How Dr. Pickrell got a 34-year-old foreman back on the job site.

Our patient was a 34-year-old foreman on a mid-rise residential build. He stepped off the second-to-top rung of an extension ladder, the ladder kicked, and he fell roughly ten feet onto a dirt subgrade — landing primarily on his right (dominant) outstretched hand. He went to a nearby emergency department within an hour. Imaging there showed a displaced, dorsally angulated distal radius fracture with intra-articular extension and approximately 20 degrees of dorsal tilt. The ER team performed a closed reduction under hematoma block, applied a sugar-tong splint, and sent him home with a hand-surgery follow-up referral.

He came to us at LAOSS five days later for that follow-up. The story we wanted to tell from those repeat films was the story of a fracture sitting quietly in good alignment. That's not the story the films told. The radial height had collapsed, the dorsal tilt had recurred to roughly 15 degrees, and the intra-articular step-off was about 2 millimeters at the radiocarpal joint. By the accepted criteria — radial inclination, radial height, dorsal tilt, intra-articular step-off — this fracture had lost acceptable reduction. In a 34-year-old whose entire career depended on a strong, well-aligned dominant wrist, that mattered.

There is a real and respectable path for distal radius fractures that involves a well-molded cast, weekly imaging, and patience. We use it often — particularly for non-displaced fractures, for fractures in older lower-demand patients where modest residual deformity is acceptable, and for patients who decline surgery after a clear conversation about risk. We considered that path here. The conversation was short for two reasons.

The first was the fracture pattern. An intra-articular step-off of 2 millimeters in a young, active, dominant wrist has a well-documented association with post-traumatic arthritis if left uncorrected — and our patient had decades of joint-life ahead of him. The second was occupational. His job demanded heavy lifting, repetitive gripping, impact loading from nail guns and hammers, and ladder work that required a wrist he could trust. A wrist that healed with a residual dorsal tilt and a step-off would likely have worked, in the short term — but it would have given him a worse twenty-year outcome than a well-reduced surgical fixation. We laid out both paths, including the risk of surgery (infection, hardware irritation, tendon irritation, stiffness), and he chose ORIF.

Volar locking plate fixation is the most studied and most reproducible operation we have for displaced distal radius fractures in this demographic. Through a Henry approach on the volar (palm) side of the wrist, we visualize the fracture, restore radial height, restore the volar tilt of the joint surface, anatomically reduce the intra-articular step-off under direct and fluoroscopic visualization, and lock the construct with fixed-angle screws that support the subchondral bone of the joint surface. The plate sits under the pronator quadratus, away from the extensor tendons — the historical site of hardware-related tendon problems with older dorsal plating.

We scheduled him within ten days of the original injury. Operating sooner than three weeks gives us the best chance of an anatomic reduction; waiting beyond about three weeks lets early callus form and makes the reduction harder to achieve. The operation itself took about 75 minutes under regional block and light sedation, and he went home the same afternoon in a well-padded volar splint.

Distal radius fractures vary widely. Younger patients with stable, non-displaced fractures often heal beautifully in a cast alone with no surgery and an outstanding long-term result. This patient's fracture was different — it was displaced, it was intra-articular, and it could not be held in acceptable alignment by closed reduction. That is what made surgery the right call here, not a default preference for an operation. If your fracture is non-displaced and stable, we will say so, and we will cast you. The longest-lasting issue in this recovery was not the fracture and not the hardware — it was hand stiffness. Even with early aggressive occupational therapy, his grip strength took a full six months to match his other side. That is normal for this injury and we tell every distal radius patient the same thing on day one: the bone heals in six to eight weeks; the wrist takes six months.

Composite case based on common LAOSS treatment outcomes. Anonymized for patient privacy.