What is the treatment for a night stick fracture?

Treatment of Nightstick Fractures

For isolated ulnar shaft (nightstick) fractures, early mobilization with a removable forearm support for comfort produces the best outcomes, with the shortest time to union and lowest nonunion rates, particularly for nondisplaced or minimally displaced fractures. 1

Treatment Algorithm Based on Displacement

Nondisplaced or Minimally Displaced Fractures (<50% displacement)

• Early mobilization is the preferred approach with a removable forearm support used only as needed for comfort 1
• This method achieves radiological union in a mean of 8.0 weeks with only 0.6% nonunion rate 1
• Alternative acceptable options include short arm cast or functional forearm brace, though these result in slightly longer healing times (mean 9.2 weeks) and higher nonunion rates (2.1-3.8%) 1, 2
• Begin active finger motion exercises immediately to prevent stiffness 3

Moderately to Significantly Displaced Fractures (>50% displacement)

• Open reduction and internal fixation (ORIF) is recommended for fractures with significant displacement, angulation, or comminution 4, 5
• ORIF using 3.5mm locking compression plates provides stable fixation and allows immediate mobilization 6
• Surgical treatment shows satisfactory outcomes in 95% of cases (40/42 patients) with an average of only 4 follow-up visits 5
• In contrast, non-operative management of displaced fractures has a 50% failure rate (5/10 patients) requiring an average of 9 follow-up visits 5

Key Decision Factors for Surgical vs. Conservative Treatment

Consider the following when deciding between operative and non-operative management 5:

• Degree of displacement (>50% is a critical threshold)
• Location of fracture along the ulnar shaft
• Fracture pattern (transverse, oblique, comminuted)
• Patient age and functional demands
• Compliance with immobilization protocols
• Associated injuries to radius or other structures

Timing and Follow-Up

• For surgical cases, average wait time is 2.5 days, with immediate post-operative mobilization (non-weight bearing) 5
• Obtain radiographic follow-up at 3 weeks to assess healing 7
• Continue monitoring until complete radiographic union is confirmed 1

Common Pitfalls to Avoid

• Do not use rigid above-elbow immobilization unless absolutely necessary, as it produces longer healing times without improved outcomes compared to early mobilization 1
• Avoid compression in acute management despite following the PRICE protocol for other aspects 2
• Do not underestimate moderately displaced fractures - these should be evaluated individually rather than automatically treated conservatively, as failure rates are high 5
• Watch for associated median nerve injury in cases with concomitant distal radius involvement 4

Evidence Quality Note

While the systematic review of 27 studies (1629 fractures) demonstrates clear trends favoring early mobilization, all studies had significant methodological biases 1. However, until higher-quality randomized controlled trials are available, the current evidence consistently supports early mobilization for undisplaced fractures and surgical fixation for significantly displaced fractures 1, 5.