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HPI
A 63-year-old female who presents to the office for evaluation of left wrist deformity. The patient sustained a distal radius fracture 12 weeks ago at the start of the COVID pandemic. She was initially seen at an outside urgent care and splinted in situ. Surgery was recommended at that time, however, she refused given the pandemic. Risks of malunion and functional deficits were discussed with the patient at that time, she continued to refuse despite the less than acceptable position of her fracture. After radiographic healing was identified, immobilization was discontinued and the patient was pain-free. As time went on, contrary to what she previously thought, she was unable to tolerate the deformity and decreased range of motion and re-presented for evaluation.
PMH
PE
Focused exam of the left upper extremity demonstrates an obvious deformity to the distal radius. She has no tenderness to palpation about the wrist. Motor grossly intact as demonstrated by the cardinal hand motions. Sensation is intact to all distributions of the hand. Radial pulse palpable. Active range of motion from 105 degrees of wrist extension to 5 degrees short of neutral.
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Dorsal opening wedge osteotomy of the radius; internal fixation