descrepancy in the tolerance from right to left. The other thing to look for is ulnar sided wrist pain with resisted end range supination and pronation and pain with grip.

If you get me the numbers for grip and weight bearing tolerance between right and left, I can tell you.

Another place to look is the EPL. This is commonly ruptured as it crosses the wrist over the plate.

Good luck!

Wendy