What is the management for a transverse fracture of the radial and ulnar styloid process?

Management of Transverse Fractures of Radial and Ulnar Styloid Processes

For transverse fractures of the radial and ulnar styloid processes, surgical intervention with open reduction and internal fixation is recommended for displaced fractures, especially when there is instability of the distal radioulnar joint, while non-displaced fractures can be managed conservatively with immobilization. 1, 2

Assessment and Diagnosis

• Initial evaluation should include standard radiographs as the first imaging modality 3
• If radiographs are inconclusive but symptoms persist, consider:
  • CT without IV contrast to identify occult fractures, malunion, or fragment displacement 3
  • MRI without IV contrast or ultrasound to evaluate associated soft tissue injuries 3

Management Algorithm

1. Non-displaced Fractures

• Conservative management with:
  • Closed reduction if minimal displacement is present 3, 2
  • Immobilization with a forearm splint or short-arm cast for 3-4 weeks 3, 2
  • Radiographic follow-up at 10-14 days to evaluate position 3
  • Progressive range of motion exercises after immobilization period 3

2. Displaced Fractures

• Surgical intervention indicated for:
  • Significant displacement or angulation 3, 1
  • Involvement of the ulnar fovea 1
  • Instability of the distal radioulnar joint 1
  • Failed closed reduction 3

Surgical Options:

• For radial styloid fractures:

  • Open reduction with K-wire fixation or plate fixation 3, 4
  • When using K-wires, make small incisions to identify and protect underlying structures, as K-wires can be as close as 0.35 mm to branches of the superficial radial nerve 4

• For ulnar styloid fractures:

  • Angle-stable hook plate fixation has shown 100% bony healing in cases of displaced fractures 1
  • Surgical approach: Dorsoradial access between the 6th extensor compartment and flexor carpi ulnaris tendon 1

Post-treatment Management

• Immobilization in a forearm splint for 1-2 weeks following surgery 1
• Active finger motion exercises from postoperative day 1 3, 1
• Progressive range of motion exercises after immobilization period 3
• Full recovery typically expected within 6-8 weeks 3
• Consider lymph drainage if needed 1
• Load build-up under ergotherapy guidance after bone healing 1

Prognostic Factors and Special Considerations

• Bone mineral density (BMD) significantly affects union rates of ulnar styloid fractures, with BMD ≥ -0.12 independently predicting better union 5
• Type IIC ulnar styloid fractures (according to Gaulke classification) show higher rates of union than other fracture types 5
• Approximately 30% of basal ulnar styloid fractures associated with distal radius fractures unite after volar locking plate fixation of the radius alone 5

Pain Management

• NSAIDs for pain and inflammation control 3
• Oral analgesics and ice application for symptomatic relief 3

Complications to Monitor

• Joint stiffness (most common) 3
• Chronic pain 3
• Recurrent instability 3
• Post-traumatic arthritis 3
• Extensor lag (inability to fully extend) 3
• Median nerve injury may complicate distal radius fractures 2

Important Caveats

• Research suggests that unrepaired ulnar styloid fractures accompanying treated distal radius fractures may not significantly impact wrist function, radiographic outcomes, or motion 6
• When using K-wires for fixation, be aware that volar radial styloid, transverse radial, and dorsoulnar K-wires have all been shown to potentially penetrate tendons or nerves 4
• Delayed treatment can lead to poor outcomes; persistent symptoms warrant prompt advanced imaging rather than prolonged observation 3