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70 (); 307-313
doi:
10.1016/j.jor.2025.11.027

Understanding isolated ulnar styloid fractures: A retrospective analysis of nonunion and healing outcomes

, ,
a Department of Orthopedics and Traumatology, Esenyurt Necmi Kadıoğlu State Hospital, Istanbul, Türkiye
b Division of Hand Surgery, Department of Orthopedics and Traumatology, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
c Department of Orthopedics and Traumatology, University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye

⁎Corresponding author: Yusuf Sülek. ysf.ssulek@gmail.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Isolated ulnar styloid fractures (AO-Q1 or AO-OTA 2U3A1.1,2) are uncommon injuries often treated conservatively. However, the outcomes of such treatment are not well-studied. The aim of this study is to evaluate the radiological and functional outcomes of isolated ulnar styloid fractures, to compare case of nonunion and union, and to assess whether nonunion is associated with worse functional outcomes.

This retrospective study included 39 patients diagnosed with isolated ulnar styloid fractures (AO-Q1 or AO-OTA 2U3A1.2) between 2015 and 2022. The patients were divided into two groups, Group A (nonunion) and Group B (union), based on radiographic evidence obtained after a minimum follow-up period of 12 months. The functional outcomes were evaluated using the DASH score, Mayo Wrist Score, Visual Analogue Scale (VAS) pain scores, and DRUJ instability testing via the ballotment test.

Nonunion was observed in 51.3 % of patients (n = 20, Group A), while 48.7 % (n = 19, Group B) achieved union. Group A had significantly worse outcomes in supination, extension, flexion, and ulnar deviation (p < 0.05). VAS pain scores were higher in Group A (p = 0.012), and DASH and Mayo Wrist scores were also significantly lower in Group A (p < 0.001 for both). The incidence of DRUJ instability was higher in Group A, with a greater proportion of cases exhibiting positive results on the ballotment test (p = 0.011).

In this study of patients with isolated ulnar styloid fractures, nonunion was associated with reduced wrist motion, lower functional scores, and greater pain compared with union. These findings suggest that ulnar styloid nonunion may not always be associated with favorable outcomes, as ulnar styloid nonunions associated with distal radius fractures do. These findings, when considered in conjunction with future comprehensive studies, suggest that different approaches may be necessary in the treatment of isolated ulnar styloid fractures.

Keywords

Ulnar styloid
Fracture
Nonunion
Functional outcome
1

1 Introduction

Ulnar styloid fractures, which play a functionally significant role in wrist anatomy, accompany 50–60 % of distal radius fractures.1–4 The distal radioulnar joint (DRUJ), is a complex structure located in the distal forearm, allowing forearm rotation.5 The primary stabilizer of the DRUJ is the triangular fibrocartilage complex (TFCC), which attaches to the ulnar styloid and the fovea. It can be reasonably deduced that ulnar styloid fractures may result in DRUJ instability.6–8

In cases where both bones are fractured, during fixation of the distal radius fracture with a plate or closed reduction and cast immobilization, styloid base fractures may reduce and heal. However, ulnar styloid fractures, especially those that are severely displaced, may result in nonunion. It is generally assumpted that ulnar styloid nonunion does not significantly affect wrist function scores.1–3,6,9 In cases where symptoms are present, conservative treatment is the first-line therapy. In case where patients do not respond to conservative management, surgical treatment may be indicated. Surgical options for ulnar styloid nonunion include styloid excision and methods aimed at achieving union of the styloid.10–12 However, information in the literature regarding isolated ulnar styloid fractures is extremely limited, and uncertainty regarding the clinical outcome of nonunion remains. Therefore, current understanding is largely based on cases associated with distal radius fractures, and studies evaluating the clinical effects of isolated fractures are lacking.

Isolated ulnar styloid fractures (AO-OTA 2U3A1.1 and 2U3A1.2) are quite rare, and in a large series of 96 patients treated for distal ulnar fractures, only 22 had isolated fractures, with only one patient having a conservatively managed 2U3A1.2 fracture. 4,13 The most comprehensive study on distal ulnar fractures is the Swedish national registry, which reports an incidence of distal ulnar styloid fractures as 59 per 100,000 patients. They found that only styloid fractures were related to standing height and that none of the Q1 styloid fractures, according to the AO-Q modifier, were surgically treated, while 30 % of Q2-6 fractures were treated surgically.14.

To our knowledge, no study has yet been published on the treatment and outcomes of isolated ulnar styloid fractures (AO-Q1 or AO-OTA 2U3A1.2). Accordingly, the objective of this study aims to radiologically and functionally evaluate isolated ulnar styloid fractures, analyze the outcomes of patients whose treatment resulted in nonunion, and compare the clinical and functional outcomes with those of patients whose fractures resulted in union. We hypothesise that patients with non-union of ulnar styloid fractures will have lower Mayo Wrist Scores, higher DASH scores and higher VAS pain scores, along with significantly lower functional scores compared to those with union.

2

2 Materials and methods

2.1

2.1 Study design

This retrospective comparative study was conducted with the approval of the authors’ affiliated institutions and in accordance with the Declaration of Helsinki. All patients provided informed consent prior to participation.

2.2

2.2 Setting

The study was conducted in the outpatient clinic of our orthopedic department, where patients diagnosed with AO-Q1 or AO-OTA 2U3A1.1,2 ulnar styloid fractures between 2015 and 2022 were retrospectively reviewed using medical records.

2.3

2.3 Participants

Patients aged between 18 and 65 years who were diagnosed with ulnar styloid fractures, who underwent radiological imaging at the time of initial presentation and follow-up, and who were followed for at least one year were included in the study. Patients were excluded if they had concurrent distal radius fractures, fractures in the same extremity, polytrauma, were those under 18 or over 65 years of age, had those with inadequate radiological imaging at initial presentation or follow-up, or sustained a new fracture in the same extremity during the follow-up period. (Fig. 1).

Study flow chart of patients screened, excluded, included and grouped.
Fig. 1 Study flow chart of patients screened, excluded, included and grouped.
2.4

2.4 Variables

The primary variables were of interest radiological and functional outcomes. Based on radiographic evaluation at the end of the 1-year follow-up period, patients were classified into two groups: Group A (Non-union): Patients who exhibited with no evidence of fracture union. Group B (Union): Patients exhibiting evidence of fracture union (Fig. 1).

The functional assessments conducted at the final follow-up were based on an anteroposterior (AP) and lateral wrist X-ray examination and the results of a physical examination. The functional status of the subjects was evaluated using the DASH score, the Mayo wrist score, the range of motion of the wrist joint, and the range of motion of the forearm in supination and protonation. Pain levels were quantified using the Visual Analogue Scale (VAS). The stability of the DRUJ (distal radioulnar joint) was evaluated using the ballotment test, with the results compared to those of the contralateral side. The presence of crepitus or pain during the test was taken to indicate DRUJ instability.8,9

Furthermore, ulnar styloid fractures (Q1) were classified into four distinct types: tip, middle, base-horizontal, and base-oblique.4 To ensure the integrity of the study, inclusion and exclusion criteria were rigorously adhered to, and radiographic assessments were subjected to independent review. Furthermore, functional scores were assessed using standardized scales to ensure uniformity in the evaluation process. The study size was determined by the number of patients who met the inclusion criteria during the defined study period (2015–2022).

2.5

2.5 Treatment selection

Treatment selection, including the choice between casting and splinting, was determined based on clinical and radiological findings. This decision was primarily made by the on-call orthopedic surgeon at the time of the patient's presentation to the emergency orthopedic clinic, considering factors such as fracture displacement, patient age, and functional demands. Patients followed a standard rehabilitation programme including exercises designed to restore joint mobility and muscle strength as needed.

2.6

2.6 Statistical methods

The statistical analysis was conducted using the IBM SPSS Statistics software, version 29. The demographic data of patients in Groups A and B were subjected to analysis and comparison based on the functional evaluation data. Pearson Chi-Square test was used for analysis of categorical variables. The Shapiro-Wilk test was employed to assess the normal distribution of variables within the groups. Variables showing normal distribution and homogeneous group variances were analyzed using independent samples t-test. Conversely, non-normally distributed variables were evaluated with the Mann-Whitney U test. A p-value of less than 0.05 was considered statistically significant. Post-hoc power analyses demonstrated high statistical power for the Mayo Wrist Score (Cohen's d = 1.78; power = 1.00), the DASH score (d = 1.03; power = 0.91), and flexion–extension range of motion (d = 1.16; power = 0.95), while the power for the DRUJ ballotman test was lower (Cohen's h = 0.85; power = 0.76). Given the number of variables assessed relative to the sample size, the risk of type I error was acknowledged, and findings were interpreted with appropriate caution.

3

3 Results

A total of 39 patients were included in the study, with an average follow-up period of 69 months (ranging 14–86 months). The patient cohort consisted of 30 males and 9 females, with an average age of 33.6 years (range 19–64 years). Of the patients included in the study, 25 sustained injuries to the right wrist, while 14 had injuries to the left wrist. The initial treatment for 22 patients was casting, while 17 patients were treated with splinting. The mean duration of immobilization was 29.9 days (range 20–45 days).

The incidence of ulnar styloid non-union was observed in 51.3 % of patients (n = 20, Group A), while 48.7 % (n = 19, Group B) demonstrated union. No statistically significant differences were identified between the groups in terms of demographic data such as age and gender. (p > 0.05) (Table 1) Radiographically, ulnar styloid fractures (USFs) were classified as either tip + middle fracture (48.7 %, n = 19) or base-horizontal fracture (51.2 %, n = 20). No patients presented with a base-oblique fracture. A significant difference between the groups was observed, with base-horizontal fractures being more common in Group A, while tip + middle fractures were more prevalent in Group B (p = 0.016) (Table 2) (Fig. 2).

Table 1 Demographic and treatment characteristics of the patients.
Variable Group A, (n = 20) 95 % CI Group B, (n = 19) 95 % CI p-value
Mean age (years) 34,1 (range 19–61) 28.1–40.1 33,1 (range 19–64) 26.9–39.4 0,821
Sex 0,770
Women, n (%) 5 (25,0 %) 11.2–46.9 % 4 (21,1 %) 8.5–43.3 %
Men, n (%) 15 (75,0 %) 53.1–88.8 % 15 (78,9 %) 56.7–91.5 %
Injured wrist 0,584
Right, n (%) 12 (60,0 %) 38.7–78.1 % 13 (68,4 %) 46.0–84.6 %
Left, n (%) 8 (40,0 %) 21.9–61.3 % 6 (31,6 %) 15.4–54.0 %
Treatment 0,855
Cast, n (%) 11 (55,0 %) 34.2–74.2 % 11 (57,9 %) 36.3–76.9 %
Splint, n (%) 9 (45,0 %) 25.8–65.8 % 8 (42,1 %) 23.1–63.7 %
Dominant side injury, n (%) 12 (60,0 %) 38.7–78.1 % 10 (52,6 %) 31.2–73.2 % 0,589
Duration of immobilization (days) 28,6 (range 20–45) 25.1–32.1 31,32 (range 20–45) 28.2–34.4 0,233
Table 2 Classification of isolated ulnar styloid fractures.
Clasification Group A (n = 20), n (%) 95 % CI Group B (n = 19), n (%) 95 % CI p-value
Tip + Middle 6 (30,0 %) 14.5–51.9 % 13 (70,0 %) 46.0–84.6 % 0,016∗
Base-Horizontal 14 (88,9 %) 48.1–85.5 % 6 (31,6 %) 15.4–54.0 %
Base-Oblique 0 (0 %) 0 (0 %)
Comparison of fracture types between union and nonunion groups.
Fig. 2 Comparison of fracture types between union and nonunion groups.

The functional outcomes are presented in Table 3. Group A exhibited lower mean values for grip strength, pinch strength, and wrist and forearm range of motion (including supination, protonation, extension, flexion, flexion + extension, radial deviation, and ulnar deviation) compared to Group B. The observed differences in supination, extension, flexion, flexion + extension, and ulnar deviation were statistically significant (p < 0.05) (Figs. 3 and 4). No statistically significant difference was observed between the two groups with regard to grip and pinch strength.

Table 3 Functional and clinical outcomes of the patients according to union status of isolated ulnar styloid fractures.
Outcome Group A, (n = 20) 95 % CI Group B, (n = 19) 95 % CI p-value
Grip strength (kg) 31,1 ± 13,2 24.9–37.3 37,9 ± 10,7 32.7–43.1 0,106
Pinch strength (kg) 9,6 ± 3,3 8.1–11.2 10,6 ± 2,9 9.2–12.0 0,358
Range of motion (degrees)
Supination (°) 65 ± 21 55.5–75.5 79 ± 3 77.4–80.5 < 0,001∗
Pronation (°) 74 ± 16 66.3–81.7 80 ± 1 78.6–82.0 0,123
Extension (°) 57 ± 11 51.8–62.2 69 ± 11 63.9–74.5 < 0,001∗
Flexion (°) 55 ± 7 51.3–58.1 61 ± 7 56.7–64.9 0,027∗
Flexion + Extension (°) 114 ± 17 105.8–121.6 131 ± 10 126.6–136.1 < 0,001∗
Radial deviation (°) 13 ± 4 11.5–15.5 15 ± 1 14.7–15.8 0,151
Ulnar deviation (°) 25 ± 8 21.4–28.6 33 ± 5 29.9–36.4 < 0,001∗
VAS 2,7 ± 2,2 1.7–3.7 0,9 ± 0,9 0.5–1.3 0,012∗
Mayo Wrist Score 65,7 ± 23 55.0–76.5 96,3 ± 6,8 93.0–99.6 < 0,001∗
DASH score 21,4 ± 23,5 10.4–32.4 1,4 ± 2,2 0.3–2.4 < 0,001∗
DRUJ ballotment test (+) 11 (55,0 %) 34.2–74.2 % 3 (15,8 %) 5.5–37.6 % 0,011∗
DRUJ pain (+) 13 (65,0 %) 43.3–81.9 % 0 (0 %) 0.0–16.8 % < 0,001∗
Comparison of grip and pinch strength between union and nonunion groups (mean values with 95 % confidence intervals).
Fig. 3 Comparison of grip and pinch strength between union and nonunion groups (mean values with 95 % confidence intervals).
Comparison of wrist range of motion parameters (flexion + extension, flexion, extension, protonation, supination, radial and ulnar deviation) between union and nonunion groups (mean values with 95 % confidence intervals).
Fig. 4 Comparison of wrist range of motion parameters (flexion + extension, flexion, extension, protonation, supination, radial and ulnar deviation) between union and nonunion groups (mean values with 95 % confidence intervals).

Significant statistical differences were observed between the two groups for VAS pain scores, Mayo wrist scores, and DASH scores, with Group A demonstrating worse outcomes in all three assessments (p = 0.012, p < 0.001, and p < 0.001, respectively). Additionally, the ballotment test for DRUJ instability was positive in a significantly higher proportion of patients in Group A compared to Group B (p = 0.011). Moreover, DRUJ pain was significantly more common in Group A (p < 0.001) (Fig. 5).

Comparison of functional outcome scores (DASH and Mayo) between union and nonunion groups (mean values with 95 % confidence intervals).
Fig. 5 Comparison of functional outcome scores (DASH and Mayo) between union and nonunion groups (mean values with 95 % confidence intervals).
4

4 Discussion

The most significant finding of this study is that approximately half of isolated ulnar styloid fractures result in non-union. In cases of non-union, the range of motion and functional scores are significantly worse compared to the union group. These findings support our hypothesis, suggesting that the rate of non-union after conservative treatment for isolated ulnar styloid fractures is higher than expected, negatively affecting patients’ functional outcomes.

Ulnar styloid fractures typically occur alongside distal radius fractures, and the majority of cases resulting in non-union are reported to be asymptomatic.4,8,10–12 There are a few studies showing that ulnar styloid fractures together with distal radius fractures result in worse clinical and functional outcomes compared to isolated distal radius fractures.13,14 However, Daneshvar et al. noted that grip strength and wrist flexion recover more slowly, although no significant differences were found at the one-year mark.15 Most of the literature suggests that the presence of ulnar styloid fractures alongside distal radius fractures does not impact clinical or functional outcomes.2,3,11,16–19 Additionally, no significant effect of the ulnar styloid fracture level on functional outcomes has been reported.2

When treating ulnar styloid fractures, factors such as fracture type, displacement, DRUJ instability, and TFCC injury should be considered. The relationship between these fractures and instability has been widely discussed in the literature, yet no consensus has been reached.10,20,21 However, most studies have focused on the effect of ulnar styloid fractures associated with distal radius fractures on DRUJ instability and TFCC injury.4,5,12,22,23 Isolated ulnar styloid fractures are much rarer, and their primary complication is non-union, which may require surgical treatment in symptomatic patients.24,25 There are very few studies evaluating isolated ulnar styloid fractures in the literature, and most are limited to case reports and cadaver studies.26,27 Therefore, there is no consensus regarding their treatment. In our study, we found that nearly half of isolated ulnar styloid fractures resulted in non-union. Given the negative impact of this on functional outcomes, we believe this is a matter that cannot be overlooked.

A study by Clementsen et al.16 reported that 44 % of ulnar styloid fractures involved the styloid base, with a non-union rate of 41 %. The same study found that styloid tip fractures accounted for 53 % of ulnar styloid fractures, with a non-union rate of 26 %. Similarly, in our study, non-union was more frequent in base-horizontal fractures compared to tip + middle fractures. Further subgroup analysis based on fracture classification demonstrated that base-horizontal fractures were associated with a higher rate of non-union, while tip + middle fractures were more likely to result in union. This finding highlights the potential impact of fracture type on the likelihood of healing and functional outcomes. This may be due to the close association between base-horizontal fractures and the TFCC.

As our understanding of DRUJ anatomy and mechanics improves, the relationship between ulnar styloid fractures and the TFCC has garnered increasing attention.22,23,27–29 Fractures of the ulnar styloid base associated with distal radius fractures have been reported to cause TFCC tears at the foveal attachment site.23 Additionally, DRUJ instability has been reported more frequently in patients with ulnar styloid fractures associated with distal radius fractures compared to those with isolated distal radius fractures.22,23 Similar to studies evaluating ulnar styloid fractures associated with distal radius fractures, our study found greater DRUJ instability in the non-union group compared to the union group after isolated ulnar styloid fractures.

The functional evaluation of ulnar styloid fractures is typically conducted with distal radius injuries, with no significant differences in outcomes between non-union and union groups.18,30–32 However, to our knowledge, there is no study specifically analyzing and comparing the functional outcomes of union and nonunion groups in isolated ulnar styloid fractures. This may be due to the relatively rare occurrence of these fractures. Over the years, our clinical experience has shown an increase in the number of patients diagnosed with isolated ulnar styloid non-union, presenting with ulnar-sided wrist pain, highlighting the need to reconsider treatment options for these fractures.

From a clinical perspective, our findings indicate that isolated ulnar styloid fractures that progress to nonunion may not always be associated with favorable outcomes. While ulnar styloid fractures accompanying distal radius injuries are often reported as asymptomatic even in the presence of nonunion, our results suggest that this assumption may not be directly applicable to isolated fractures. In such cases, persistent pain, limited range of motion, and inferior functional outcomes may be encountered. Therefore, although conservative management remains appropriate for the majority of patients, closer follow-up is advisable to identify those who develop symptomatic nonunion, in whom surgical treatment may be considered. Larger prospective studies are required to determine optimal management strategies for this distinct fracture subgroup.

This study is limited by its retrospective design and the relatively small sample size. In addition, the relatively small cohort combined with multiple statistical comparisons increases the risk of type I error, and some significant findings with small effect sizes should therefore be interpreted with caution. Another limitation is that fracture displacement was not evaluated in ulnar styloid fractures and TFCC integrity was not evaluated by MRI. Another limitation of the study was that the final evaluations were performed by different surgeons. The ballotment test employed to evaluate DRUJ stability is inherently subjective, which represents another limitation of our study. In light of these limitations, further randomized controlled, multicenter studies with larger patient populations are required to obtain more definitive conclusions regarding the treatment and non-union rates of isolated ulnar styloid fractures.

5

5 Conclusion

In conclusion, nearly half of the isolated ulnar styloid fractures in our series progressed to nonunion, and these patients demonstrated worse functional outcomes compared with those who achieved union. These findings suggest that ulnar styloid nonunion may not always be associated with favorable outcomes, as ulnar styloid nonunions associated with distal radius fractures do. These findings, when considered in conjunction with future comprehensive studies, suggest that different approaches may be necessary in the treatment of isolated ulnar styloid fractures.

Ethical approval

Ethics committee approval was obtained for this study.

CRediT author statement

•Yusuf Sülek: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Visualization, Writing – Original Draft.

•Ömer Faruk Kümbüloğlu: Conceptualization, Resources, Investigation, Data curation, Writing – Review & Editing.

•İsmail Demirkale: Supervision, Project administration, Validation, Writing – Review & Editing.

Ethical statement (JOR 2714)

This study titled “İzole ulna stiloid kırıklarında kaynamama ve fonksiyonel sonuçlara etkisi” was reviewed and approved by the Sağlık Bilimleri Üniversitesi Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi Klinik Araştırmalar Etik Kurulu. The committee confirmed that the study poses no ethical concerns, as stated in the approval dated February 27, 2024 (Decision No: 4314).

Funding

No financial support was received for this study.

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