What type of splint is recommended for a distal ulnar fracture in the Emergency Department (ED)?

Splinting for Distal Ulnar Fracture in the Emergency Department

For isolated distal ulnar fractures in the ED, apply a sugar-tong splint that immobilizes the wrist and forearm while allowing finger motion. 1, 2

Splint Selection Algorithm

For Displaced or Minimally Displaced Distal Ulnar Fractures

• Use a sugar-tong splint as the initial immobilization method 2, 3
• The sugar-tong configuration provides three-point control and prevents forearm rotation, which is critical for ulnar fractures 2
• This splint extends from the metacarpal heads, around the elbow, and back to the dorsal metacarpals, effectively controlling pronation-supination 2

Key Technical Points

• Ensure the splint immobilizes the wrist and elbow while maintaining finger mobility 1
• Active finger motion exercises should begin immediately to prevent stiffness 1, 4
• The splint should be padded and comfortably snug but not constrictive 4

Evidence Supporting Sugar-Tong Splinting

The sugar-tong splint has demonstrated effectiveness in maintaining reduction of forearm fractures, with studies showing it performs particularly well for mid-shaft and proximal forearm fractures 2. While the evidence base specifically addresses distal radius fractures more extensively than isolated ulnar fractures, the biomechanical principles apply equally to distal ulnar injuries requiring rotational control 2, 3.

A randomized trial comparing sugar-tong splinting to circumferential casting and volar-dorsal splinting found no statistically significant difference in loss of reduction rates, though there was a trend toward slightly higher loss of reduction with sugar-tong splints (30% vs 20% for casting) 3. However, functional outcomes at 8 weeks and 6 months were equivalent across all immobilization methods 3.

Alternative Considerations

When Rigid Casting May Be Preferred

• If the fracture is significantly displaced (>3mm displacement or >10° angulation), rigid immobilization with circumferential casting is preferred over removable splints 5, 1
• The American Academy of Orthopaedic Surgeons recommends rigid immobilization for displaced fractures to prevent loss of reduction 5

For Truly Minimally Displaced Fractures

• Removable splints are an acceptable option only for minimally displaced fractures without significant angulation 5, 1
• However, most distal ulnar fractures requiring ED evaluation warrant more secure immobilization initially 6

Follow-Up Protocol

• Obtain radiographic follow-up at approximately 3 weeks and at cessation of immobilization 1
• Transition to a short-arm cast may occur at the first follow-up visit if reduction is maintained 6, 2
• Total immobilization duration is typically a minimum of 3 weeks for distal forearm fractures 6

Critical Pitfalls to Avoid

• Do not immobilize the fingers—this leads to unnecessary stiffness and poor functional outcomes 1, 4
• Avoid over-immobilization—prolonged rigid immobilization beyond what is necessary causes joint stiffness requiring extensive therapy 4, 7
• Check for associated injuries—distal ulnar fractures may be associated with distal radius fractures or TFCC injuries that require different management 5
• Assess for ulnar styloid involvement—while fixation of ulnar styloid fractures remains controversial, recognition is important for prognosis 5