What is the recommended treatment for a patient with an ulnar styloid fracture, considering potential comorbidities such as impaired renal function or gastrointestinal issues, and a history of osteoporosis?

Treatment of Ulnar Styloid Fracture

Most ulnar styloid fractures associated with distal radius fractures do not require surgical fixation and should be managed conservatively, as the evidence shows no difference in patient-reported outcomes whether these fractures are treated operatively or left alone. 1

Initial Assessment and Classification

When evaluating an ulnar styloid fracture, determine:

• Distal radioulnar joint (DRUJ) stability - This is the critical decision point that determines treatment 2, 3
• Fracture location - Tip fractures (type I) versus base fractures (type II) 4, 5
• Associated distal radius fracture - Present in approximately 50% of cases 4
• Presence of nerve injury - Assess for dorsal branch of ulnar nerve involvement with sensory testing of the ulnar wrist 5

Treatment Algorithm Based on DRUJ Stability

Stable DRUJ (Type 1 Nonunion Pattern)

Conservative management is recommended for all ulnar styloid fractures with a stable DRUJ, regardless of fracture size, displacement, or eventual healing status. 1, 2

• No surgical fixation is indicated - Multiple studies demonstrate no difference in patient-rated outcomes (QDASH, PRWE, MHQ scores) between treated and untreated ulnar styloid fractures when the DRUJ is stable 4, 2
• Immobilization - Treat the associated distal radius fracture appropriately; the ulnar styloid requires no separate immobilization beyond what is needed for the radius 1
• Accept nonunion - Approximately 76% of ulnar styloid fractures remain ununited at 1 year, yet this does not affect functional outcomes 4

Unstable DRUJ (Type 2 Nonunion Pattern)

Surgical intervention is required when DRUJ instability is present, as this indicates disruption of the triangular fibrocartilage complex (TFCC). 3

• Large base fragments - Perform open reduction and internal fixation to restore TFCC anatomy 3
• Small fragments with DRUJ instability - Excise the fragment and repair the TFCC to the distal ulna 3
• Intraoperative assessment - If DRUJ instability is discovered during distal radius fixation, address it at the same surgery 2

Adjunctive Conservative Measures

• Ice application at 3 and 5 days post-injury for symptomatic relief 6
• Immediate active finger motion exercises to prevent stiffness 6
• Vitamin C supplementation for prevention of disproportionate pain (moderate strength recommendation) 1, 6
• Low-intensity ultrasound may be considered for short-term pain improvement, though long-term benefits are unproven 1, 6

Follow-Up Protocol

• Radiographic assessment at 3 weeks to evaluate healing and rule out secondary displacement 6
• Monitor for chronic ulnar-sided wrist pain - If this develops with a stable DRUJ, simple excision of the styloid fragment provides satisfactory pain relief 3
• No routine follow-up imaging needed for asymptomatic nonunion in stable DRUJ cases 4

Special Consideration: Nerve Injury

If dorsal branch of ulnar nerve injury is suspected (numbness over ulnar wrist), surgical exploration with nerve repair is indicated regardless of DRUJ stability. 5

• Perform epineurium neurolysis for nerve contusion 5
• Use sural nerve graft for complete nerve rupture 5
• This prevents chronic ulnar wrist pain and promotes sensory recovery to S3+ or S4 levels 5

Osteoporosis Management in Fragility Fractures

Given the patient's history of osteoporosis, initiate comprehensive secondary fracture prevention immediately upon fracture consolidation:

• Bisphosphonate therapy - Alendronate or risedronate as first-line agents (reduce vertebral fractures by 47-48%, non-vertebral by 26-53%, hip fractures by 51%) 1, 7
• Calcium 1000-1200 mg/day and vitamin D 800 IU/day - Reduces non-vertebral fractures by 15-20% and falls by 20% 1, 7
• Alternative agents for GI intolerance or renal impairment - Consider zoledronic acid (IV) or denosumab (subcutaneous) if oral bisphosphonates are contraindicated 1
• Fall prevention strategies including balance training and home safety assessment 1, 7

Common Pitfalls to Avoid

• Do not routinely fix ulnar styloid fractures - The 2010 AAOS guidelines explicitly state they are "unable to recommend for or against fixation" due to lack of evidence showing benefit, and subsequent research confirms no benefit from routine fixation 1, 4, 2
• Do not assume nonunion requires treatment - Three-quarters of ulnar styloid fractures remain ununited without functional consequence 4
• Do not miss DRUJ instability - This is the only indication for surgical intervention and requires intraoperative assessment if uncertain 2, 3
• Do not overlook nerve injury - Sensory deficits require surgical exploration and repair 5