What is the initial treatment for an ulnar process fracture?

Initial Treatment for Ulnar Process Fracture

For non-displaced ulnar styloid fractures, the initial treatment is conservative management with rigid immobilization using a cast for 3-6 weeks, with the wrist in a neutral position. 1

Assessment and Diagnosis

• Initial imaging should include proper radiographs to assess alignment and displacement
• For complex cases or when initial radiographs are negative but suspicion remains high, additional imaging may be considered:
  • MRI without IV contrast for complex cases 1
  • CT scan for complex intra-articular fractures 1
  • Repeat radiography in 7-14 days if initial imaging is negative but suspicion persists 2

Treatment Algorithm

For Non-Displaced Ulnar Styloid Fractures:

1. Conservative Management:

   • Rigid immobilization with a short arm cast for 3-6 weeks 1
   • Position the wrist in neutral position 1
   • Splinting can be useful to reduce pain, reduce risk for further injury, and facilitate transport to a medical facility 3
   • Active finger motion exercises should begin immediately following diagnosis to prevent stiffness 1
   • Ice application during the first 3-5 days for symptomatic relief 1

2. Follow-up Care:

   • Radiographic follow-up at 3 weeks and at cessation of immobilization 1
   • Progressive range of motion exercises after the immobilization period 1
   • Directed home exercise program after immobilization 1

For Displaced Fractures:

Surgical fixation should be considered if the fracture meets any of these criteria 1:

• Postreduction radial shortening >3 mm
• Dorsal tilt >10°
• Intra-articular displacement
• DRUJ instability despite adequate immobilization
• Large displaced base fractures involving >50% of the styloid

Important Considerations

• If a fractured extremity appears blue, purple, or pale, activate emergency response system immediately 3
• If associated with an open wound and severe bleeding, follow first aid for severe external bleeding 3
• Cover open wounds with clean dressing to lower risk of contamination and infection 3
• Treat the fracture in the position found unless straightening is necessary for safe transport 3
• Non-union of ulnar styloid fractures is common but typically does not affect functional outcomes 1

Rehabilitation

After the immobilization period:

• Progressive weight bearing as tolerated
• Range of motion exercises
• Strengthening exercises
• Balance training to prevent future falls 1

Pitfalls to Avoid

• Inadequate immobilization may lead to malunion or delayed union
• Excessive immobilization may lead to stiffness and reduced range of motion 1
• Low-intensity pulsed ultrasonography (LIPUS) should NOT be used as it does not accelerate healing or lower rates of nonunion 1
• All patients with unremitting pain during follow-up should be reevaluated 1

The American Academy of Orthopaedic Surgeons guidelines emphasize that non-displaced ulnar styloid avulsion fractures can be effectively managed with conservative treatment and generally do not require surgical fixation 1, which aligns with the goal of minimizing morbidity while optimizing functional outcomes.