Distal Radius Fracture: Ace Your FRCS Oral Exam Case
Key Takeaway
Learn more about Distal Radius Fracture: Ace Your FRCS Oral Exam Case and how to manage it. A distal radius fracture is a break in the radius bone near the wrist, often characterized by dorsal angulation and displacement. Radiographs typically show dorsal tilt on AP views and dorsal displacement on lateral views. Management depends on patient and injury factors, frequently involving closed manipulation for unstable fractures to restore alignment and reduce soft tissue tension.
A 55-year-old active female presents following a high-energy fall onto an outstretched hand. She has sustained a complex distal radius fracture. The initial radiographs are shown below. Describe the radiological features and how they influence your management strategy.
Candidate: "This is a comminuted, intra-articular distal radius fracture. It appears to involve the radio-carpal joint and likely the DRUJ. I would assess for stability, check the median nerve status, and likely plan for surgical fixation, probably with a volar locking plate."
Failing to describe the specific radiographic markers of instability (e.g., radial shortening >3mm, dorsal tilt >10-15°, articular step-off >2mm). Candidates often jump straight to "plating" without defining the goals of fixation (anatomical restoration vs. spanning fixation) or acknowledging soft-tissue status, which is vital in high-energy injuries.
Start with a structured description: "This is a high-energy, intra-articular, comminuted distal radius fracture (AO/OTA 23-C3). Key features include significant shortening, loss of volar tilt, and articular impaction. My management strategy involves: 1) Neurovascular assessment, particularly the median nerve; 2) Evaluation for soft-tissue injury; 3) Definitive management aims for anatomical restoration of the articular surface to minimize post-traumatic arthritis. Given the comminution, I would discuss the use of a low-profile volar locking plate, potentially with structural bone grafting for the metaphyseal void, or external fixation/spanning plating if the soft-tissue envelope precludes primary internal fixation."
The patient is now 6 months post-operatively after a volar plate fixation. She complains of persistent pain with pronation and supination and localized tenderness over the ulnar head. What is your differential diagnosis, and how do you investigate?
Candidate: "The differential includes TFCC injury, DRUJ instability, post-traumatic arthritis, or perhaps ulnar impaction syndrome. I would examine for the 'piano key' sign and order an MRI to look at the ligaments."
Focusing only on the MRI. A strong candidate must emphasize physical examination findings first. Missing the significance of the DRUJ stress test or failing to mention standard provocative tests for the TFCC (e.g., TFCC compression test) is a major oversight.
"Differential includes TFCC tear, DRUJ instability, ECU tendonitis, or ulnocarpal impaction. I would proceed with a structured clinical exam: testing DRUJ stability (Piano Key sign, Ballottement test), comparing passive and active rotational range of motion against the contralateral side, and specific provocative tests like the TFCC compression test. Radiographically, I’d request comparative views (AP/Lateral) to assess ulnar variance. If inconclusive, I would consider an MRI arthrogram to evaluate the TFCC and, if the clinical picture suggests instability, proceed to diagnostic arthroscopy, which is the gold standard."
