What is the best management approach for a 54-year-old male patient with left wrist pain due to an old ununited fracture of the ulnar styloid and osteoarthritic changes?

From the Guidelines

The best management approach for a 54-year-old male patient with left wrist pain due to an old ununited fracture of the ulnar styloid and osteoarthritis would initially involve conservative treatment, focusing on a combination of non-pharmacological and pharmacological interventions individualized to the patient's requirements, as recommended by the 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee 1. This approach should begin with oral NSAIDs, such as ibuprofen (400-600mg three times daily) or naproxen (500mg twice daily), for 2-4 weeks, combined with activity modification to avoid painful movements.

• A wrist splint should be worn during activities and at night to immobilize and rest the joint.
• Physical therapy focusing on gentle range of motion exercises and strengthening of the forearm muscles would help maintain function while reducing pain.
• Education concerning joint protection and an exercise regimen involving both range of motion and strengthening exercises are also recommended for all patients with hand OA, as suggested by the EULAR evidence-based recommendations for the management of hand osteoarthritis 1. If conservative measures fail after 3-6 months, corticosteroid injections (such as methylprednisolone 40mg with lidocaine) may provide temporary relief, as supported by the 2019 American College of Rheumatology/Arthritis Foundation guideline 1. For persistent symptoms, surgical options should be considered, including ulnar styloid excision, TFCC repair, or partial wrist fusion depending on the specific pathology and functional requirements. This stepped approach addresses both the mechanical issues from the ununited fracture and the inflammatory component of osteoarthritis while preserving wrist function as much as possible, in line with the recommendations from the American College of Radiology Appropriateness Criteria for chronic wrist pain 1.

From the Research

Management Approach for Wrist Pain

The patient's condition, characterized by an old ununited fracture of the ulnar styloid and osteoarthritic changes, requires a comprehensive management approach. The following points outline the best management strategy:

• Pain Management: For mild to moderate pain, first-line pharmacologic agents such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used 2. The choice between these medications depends on the type of pain and patient risk factors for NSAID-related adverse effects.
• Use of Wrist Orthosis: A wrist brace can provide support and reduce pain in patients with hand osteoarthritis 3. A study found that wearing a silicone wrist hand orthosis improved daily functioning by 77% and reduced perceived pain by 61%.
• Wrist Bracing for Specific Activities: Wrist bracing can be effective in reducing wrist pain during specific activities, such as gymnastics 4. A study found that wearing a wrist brace with a volar gel pad significantly reduced pain in gymnasts.
• Grip-Strengthening Algorithm: For chronic, nonspecific wrist pain in adolescents, a grip-strengthening algorithm can alleviate pain and improve function 5. This approach can also identify patients who require further intervention.
• Stabilization of the Distal Radioulnar Joint: A wrist brace that stabilizes the distal radioulnar joint can increase the weight-bearing capacity of patients with lesions of the triangular fibrocartilage complex 6. This can be particularly beneficial for patients with unstable joints or traumatic lesions.

Key Considerations

When managing the patient's condition, the following key considerations should be taken into account:

• The patient's medical history, including the old ununited fracture of the ulnar styloid and osteoarthritic changes
• The patient's current symptoms and level of pain
• The potential benefits and risks of different management strategies, including pharmacologic agents, wrist orthosis, and grip-strengthening algorithms
• The need for ongoing monitoring and adjustment of the management plan as needed