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Distal Ulnar Fractures

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Last Update: April 16, 2022.

Continuing Education Activity

The most common upper extremity fractures presenting to the emergency department are distal radius and ulna injuries. Distal ulnar fractures have historically not had a clear consensus on management compared to their distal radius counterparts. While most distal ulnar fractures are nonoperative, failure to adequately address these varied and often complex injuries can lead to poor outcomes. The aim is to provide the interprofessional team with a better understanding of distal ulna fractures and their management.

Objectives:

  • Identify the typical demographics and fracture types that present with distal ulna fractures.
  • Describe the impact of distal ulna fractures on wrist stability.
  • Explain when surgical intervention on distal ulna fractures is indicated.
  • Review the complications of distal ulna fractures.
Access free multiple choice questions on this topic.

Introduction

The most common upper extremity fractures presenting to the emergency department are distal ulna and radius injuries.[1] First responders, physicians, and support staff must understand how to manage them.[2] The appropriate treatment for a distal ulna fracture is typically surgical correction of the radius first. Once the radius is stable, most distal ulna fractures heal well with conservative management alone. However, healthcare professionals must consider patient factors such as age, activity level, and expectations to maximize outcomes.

While most distal ulna injuries do not undergo surgery, there are situations where intervention is indicated.[3] Poor understanding of this condition can lead to malunion, weakened grasp, and other serious complications.[4][5] (Xiao, 2021) This review aims to provide healthcare professionals from multiple disciplines with a better understanding of distal ulna fracture management. It will cover key distal ulna fracture concepts, including epidemiology, pathophysiology, presentation, intervention, prognosis, and complications.

Etiology

Both distal ulna and radius fractures are usually the result of a fall on an outstretched hand (FOOSH). The predominant wrist position is dorsiflexion. In advanced age individuals, the fracture pattern is usually extraarticular from low-energy causes. The opposite is true of younger patients who suffer intraarticular injuries from high-impact trauma. High energy mechanisms also increase the likelihood of a simultaneous distal ulna fracture.[6][7] 

The ulna styloid is fractured more than any other part of the ulna and is found in 80% of intraarticular distal radius injuries.[4][5] Distal ulnar metaphyseal fractures occur within 5 cm of the dome of the ulnar head—only 5% of distal radius fractures present with this associated injury. The least common presentation is an ulnar head fracture and is a sign of likely wrist instability.[8][6]

Isolated fractures of the distal ulna occur without an accompanying radius injury. A nightstick fracture (isolated ulnar shaft fracture) is usually the result of a direct blow to the ulna while a person is attempting to shield themselves with their arms.[6][7][9][10] Other less common mechanisms involve extreme supination or pronation. Healthcare providers should always maintain a high index of suspicion for possible abuse with any upper extremity fracture presenting with an unclear mechanism of injury, as they have been tied to intimate partner violence.[11] However, two recent retrospective studies failed to demonstrate any specific correlation between distal ulnar shaft fractures and abuse in children.[12][10]

Isolated ulnar physeal injuries are extremely uncommon and have a greater propensity for early growth plate arrest.[13] Thus, proper treatment must be provided as the ulnar epiphyseal plate is responsible for up to 80% of the ulna growth. Isolated ulna fractures of the styloid and metaphysis are rare.[5][4] Support structures of the wrist, the triangular fibrocartilage complex (TFCC), and the distal radioulnar joint (DRUJ) are also commonly injured.[6]

Epidemiology

Over 40% of distal radius fractures have a concomitant injury to the distal ulna.[5][14] Approximately 1 in 6 fractures treated in the acute care setting involves the distal radius. (Xiao, 2021) They comprise 1.5% of all emergency department visits. The bimodal distribution of patients affected is generally young men and older women.[15]

Osteoporosis is a significant risk factor placing advanced age individuals and postmenopausal women at risk. Obesity, history of falls, alcohol, and dementia are other important risk factors.[16]

Healthcare providers should anticipate an increased incidence of these injuries as the average life expectancy rises in the United States. In children, distal ulna physeal fractures account for 5% of physeal fractures, and Salter-Harris type II involving the metaphysis and physis are the most common.[17]

Pathophysiology

Anatomy

Ulna The ulna is the medially located forearm bone and narrows distally. The crucial anatomical parts of the distal ulna are the metaphysis, styloid, and head. Biomechanically the distal ulna acts as a stationary object for the radius to move around. This arrangement causes various load changes on the wrist depending on the grip and degree of pronation-supination. The ulnocarpal joint carries around 20% of the load capacity when in a neutral position.

Ulnar Styloid The ulnar styloid is a bony protrusion on the distal aspect of the ulnar head and is the attachment site for the superficial dorsal and palmar radioulnar ligaments. These ligaments are primary stabilizers of the DRUJ. The ulnar styloid is also an attachment site for the TFCC, providing support and protection for the ulnar side of the wrist.[6]

Distal Radioulnar Joint (DRUJ) Assessment of DRUJ stability is essential in determining if a distal ulna fracture requires surgical correction. The DRUJ maintains equilibrium during rapid energy load transfers between the forearm and the wrist during forearm pronation-supination. (Xiao, 2021) Thus, the DRUJ is crucial in facilitating the efficient lifting of objects.[18]

Ulnar Head The dome and the seat comprise the ulnar head, known as the "keystone" for the DRUJ. The dome abuts the carpus, and the cartilage-covered seat articulates with the sigmoid notch to form the DRUJ.

Fovea The fovea acts as the central axis of rotation for the ulnar head. In contrast to the styloid, it provides the attachment site for the deep dorsal and palmar radioulnar ligaments (aka, ligamentum subcruentum) that support the DRUJ. It also attaches to the TFCC, an intricate support system that preserves ulnar-sided wrist stability.

Triangular Fibrocartilage Complex (TFCC) The TFCC prevents excessive DRUJ translation via the deep dorsal and volar radioulnar ligaments. (Xiao, 2021) Due to the complex interactions between the distal ulna, radius, carpus, and TFCC, consensus on the pathophysiology and treatment of the distal ulna has not been achieved.[8]

Pathology

Ulnar Styloid Fractures The level of importance the ulnar styloid has on wrist stability has long been debated.[19] Since the radioulnar ligaments attach to the styloid base, operative intervention is generally considered if greater than 2 mm of displacement is present. Over 40% of ulnar styloid fractures occur at the base level.[20] Theoretically, this should compromise TFCC and DRUJ function. Recent studies, however, have challenged this notion by demonstrating no compromise in long-term outcomes with nonoperative management of ulnar styloid fractures.[19]

Non-Styloid Distal Ulnar Fractures Injuries not limited to or not involving the ulnar styloid are less common but generally portend worse outcomes. Isolated distal ulna fractures (injuries without a concomitant distal radius fracture) and ulnar head fractures most correlate with wrist instability as they cause injuries to the interosseous membrane, DRUJ, and TFCC.[8] Ulnar head fractures impair forearm rotation and require intervention.

History and Physical

History

The history and physical evaluation are similar to a distal radius fracture workup. Examples of pertinent history include age, hand dominance, the onset of injury, location, mechanism, previous surgeries, osteoporosis, drugs or alcohol use, motor or sensory deficits, decreased range of motion, and comorbidities. A detailed mechanism of injury is crucial, noting the force of impact, extremity position upon contact, and acute changes in the range of motion, strength, and sensation afterward.  

Physical Exam

Begin with a comprehensive physical exam to rule out potential missed injuries that need further evaluation. Compare bilateral upper extremities to obtain baseline strength, sensation, and range of motion. The assessment then focuses on the injury itself. Notice compartment swelling, ecchymoses, abrasions, open wounds, and deformities which may indicate a need for urgent or emergent intervention. As detailed as possible, distinguish specific anatomical areas of point tenderness (i.e., ulnar styloid, fovea, Lister's tubercle).

Starting with a more generalized approach, it also recognizes confounding information; for example, discovering an ipsilateral weakness in a patient with a previous stroke or cold fingers from Raynaud disease. Grip strength, wrist flexion, extension, and pronosupination are evaluated and compared to the uninjured extremity.

A thorough neurovascular examination is needed as any acute deficits may warrant urgent surgical exploration by a hand surgeon. Key provocative maneuvers of the distal forearm include the "OK" sign (anterior interosseous nerve palsy), "thumbs up" sign (posterior interosseous nerve palsy, "crossing the fingers" maneuver (ulnar motor nerve palsy), and "wrist drop" (radial nerve palsy).[21][22] Utilize capillary refill, Allen's test, and a Doppler ultrasound to evaluate vascular injury.[23]

Distal Ulna-Specific Assessments

Careful inspection of the ulnar aspect of the wrist to localize tenderness is critical as the differential for ulnar-sided wrist pain is extensive in the absence of obvious injury.[24] The fovea sign can test for ulnar-sided pathology. The two most common conditions associated with a positive fovea sign are foveal disruption and lunotriquetral ligament injury, but they can also indicate DRUJ instability.[25]

Assess the DRUJ intraoperatively before and after repairing the concomitant distal radius fracture. This step determines if the distal radius repair improved DRUJ stability or if the distal ulna may require surgical intervention. Recent literature has questioned whether an assessment of the DRUJ is a reliable indicator for operative intervention on distal ulna fractures since what defines "unstable" is subject to interpretation. However, it remains a standard part of the intraoperative assessment.

An "unstable" DRUJ assessment has previously been described as the abnormal translation of the radius about the distal ulna in the neutral, pronated, and supinated positions of the forearm. The ulnocarpal stress test is another provocative maneuver that can examine for possible TFCC injury, ulnar styloid fractures, ulnocarpal abutment syndrome, ECU injury, or DRUJ subluxation.[24][26]

Fovea Sign

  1. Position forearm in neutral rotation
  2. Palpate the ulnar styloid process 
  3. Find the flexor carpi ulnaris tendon (FCU) 
  4. The fovea is located between the ulnar styloid and FCU
  5. It is just proximal to the level of the pisiform and just distal to the ulnar head
  6. Positive test equates to tenderness with direct palpation on the ulnar fovea

DRUJ Assessment

  1. Flex the patient's elbow 90 degrees and position the forearm neutrally.
  2. The evaluator takes the distal radius with one hand and the distal ulna with the other.
  3. The evaluator moves the distal ulna dorsally and volarly while keeping the distal radius fixed.
  4. Repeat the above steps with the forearm in pronation and supination.
  5. The DRUJ is considered unstable if increased laxity is appreciated with translation, clunking, or lack of an endpoint is reached.[19]

Ulnocarpal Stress Test

  1. Position patient's wrist in maximum ulnar deviation
  2. Passively supinate and pronate wrist while applying axial stress
  3. A positive test equates to ulnar-sided wrist pain[24][26]

Evaluation

Labs

Laboratory workup can include CBC, BMP, and CRP to assist with preoperative planning or rule out infection, but otherwise do not assist in diagnosing a distal ulna fracture.

Radiograph

The gold standard for diagnosing distal forearm fractures is plain film.[27] Initial diagnostic imaging consists of AP, lateral, and oblique views of the elbow, forearm, and wrist. Radiographs of the elbow assist in ruling out occult injury.[8] Since a critical determinant of distal ulna stability is the appropriate treatment of the distal radius, assessing radial inclination, volar tilt, and radial height on radiograph are essential to deciding if surgery is necessary—test DRUJ stability using a lateral view, although CT is more accurate. More than 5 mm radioulnar distance in the injured wrist compared to the uninjured on plain film may indicate DRUJ subluxation.[19] 

Computed Tomography (CT)

Use CT for preoperative planning, suspected occult fractures, comminution, and intraarticular fractures. Unique applications of CT for distal ulna fractures include DRUJ instability, TFCC or intraosseous membrane injury, ulnar head fractures, and isolated intraarticular ulna fractures.[19][28]

Magnetic Resonance Imaging (MRI)

MRI is the most accurate noninvasive modality for assessing if a TFCC or DRUJ injury is present (arthroscopy is the gold standard for TFCC and DRUJ injuries).[29] It can distinguish whether a TFCC tear is central or peripheral. Like CT, it is also used for preoperative planning. Some studies have demonstrated that Magnetic Resonance Angiography (MRA) may be more precise than MRI in determining the extent of TFCC tears but is still not commonly utilized.[30]

Ultrasound

Useful for fracture identification in the emergency department setting. Without radiation risk, it is becoming popular for rapid fracture identification and an alternative for patients susceptible to radiation exposure, such as children and pregnant women. It also has shown promise in identifying ligamentous injuries. A meta-analysis of 16 studies including over 1,200 patients exhibited high sensitivity and specificity for diagnosing distal forearm fractures. The main disadvantage is that it is more operator-dependent than other modalities.[27]

Treatment / Management

Nonoperative Management

Treat most distal ulna fractures nonoperatively. Stabilize the distal radius fracture first, then assess if the distal ulna fracture requires intervention. Maintain a high threshold for operating on ulnar styloid fractures unless greater than 2 mm of fracture displacement is present at its base. If the DRUJ is stable, treat with a long-arm cast for two to four weeks. If the DRUJ is unstable, closed reduction and immobilization with a long-arm cast for the first six weeks to limit pronation-supination.[4][5]

After re-evaluation, a short arm cast is placed for an additional 4 to 6 weeks if the fracture is healing appropriately. (Xiao, 2021) An unstable DRUJ, however, may ultimately require surgical intervention. Mackay et al. in 2000 found no difference in outcomes with short-arm versus long-arm casting or arm positioning for isolated ulnar shaft fractures.[9] The most important determinant of a successful outcome was early mobilization. Hussain (2018) demonstrated no difference in functional outcomes between conservative and operative management of isolated ulnar shaft fractures in patients placed in long-arm casting.[31]

Operative Management

There is no standard treatment algorithm for distal ulna fractures.[31] Nonreducible and unstable distal ulna fractures still benefit from surgical care.[5] Generally, the distal radius's degree of stability and fracture pattern determines the outcome. Correct the distal radius deformity surgically if indicated, then evaluate the distal ulna fracture intraoperatively. If unstable, repair the distal ulna fracture at that time.[5] Below summarizes three main operative techniques for distal ulnar fractures and fracture subtype considerations.

Kirschner Wire (K-wire)

Consider Kirschner wires for the ulnar styloid base and distal metaphyseal fractures, as well as DRUJ injuries. They are quick and minimally invasive but relatively weak constructs that require removal after 4-6 weeks. (Xaio, 2021) Tension bands, suture fixation, and interosseous wiring are options for osteoporotic or complicated fracture patterns.[3]

Plate Screw Fixation

Use lag screws for large oblique fracture fragments.[8] Plates can reduce complicated fractures but sometimes struggle to achieve a good purchase.[3] Consider minicondylar locking plates and blade plates for more complicated head and neck fractures. Volar placement of the plate reduces postoperative pain complaints due to a more substantial soft tissue buffer. Locking compression plates is versatile and acceptable for patient satisfaction scores and functional outcomes. The distal hook is the defining feature of these plates, which orientates the surgeon for more accurate placement and improved reductions with decreased operating time.

Salvage Procedures

Utilize salvage procedures when the degree of comminution and stability prohibit alternatives.[8] The most commonly used is the Darrach procedure, which excises the ulnar head and addresses severe TFCC and DRUJ injuries. Other options are the Suave-Kapandiji and ulnar head arthroplasty. The Aptis-Scheker DRUJ prosthesis developed by Dr. Luis Scheker out of the Christine M. Kleinert Institute in Louisville, Kentucky, has demonstrated significant functional improvement in high- and low-demand individuals with DRUJ injuries compared to ulnar head prostheses alone. The advantage is that the DRUJ replacement is not affected by pathology at the sigmoid notch, making previous ulnar head prostheses often unreliable long-term.[32]

Ulnar Styloid Fractures

Nonoperative versus operative management is controversial. Conventional thought is greater than 2 mm of displacement of the styloid base warrants surgical correction, but there is some evidence to suggest this is not always necessary.[5][19][33] Options include suture fixation, K-wires, and volar plating.[8][5][34]

Distal Ulnar Metaphyseal Fractures

Undertreating these fractures can lead to interosseous membrane injury and decreased forearm function. The indications to operate are (1) persistent instability after the intervention, (2) the presence of severe comminution, (3) greater than 50 degrees of displacement, or (4) more than 10 degrees of angulation.[4][35][3] Treat with K-wires, tension banding, intraosseous wiring, or mini-locking plates. Mini-locking plates minimize postoperative pain by utilizing fewer screws for fixation than other designs.

Distal Ulnar Neck or Shaft Fractures

It is controversial whether isolated ulnar shaft fractures should receive surgical intervention. In general, the two most utilized indications are irreducibility and greater than 5 mm (50% or more) of displacement.[9] Surgical intervention has been shown to improve functional outcomes and accelerate healing. Blade plating or tension bands with internal locking screws are options commonly used.[5] However, a Cochrane Database Review in 2012 found no clear advantage of which operative technique consistently led to better outcomes.[36] 

Isolated Ulnar Head Fractures

Unlike other locations on the distal ulna, most of these fractures require surgery. Literature available on operative management is limited. Nonoperative management is reserved only for non-displaced ulnar head fractures with minimal comminution. Instability is defined as (1) significant displacement, (2) comminution, or (3) mild displacement but with intra-articular extension. Use buried headless screws for inter-articular extension, tension bands for ulnar styloid involvement, and condylar blade or internal locking plates for extraarticular extension.[5]

TFCC Injury

TFCC tears typically heal without operative intervention. However, consider operative intervention for a persistently unstable DRUJ despite distal radius and ulna fixation.[8][19] Stabilizing the TFCC with K-wire placement will facilitate improved DRUJ stability. The wafer procedure is used for more extensive injuries. Arthroscopic diagnosis, debridement, and repair are considered the gold standard for these injuries.[30] (Xiao, 2021)

Differential Diagnosis

  • Both-bone fractures of the forearm
  • Distal radius fracture
  • Distal radioulnar joint arthritis (DRUJ OA)
  • Distal ulnar nonunion/malunion
  • DRUJ injury
  • DRUJ subluxation
  • Elbow fracture
  • Elbow dislocation
  • Extensor carpi ulnaris injury
  • Extensor carpi ulnaris tendonitis
  • Galeazzi fracture (distal third radial shaft fracture and concomitant DRUJ injury)
  • Hook of hamate fracture
  • “Nightstick” or “Parry” fracture (isolated ulnar shaft fracture)
  • Pisotriquetral arthritis (PTA)
  • Triangular fibrocartilage complex (TFCC) injury
  • Triquetral fracture[24]
  • Triquetral nonunion
  • Ulnocarpal abutment syndrome (UCAS)[24][26]
  • Ulnocarpal arthritis
  • Ulnar tunnel syndrome
  • Ulnar variance

Staging

Distal ulna fracture classifications generally depend on fracture pattern, location, intraarticular involvement, and distal radius stability. The AO Comprehensive Classification is the most cited as it is associated with distal radius fracture injury.

AO Comprehensive Classification

  • Q1 - Ulnar styloid base fracture
  • Q2 - Simple ulnar neck fracture
  • Q3 - Comminuted ulnar neck fracture
  • Q4 - Ulnar head fracture
  • Q5 - Combined ulnar neck and head fracture[4]

Distal Ulnar Metaphyseal Fractures

  • Type A - Simple ulnar neck fracture
  • Type B - Fracture of the ulnar neck and styloid
  • Type C - Fracture of the ulnar head
  • Type D - Comminuted ulnar head and neck fracture[35]

Ulnar Neck Fractures Classification

  • Type I - Simple ulnar neck fracture
  • Type II - Inverted T or Y-shaped fracture
  • Type III - Combined ulnar neck and ulnar styloid fracture 
  • Type IV - Comminuted ulnar neck fracture[4]

Ulnar Head fractures Classification

  • Two Types
    • Ulnar head fractures alone
    • Ulnar head fracture with extraarticular distal ulna extension (i.e., including the ulnar styloid)[35]

Nightstick Fracture Criteria – Four criteria necessary

  • No radius fracture
  • Transverse fracture pattern
  • Distal third of the forearm
  • Minimal displacement[10]

Prognosis

In general, distal ulna fractures have good prognoses when appropriately managed. Many contributing factors play a role, and the best outcomes are achieved when treatment is individualized to meet patient needs. Xiao et al. in 2021 reported the best postoperative range of motion results with simple cast immobilization. Grip strength had the best prognosis when K-wire stabilization of the distal ulna fracture was performed. However, there were no differences in patient satisfaction or long-term function.

Ulnar Styloid Fractures

Ulnar styloid fractures generally have good outcomes without surgical intervention. Kim et al., 2010 demonstrated successful nonoperative management of ulnar styloid base fractures, including those with displacement more significant than 2 mm.[19] Ayalon et al. in 2016 found no significant difference in healing rates between intraarticular and extraarticular ulnar styloid fractures.[37]

Non-styloid Distal Ulnar Fractures

Non-styloid distal ulnar fractures more often require operative intervention to obtain satisfactory outcomes compared to styloid fractures.[35] Comminuted intraarticular distal ulna fractures are associated with a poor prognosis and DRUJ injury. Distal ulnar head fractures have the worst prognosis and usually require surgical intervention. Non-styloid injuries are more likely to cause chronic grip weakness, decreased range of motion, and pain.[5]

Complications

Distal Forearm Injuries

There are many potential complications resulting from distal forearm fractures, including compartment syndrome, neurovascular injury, tendon rupture, arthritis, carpal tunnel syndrome, malunion/nonunion. Incorrect management of a distal ulnar fracture can result in decreased pronation-supination, chronic ulnar-sided wrist pain, DRUJ instability, tendon injury, and arthritis.[4] Hardware removal is commonplace due to patient complaints. This is primarily due to the decreased soft tissue coverage at the distal ulna than the distal radius.

Distal Ulnar Metaphyseal Fractures

The ulnar nerve and artery are located just dorsal to the flexor carpi ulnaris and are at risk for injury during dissection and plate fixation. The ulnar nerve bifurcates into the dorsal sensory branch approximately 9 cm proximal to the distal wrist crease. It arises from the deep fascia 1 to 4 cm proximal to the ulnar styloid.[4]

DRUJ Injury

Injury to the distal radioulnar joint can risk damage to the extensor carpi ulnaris (ECU) and extensor digiti minimi (EDM). DRUJ injury can result in ligament entrapment, limiting wrist mobility and reducing grip strength.[4] (Xiao, 2021) 

Malunion

Distal ulna fracture malunion is uncommon and unlikely to occur if appropriate reduction and fixation are performed. Treating the distal radius alone makes malunion unlikely in concomitant distal radius fractures.[8] Treat symptomatic patients with bone graft, which can be vascularized or non-vascularized. Potential harvest sites include the iliac crest (small segments <6 cm), fibula (large segments >6 cm), or femoral condyle.[8]

Nonunion

Ulnar styloid nonunion is frequently encountered with an incidence between 20 to 70%).[5][4][8] However, most cases are asymptomatic and managed conservatively—symptomatic patients present with ulnar-sided wrist pain, especially with rotation. Focal tenderness over the ulnar styloid is usually present. Consider surgery if symptoms do not improve over an extended time or if the nonunion may jeopardize wrist stability. Nonunion at the styloid base, for example, puts the primary wrist stabilizers (superficial radioulnar ligaments) at risk for injury.[5]

Rarely nonunion can lead to other complications such as carpus abutment, ECU tendon impingement, TFCC detachment, or DRUJ instability.[8] Nonunion treatment options include excision with or without reattachment of bony nonunion and ligaments, arthroscopic intervention, bone graft, or osteotomy. Isolated ulnar shaft fractures have worse nonunion rates compared to other distal ulnar fractures, especially if displacement is greater than 5 mm.[9]

Specific Operative Complications

  • Darrach Procedure is associated with radioulnar pain and impingement[8]
  • Tension Banding can cause nerve and soft tissue irritation secondary to pin placement or migration.[38]
  • Plate Fixation frequently leads to symptomatic hardware prominence, irritation of the dorsal branch of the ulnar nerve, longer operative times, ECU and FCU tendinopathy, and tendon rupture.
  • Scheker DRUJ Prosthesis can cause extensor carpi ulnaris tendinitis but is managed by placing an adipofascial flap in between the prosthesis and tendon.[32]

Consultations

Distal ulna fractures may warrant surgical consultation. At the discretion of the emergency physician, simple and nondisplaced distal ulna fractures can be immobilized and provided outpatient follow-up with an orthopedic or hand surgeon. However, an urgent evaluation is recommended for complex or irreducible fractures or concern for neurovascular compromise.

Deterrence and Patient Education

Parents, caretakers, and healthcare professionals must recognize that upper extremity injuries can be a sign of nonaccidental trauma in at-risk populations. Perform a comprehensive history and physical evaluation to rule out occult injuries. Lastly, educate patients and family members on possible non-operative and operative distal ulna fracture complications. Significant complications include compartment syndrome, neurovascular injury, occult fractures, and hardware irritation. Instruct patients to notify a medical professional immediately for any acute weakness, paresthesias, cold extremity, skin color changes.

Pearls and Other Issues

  • The most common mechanism of injury for both distal radius and ulna fractures is from a fall on an outstretched hand (FOOSH).
  • The most common distal ulna injury presentation is a distal radius fracture with a neighboring ulnar styloid fracture.
  • An ulnar styloid fracture with greater than 2 mm at its base is at increased risk of DRUJ instability and may require surgical intervention.
  • An isolated distal ulnar shaft fracture is rare and should warrant evaluation for possible abuse in at-risk populations (i.e., nightstick fracture).
  • In cases where both distal radius and ulna fractures are present, the DRUJ should be assessed before and after fixation of the distal radius to determine if the distal ulna requires repair.
  • Most distal ulna fractures only need proper stabilization of the concomitant distal radius fracture to heal appropriately.
  • Hardware irritation is a common complaint with distal ulna fracture repair due to inadequate soft tissue coverage.
  • Extensor carpi ulnaris rupture and ulnar neurovascular structures are at risk with distal ulna injuries and operative repair.

Enhancing Healthcare Team Outcomes

First responders significantly enhance patient care when an appropriate history and physical evaluation is performed in the field, especially in cases involving high-energy trauma like motor vehicle accidents. Noting the vehicle size, speed, location (i.e., highway, side of a vehicle damaged), airbag deployment, seatbelt use, extrication time, etc., can be invaluable to emergency and trauma physicians when deciding on a treatment plan. Whenever possible, distal forearm injuries should be immobilized at the scene to minimize discomfort, displacement, and damage to critical surrounding structures. Have splint materials available at the scene, but even temporary materials like cardboard can provide enough stabilization for safe transport for definitive care.[39]

Once in an acute care facility, triage should determine whether the patient warrants a possible trauma activation or is safe to be seen non-emergently. Initiate Advanced Trauma Life Support (ATLS) if there is a concern for life-threatening injuries. Nurses, physicians, and other support staff should take histories and perform secondary and tertiary surveys to rule out occult injuries. Open fractures require urgent surgical evaluation, exploration with washout, antibiotics, and tetanus prophylaxis. Especially in circumstances of severe instability or soft tissue compromise, urgent consultation to orthopedic or hand surgery services should be done.

Review Questions

AO Classification for Distal Ulna Fractures

Figure

AO Classification for Distal Ulna Fractures. Used with permission from Dr. Evan Schumer.

Volar ulnar plate developed by Dr

Figure

Volar ulnar plate developed by Dr. William Geissler used to repair a distal ulna fracture. To minimize restriction of motion, the plate is placed just proximal to the sigmoid notch. Used with permission from Dr. William Geissler (Management Distal Radius (more...)

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