Does an acute comminuted fracture of the distal ulna require immediate intervention or can it wait a couple of days to see an orthopedic physician?

Management of Acute Comminuted Fracture of the Distal Ulna

An acute comminuted fracture of the distal ulna does not require immediate intervention and can safely wait a couple of days to see an orthopedic physician, provided there is no associated vascular injury, open fracture, or compartment syndrome. 1

Initial Assessment and Management

• Fragility fractures should be managed in a multidisciplinary clinical system with adequate pain relief and appropriate fluid management 1
• For distal ulna fractures associated with distal radius fractures, if the distal radius is anatomically reduced and stable, and the distal ulna fragments are also anatomically reduced, conservative management is appropriate 2
• Radiographic evaluation with at least 3 views (posteroanterior, lateral, and 45° semipronated oblique) is standard for initial assessment 3

Timeframe for Orthopedic Consultation

• For closed distal ulna fractures without neurovascular compromise, surgical intervention within 48 hours is not mandatory 1
• The EULAR/EFORT recommendations indicate that surgery within 48 hours is beneficial primarily for hip fractures, not distal upper extremity fractures 1
• Patients can be initially managed with appropriate splinting and pain control while awaiting orthopedic evaluation 1

Indications for Immediate Intervention

Immediate intervention (within 24 hours) is required only in the following scenarios:

• Open fractures requiring debridement and antibiotics 1
• Vascular injury or mangled extremity 1
• Compartment syndrome 1
• Severe soft tissue compromise 1

Management Options for Distal Ulna Fractures

• Conservative treatment is appropriate for stable, minimally displaced fractures 2
• Surgical options include:
  • Plate osteosynthesis for unstable or significantly displaced fractures 2
  • Primary distal ulna resection in cases of highly comminuted fractures where anatomic restoration cannot be achieved 4
  • Ulnocarpal-spanning plate fixation for complex fractures with limited bone stock 5

Potential Complications

• Distal radioulnar joint (DRUJ) instability may occur with comminuted distal ulna fractures 2
• Non-union of the distal ulna is a potential complication in both surgically and conservatively managed cases 2
• Hardware prominence and pain may necessitate implant removal in surgically managed cases 2, 6

Follow-up Considerations

• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal 3
• Active finger motion exercises should be performed to prevent stiffness 3

Clinical Pearls

• The distal ulna can be treated conservatively if anatomical reduction is achieved, even when the associated distal radius fracture requires surgical fixation 2
• When a distal radius fracture is managed surgically but anatomical reduction of distal ulna fragments cannot be achieved, surgical stabilization of the ulna should be considered 2
• Acute primary distal ulna resection can yield satisfactory results in appropriately selected patients with highly comminuted distal ulna fractures 4

In conclusion, while immediate orthopedic evaluation is ideal, most acute comminuted distal ulna fractures can safely wait a couple of days for definitive orthopedic management, provided appropriate initial care with splinting and pain control is administered.