A 28-year-old male construction worker presents to the emergency department 6 hours after a fall from scaffolding onto his left wrist. He reports severe wrist pain and swelling. On examination, the wrist is held in a dorsally angulated position. Plain radiographs (PA and lateral views) show a transverse fracture through the distal radius with dorsal displacement and angulation of the distal fragment. However, the radiographs appear technically adequate with no obvious soft tissue artifact. Which imaging modality would be most appropriate as the next step to fully characterize this injury and guide surgical planning?

Explanation

## Clinical Context This patient has a distal radius fracture (likely a Colles' fracture variant) with dorsal displacement. While plain radiographs provide initial assessment, complex intra-articular fractures require detailed 3D anatomical information for surgical planning. ## Why CT with 3D Reconstruction is Correct **High-Yield:** CT is the gold standard for evaluating complex intra-articular fractures of the distal radius because it: - Detects occult fracture lines and comminution not visible on plain films - Provides multiplanar (axial, coronal, sagittal) assessment - Enables 3D reconstruction for precise surgical planning - Identifies associated injuries (ulnar styloid fracture, TFCC involvement) - Guides reduction strategy and implant selection **Key Point:** Distal radius fractures with intra-articular extension, dorsal angulation, or comminution warrant CT imaging to prevent post-reduction articular step-off and long-term complications. **Clinical Pearl:** Even if initial plain films appear adequate, CT should be obtained before surgical intervention in displaced intra-articular fractures to avoid suboptimal reduction and post-traumatic arthritis. ## Why Other Options Are Suboptimal | Modality | Limitation | |----------|------------| | MRI | Excellent for soft tissue but overkill for acute fracture; longer acquisition; contraindicated with metal implants if ORIF planned | | Ultrasound | Real-time assessment possible but operator-dependent; poor for bone detail; not standard for fracture characterization | | Repeat plain radiographs | Different angles may clarify some features but cannot replace 3D information needed for surgical planning |