Treatment of Acute Displaced Fractures of the Distal Radius and Ulnar Styloid
Surgical fixation is recommended for distal radius fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement, while associated ulnar styloid fractures generally do not require separate fixation if the distal radioulnar joint is stable. 1
Initial Assessment and Classification
When evaluating acute displaced fractures of the distal radius with associated ulnar styloid fracture:
- Assess for:
- Degree of displacement of the distal radius fracture
- Intra-articular involvement
- Radial shortening (>3 mm indicates need for surgical intervention)
- Dorsal tilt (>10° indicates need for surgical intervention)
- Distal radioulnar joint (DRUJ) stability
- Associated nerve injuries (median and ulnar nerves)
Treatment Algorithm for Distal Radius Fractures
Surgical Management
For displaced fractures with any of the following criteria, surgical fixation is recommended:
- Postreduction radial shortening >3 mm
- Dorsal tilt >10°
- Intra-articular displacement 1
Surgical options include:
- Volar locking plates (most common)
- External fixation
- Percutaneous pinning
- Dorsal plating
Important note: The evidence does not support one specific surgical method over others for fixation of distal radius fractures. 1
Non-Surgical Management
For minimally displaced fractures:
- Rigid immobilization (cast) is preferred over removable splints for displaced fractures 1
- Removable splints can be considered for minimally displaced fractures 1
Management of Associated Ulnar Styloid Fractures
The current evidence suggests:
- Ulnar styloid fractures generally do not require separate fixation if the DRUJ is stable after distal radius fixation 2, 3, 4
- Multiple studies have demonstrated that the presence of an ulnar styloid fracture, its size, displacement, or healing status does not affect patient-rated outcomes when the DRUJ is stable 2, 4
Key point: DRUJ stability is the critical factor in determining whether ulnar styloid fractures need surgical intervention, not the presence of the fracture itself.
Special Considerations
Arthroscopic Evaluation
- Arthroscopic evaluation is an option during surgical treatment of intra-articular distal radius fractures 1
- Can help identify and treat associated ligament injuries (SLIL injuries, LT, or TFCC tears) at the time of radius fixation 1
Nerve Injuries
- High-energy, widely displaced fractures of the distal radius may be associated with nerve injuries, including ulnar nerve palsy 5
- Exploration and release of the ulnar nerve is recommended when there is an open wound or acute carpal tunnel syndrome 5
- Without these conditions, observation is appropriate as most are neurapraxic injuries that recover well 5
Post-Operative Management
- Radiographic follow-up is recommended at 3 weeks and at cessation of immobilization 1
- CT scan is an option to improve diagnostic accuracy for complex intra-articular fractures 1
Pitfalls and Caveats
Overlooking DRUJ instability: While most ulnar styloid fractures don't require fixation, careful assessment of DRUJ stability is essential as instability would warrant surgical intervention.
Underestimating nerve injuries: High-energy distal radius fractures can be associated with median or ulnar nerve injuries that require careful assessment and potential surgical exploration.
Inadequate reduction: Failure to achieve adequate reduction of the distal radius fracture (especially with respect to radial shortening, dorsal tilt, and intra-articular step-off) can lead to poor functional outcomes regardless of ulnar styloid management.
Over-treatment of ulnar styloid fractures: Current evidence suggests that routine fixation of ulnar styloid fractures in the setting of stable DRUJ does not improve outcomes and may expose patients to unnecessary surgical risks 2, 4.