Treatment of Closed Nondisplaced Styloid Fracture of the Ulna
Conservative management with short-arm cast immobilization for 3-4 weeks is the recommended treatment for closed nondisplaced ulnar styloid fractures, as surgical fixation has not demonstrated superior outcomes for these stable fractures. 1, 2
Treatment Algorithm
Initial Management
- Short-arm cast immobilization for 3-4 weeks 2
- Consider a sugar-tong splint for the first week if significant swelling is present
- Ensure the wrist is in a neutral position to avoid strain on the distal radioulnar joint (DRUJ)
Follow-up Care
- Radiographic evaluation at 3 weeks to assess healing progress
- Transition to removable splint after 3-4 weeks if clinically appropriate
- Begin gentle range of motion exercises after immobilization period
Rehabilitation
- Progressive wrist and forearm strengthening exercises
- Focus on restoration of pronation and supination
- Monitor for signs of DRUJ instability during recovery
Evidence-Based Considerations
The American Academy of Orthopaedic Surgeons (AAOS) guideline specifically states they are "unable to recommend for or against fixation of ulnar styloid fractures associated with distal radius fractures" 1. While this recommendation was made in the context of ulnar styloid fractures accompanying distal radius fractures, it highlights the lack of strong evidence supporting surgical intervention for ulnar styloid fractures in general.
Recent research supports this conservative approach. A 2023 study found that "ulna styloid fractures do not contribute to the DRUJ instability and the status of the union of the ulna styloid and the site of the ulna styloid fracture (tip or base) did not have a bearing on the range of movement and functional outcome" 3. This suggests that even if nonunion occurs, functional outcomes remain good with conservative management.
A 2021 prospective study further reinforced this approach, finding "neither the presence, type, nor bony union status of a concomitant USF has any significant effect on patient outcomes" 4. Even with a 75.7% nonunion rate at one year, patients maintained good functional outcomes without surgical intervention.
Important Clinical Considerations
DRUJ Stability Assessment: While immobilizing the fracture, carefully assess for DRUJ instability using the ballottement test and piano key sign. If instability is present, the treatment approach may need modification 3.
Nonunion Management: Asymptomatic nonunion of ulnar styloid fractures is common and generally does not require intervention. Only symptomatic nonunions with DRUJ instability (Type 2 according to classification) may warrant surgical consideration 5.
Pain Management: Standard analgesics and ice therapy can help manage pain during the initial healing phase 1.
Surgical Indications
Surgery should be considered only in specific circumstances:
- Displaced fractures with DRUJ instability
- Symptomatic nonunions with persistent pain and functional limitation
- Large fragments involving the fovea with TFCC disruption 5, 6
For the typical closed nondisplaced ulnar styloid fracture, conservative management remains the standard of care with excellent functional outcomes and minimal complications.