What is the recommended management for a distal radial fracture with mild irregularity at the ulnar styloid process?

Management of Distal Radial Fracture with Mild Ulnar Styloid Process Irregularity

For distal radial fractures with mild ulnar styloid process irregularity, non-operative management with appropriate immobilization is recommended, as routine fixation of ulnar styloid fractures is not indicated when the distal radius fracture is adequately stabilized.

Initial Management Approach

Assessment and Immobilization

• For stable, non-displaced, or minimally displaced distal radial fractures:
  • Closed reduction and immobilization with a cast is recommended 1
  • Standard radiographs should be the first imaging modality to assess the fracture 1
  • Follow-up radiographic evaluation at 10-14 days to ensure proper position 1

Indications for Surgical Intervention of Distal Radius

• Surgery for the distal radius is indicated when:
  • Significant displacement or angulation is present
  • Closed reduction has failed or would likely be unstable
  • Palmar displacement of the distal fragment
  • Interfragmentary gap >3 mm
  • Involvement of more than one-third of the articular surface 1

Management of Associated Ulnar Styloid Irregularity

Evidence on Ulnar Styloid Management

• The most recent evidence (2024) indicates that routinely fixating ulnar styloid process base fractures is not indicated 2
• Studies show that an associated ulnar styloid fracture following stable fixation of a distal radial fracture has no apparent adverse effect on wrist function or stability of the distal radioulnar joint 3
• Non-surgically treated patients had better wrist function at 6 months compared to surgically treated patients 2

When to Consider Ulnar Styloid Fixation

• Surgery for the ulnar styloid may be considered only in selective cases:
  • Persistent distal radioulnar joint (DRUJ) instability after fixation of the radius 2
  • When ballottement testing shows continued instability despite proper radius alignment

Rehabilitation Protocol

Non-Surgical Management Timeline

• Immobilization period: Typically 3-4 weeks 1
• After immobilization:
  • Begin progressive range of motion exercises
  • Implement directed home exercise programs including active finger motion exercises 1
  • Full recovery expected within 6-8 weeks 1

Pain Management

• NSAIDs are recommended for pain and inflammation control 1
• Oral analgesics and ice application can provide symptomatic relief 1

Follow-up and Monitoring

Radiographic Follow-up

• Initial follow-up radiographs at 10-14 days 1
• Further imaging if symptoms persist:
  • CT without IV contrast to identify occult fractures, malunion, nonunion, or joint incongruity
  • MRI without IV contrast to evaluate soft tissue injuries 1

Complications to Monitor

• Joint stiffness (most common complication)
• Chronic pain
• Post-traumatic arthritis
• Ulnar styloid non-union (typically asymptomatic) 4, 3

Special Considerations

Important Clinical Pearls

• Research shows that ulnar styloid non-union does not affect the outcome of an adequately fixed distal radius fracture 4
• Long-term studies indicate that most patients with ulnar styloid non-union remain asymptomatic, even those engaged in heavy manual labor 5
• Complications are more common in surgically treated ulnar styloid fractures compared to non-operative management 2

Risk Factors for Poor Outcomes

• Smoking increases the rate of nonunion and leads to inferior clinical outcomes 1
• Diabetic patients require close monitoring of skin to prevent pressure points and breakdown 1
• Elderly patients should be evaluated for osteoporosis risk factors 1