What is the treatment for a patient with displaced radial and ulnar styloid processes?

Treatment of Displaced Radial and Ulnar Styloid Processes

For displaced radial and ulnar styloid processes, surgical intervention is recommended when there is significant displacement (>3mm), articular involvement, or instability of the distal radioulnar joint (DRUJ), while conservative management is appropriate for stable fractures with minimal displacement.

Assessment and Diagnosis

• Initial evaluation should include standard radiographs to assess fracture displacement, angulation, and articular involvement 1
• If radiographs are inconclusive but symptoms persist, advanced imaging is indicated:
  • CT without IV contrast: For evaluation of occult fractures, malunion, nonunion, fragment displacement, and joint congruity 1
  • MRI without IV contrast: To evaluate associated soft tissue injuries, including ligament and tendon damage 1

Treatment Algorithm

Conservative Management

• Indicated for:
  • Stable, non-displaced, or minimally displaced fractures
  • Stable DRUJ despite styloid fracture
  • Ulnar styloid fractures with <2mm displacement 2

Conservative approach includes:

1. Closed reduction if needed
2. Immobilization with cast or splint for 3-4 weeks
3. Radiographic follow-up at 10-14 days to evaluate position 1
4. Progressive range of motion exercises after immobilization period

Surgical Management

• Indicated for:
  • Fractures with significant displacement (>3mm) or angulation
  • Articular involvement exceeding one-third of the joint surface
  • Failed closed reduction
  • Unstable DRUJ after radius fixation
  • Complex dislocations with soft tissue interposition 1

Surgical options include:

1. Open reduction with Kirschner wire fixation
2. Plate-and-screw fixation for radial styloid fractures
3. Tension band wiring for ulnar styloid base fractures 3
4. Ligament repair or reconstruction if needed

Evidence-Based Considerations

• Recent evidence suggests that routine fixation of ulnar styloid base fractures is not indicated when the DRUJ is stable 3
• A 2024 meta-analysis showed that non-surgically treated patients had better wrist function at 6 months, though this difference disappeared by 12 months 3
• While surgical fixation of ulnar styloid fractures results in fewer non-unions, it is associated with higher complication rates 3
• An unrepaired fracture of the ulnar styloid base does not significantly influence function or outcome after plate-and-screw fixation of a distal radial fracture, even with initial displacement ≥2mm 2

Post-Treatment Management

• Immobilization for 3-4 weeks depending on fracture stability
• Progressive range of motion exercises after immobilization
• Regular radiographic follow-up to assess healing
• Full recovery typically expected within 6-8 weeks 1
• Directed home exercise programs to prevent stiffness

Complications and Pitfalls

• Joint stiffness is the most common complication
• Other potential complications include:
  • Chronic pain (particularly ulnar-sided wrist pain)
  • Recurrent instability
  • Post-traumatic arthritis
  • Extensor lag 1
• Surgical complications are more common with operative treatment of ulnar styloid fractures 3
• Delayed treatment can lead to poor outcomes 1

Special Considerations

• Smoking increases nonunion rates and leads to inferior clinical outcomes 1
• Diabetic patients require close monitoring of skin to prevent pressure points
• Elderly patients should be evaluated for osteoporosis risk factors
• Pain management should include NSAIDs, ice application, and oral analgesics as needed 1

Key Decision Points

1. Assess DRUJ stability after radius fracture fixation
2. Consider surgical fixation of ulnar styloid only if DRUJ instability persists after radius fixation 3
3. For isolated radial styloid fractures, base decision on displacement, angulation, and articular involvement
4. In cases of both radial and ulnar styloid fractures, prioritize radial styloid fixation and assess DRUJ stability before deciding on ulnar styloid fixation