A 60-year-old female presented to an outpatient orthopaedic clinic in September 2021 with a one-week history of acute, traumatic right wrist pain after a mechanical ground-level fall while walking her dog. A distal radius fracture had been identified at an urgent care facility on the date of injury at which time the patient was provisionally splinted. The patient is an otherwise healthy, right-hand dominant female, non-smoker with noncontributory past medical/surgical history. The patient reported no prior history of trauma to the right wrist. On a focused musculoskeletal exam, she presented with a closed injury associated with significant swelling, but no visible deformity over the dorsum of the wrist. She was neurovascularly intact. Radiographs demonstrated a right, comminuted distal radius volar Barton fracture (Figure 1). At that time, a joint decision between the orthopaedist and the patient was to proceed with ORIF. Given significant comminution, a pre-operative computed tomography (CT) scan was obtained for surgical planning (Figure 1). The surgery took place two weeks following the date of injury. It was performed with a standard volar approach to the wrist and fixation was achieved with a 3.5 mm volar locking plate, and a hook plate (Skeletal Dynamics, Miami, FL) (Figure 2). Postoperatively, the patient initially progressed without complication, achieving a nearly symmetric range of motion (ROM) to the contralateral wrist at 12 weeks while working with a hand therapist. 
At a four-month routine clinical follow-up, in mid-January 2022, the patient presented with regression of ROM, as well as pain and swelling. She was afebrile with stable vital signs and was healthy-appearing. She expressed tenderness over the first and second extensor compartments and more wrist stiffness, concerning for intersection syndrome. Radiographs demonstrated no evidence of plate or screw prominence dorsally that could cause inflammation or tenosynovitis. A radial metaphyseal lucency was found on radiographs (Figure 3). At that time, bone resorption, infection, or cyst were considered in the differential diagnoses. Inflammatory markers, including CRP and ESR, were normal. A magnetic resonance imaging (MRI) was done and showed no signs of tenosynovitis or vascular aneurysm. Proximal to Lister's tubercle, a periosteal reaction and a peripheral enhancing cyst were found on the T2 sequence (Figure 3), the latter measuring approximately 7 x 8 x 8 mm. With normal inflammatory markers, a diagnosis of infection was considered less likely.
Over the next two months, the patient reported worsening dorsal wrist tenderness with some additional pain at the base of the thumb, mostly with pinching activities. Additional workup included an ultrasound (US) to better evaluate the flexor and extensor tendons, given the concern for tendon irritation due to the plate. This showed no signs of tenosynovitis. As for the cyst, the US was concerning for a possible giant cell tumor and revealed progression of the expansive lesion with cortical thinning.
Upon interdisciplinary team discussion with Orthopaedic Oncology, the decision was made to proceed with a biopsy for pathology and culture. A biopsy was performed through a small open dorsal approach, radial to Lister's tubercle. When incising the retinaculum overlying the second extensor compartment a non-purulent, brown fluid was encountered. The dorsal cortical aspect of the metaphyseal radius was found thinned and insignificant. Sharp excisional debridement was performed in the metaphysis through the dorsal cortical window. Several samples, including soft tissue, bone, and fluid were sent for pathology and culture. The hardware was not revised and was found to be stable.
She was seen thereafter by the Orthopaedic Oncology team. On exam, she had an unremarkable healing incision with swelling over the dorsal and volar aspect of the wrist. Shortly after the biopsy, the pathology report was conclusive for GCTB. Cultures remained negative throughout the postoperative course. A chest X-ray was ordered which was indicative of no lung metastasis. A new MRI was obtained for re-evaluation prior to definitive surgery and showed a T1 hypointense and T2 hyperintense expansile lesion with cortical destruction, measuring 3 x 2.4 x 4.2 cm (Figure 4). No other bone lesions were found around the radius and ulna.
One week after the biopsy, she underwent definitive surgery. A dual volar and dorsal approach was performed with extensive tenolysis (flexor tendons), carpal tunnel release, neurolysis (median and ulnar nerve), and extensive curettage of the radial metaphyseal tumor. Soft tissue and deep bone biopsy were sent for cultures and pathology. These were again positive for GCTB (CD 68+) with no signs of malignancy. Cytogenetic testing showed no chromosomal aberrations. While protecting soft tissue structures, stepwise cryoablation (volar cavity two cycles for seven minutes, and dorsal capsule one cycle for five minutes) and cementation with tobramycin of the cavity followed. The hardware was found stable and in a good position, and thus the decision was made to leave it in place. Postoperatively at four weeks, May 2022, she had an uneventful recovery. She was found neurovascularly intact throughout. The dorsal incision was well-healed, and the volar incision had no signs of dehiscence or infection but showed delayed healing (all sutures were kept for three to four weeks), and minimal swelling (Figure 5). At that time, ROM was still limited but improving with therapy. She was maintained on non-weight bearing (NWB) precautions with a splint for comfort and nighttime use.