Invited Article The Journal of Hand Surgery (Asian-Pacific Volume) 2016;21(2):155-160 • DOI: 10.

1142/S2424835516400075

Management of Distal Ulnar Fracture Combined with

Distal Radius Fracture
Jae Kwang Kim, Jong-Oh Kim, Yong-Do Koh
Department of Orthopedic Surgery, Ewha Womans University School of Medicine, Seoul, Korea

The distal ulna is composed of the ulnar styloid, ulnar head, and distal ulnar metaphyseal area. Most of distal ulnar metaphyseal
J Hand Surg Asian-Pac Vol 2016.21:155-160. Downloaded from www.worldscientific.com

fractures are associated with distal radius fractures and this incidence tends to be greater in osteoporotic elderly. Consideration
by WEIZMANN INSTITUTE OF SCIENCE on 07/08/16. For personal use only.

of the treatment of distal ulna metaphyseal fracture should be addressed after treating a distal radius fracture. If it is stable, cast
immobilization is preferred, however, if it shows malalignment or instability, an operative method should be considered. More than
half of distal radius fractures are combined with an ulnar styloid fracture, and considerable cases of ulnar styloid fractures result in
nonunion. However, ulnar styloid nonunion usually does not cause any problems on the wrist. Recent studies of distal radius frac-
tures treated using a volar locking plate have reported that neither the initial displacement nor the size of a concomitant ulnar sty-
loid fracture affects clinical outcome, which suggests surgical approaches may usually not be indicated for ulnar styloid fractures.

Keywords: Distal ulnar fracture, Distal radius fracture, Distal radioulnar joint

INTRODUCTION The ulnar styloid is the bony projection of the distal

The bony structure of distal ulna is composed of ul-
nar styloid, ulnar head, and distal ulnar metaphysis. The
distal ulna represents a fixed point around which the ra-
dius rotates to provide forearm rotation.1) The ulnar head
is composed of the dome and the seat,2) and the dome is
directed toward the carpus and the seat articulates with
the sigmoid notch of radius. Biomechanics at the wrist
produce variable loads across the ulnocarpal joint, which
depend on the rotational positions of the wrist and grip.
With the wrist in neutral rotation, the ulnocarpal joint
bears nearly 20% of the load across the wrist and rela-
tive increases in ulnar length and loading occur with grip
or as the forearm moves into pronation.3,4)
Received: Apr. 2, 2015; Revised: Apr. 24, 2015; Accepted: Apr. 24, 2015
Correspondence to: Jae Kwang Kim
Department of Orthopedic Surgery, Ewha Womans University School of
Medicine, Ewha Womans University Mokdong Hospital, 911-1, Mok-5-
dong, Yangcheon-gu, Seoul 07985, Korea
Tel: +82-2-2650-2591, Fax: +82-2-2642-0349
E-mail: kimjk@ewha.ac.kr
ulna and provides attachment for the superficial com-
ponents of the dorsal and palmar radioulnar ligaments.
The fovea of the ulnar head is the center for axis of ulnar
head rotation and serves as the site of attachment for
deep components of the dorsal and palmar radioulnar
ligaments.5)
The ulnar head acts as a keystone structure compos-
ing the DRUJ and the sigmoid notch of the distal radi-
us.6) Therefore, inappropriate treatment of a distal ulnar
fracture results in several complications, including re-
striction of forearm rotation, persistent ulnar-sided wrist
pain, and DRUJ instability.7-9) However, the significance
of distal ulnar fractures is often ignored and only a few
articles have summarized treatment guideline for com-
bined distal radius and distal ulnar fracture in adults.10)
In this paper, we reviewed the current literature and de-
scribed authors’ practical method to provide a guideline
for the management of these complex injuries.
CLASSIFICATION
Distal ulna fractures are classified based on location
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Jae Kwang Kim, et al. Distal Ulnar Fracture
A tures; distal ulna fractures associated with distal radius
Q1 Q2 Q3 Q4 Q5
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B
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Fig. 1. In the comprehensive classification system, associated fracture
of the distal ulna is classified using a Q system (A) (Reprinted with
permission from Kim JK, Kim JO, Yun YH. Treatment of ulnar fractures
combined with distal radius fracture. J Korean Orthop Assoc. 2013
Apr;48(2):151-156.). Classification of distal ulnar fracture as proposed
by Biyani et al. (B) (Reprinted with permission from Biyani A, Simison
AJ, Klenerman L. Fractures of the distal radius and ulna. J Hand Surg Br.
1995;20(3):357-364.).
A B
and pattern. The most frequently cited classification
system is the AO Comprehensive Classification of Frac-
fractures are classified using the Q modifier,11) as fol-
lows: Q1, ulnar styloid base fracture; Q2, simple ulnar
neck fracture; Q3, comminuted ulnar neck fracture; Q4,
ulnar head fracture; and Q5, combined ulnar neck and
head fracture. Biyani et al.7) also described a classifica-
tion scheme for distal ulnar fracture, according to which
type I is a simple ulnar neck, type II is an inverted T or
Y shaped fracture, type III is a combined ulnar neck and
ulnar styloid fracture, and type IV is a comminuted ulnar
neck fracture (Fig. 1).
DISTAL ULNAR METAPHYSEAL FRACTURE
Distal ulnar metaphyseal fracture can be defined
as a fracture from the ulnar neck to within 5 cm of the
distal dome of the ulnar head. Distal ulnar metaphyseal
fractures are uncommon in isolation, and are usually as-
sociated with distal radius fractures.10) However, it has
been reported that only 5–6% of distal radius fractures
are accompanied by a distal ulnar metaphyseal fracture.7)
Combined distal radius and distal ulna fracture in adult
typically present in the elderly (65–85 years) with osteo-
porosis.12)
Clinical outcomes are usually determined by fracture
type and severity of the distal radius fracture in the com-
bined distal ulnar metaphyseal fracture. Consideration of
the treatment of distal ulna metaphyseal fracture should
be addressed after treating a distal radius fracture.10) If a
Fig. 2. A 62-year-old female patient
treated by anatomical locking plate
fixation for a concomitant distal ulnar
metaphyseal fracture. (A) Preoperative
radiograph of the wrist. (B) Radiograph
taken at two weeks after surgery.
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The Journal of Hand Surgery (Asian-Pacific Volume) • Vol. 21, No. 2, 2016 • www.jhs-ap.org
A B
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distal ulnar metaphyseal fracture is realigned and stable
after the radius fracture has been reduced and/or fixed,
cast treatment can be successfully applied for this frac-
ture.13)
However, operative treatment should be considered
when a combined distal ulnar metaphyseal fracture is
malaligned or unstable after distal radius fracture re-
alignment and fixation.10) Distal ulnar metaphyseal frac-
ture malalignment is defined as ≥ 10 degrees of angular
deformity, ≥ 3mm of ulnar variance change, or ≥ 1/3
translation of fracture surface.13-15) Instability of distal
ulnar metaphyseal fracture is defined as a tendency for
fracture fragments to move relative to one another with
passive forearm rotation, and instability of the distal
radioulnar joint is defined as dislocation or ≥ 50% of
the distal ulnar subluxation with respect to the distal ra-
dius.13,14)
Internal fixation
Internal fixation of distal ulnar metaphyseal fractures
can be challenging, because the distal fracture fragment
is small, comminuted, osteoporotic, and covered with ar-
ticular surface over a 270° arc.13) The thin soft tissue en-
velope and triangular cross-sectional shape of the bone
at the subcutaneous border of the ulna makes placement
of fixation difficult and poorly tolerated in this region.16)
Hardware is more easily placed and better tolerated
along the volar surface of the bone where it has a wider
and flatter surface and a thicker soft tissue envelope.
Surgical exposure of the distal ulna for hardware place-
ment places the dorsal sensory branch of the ulnar nerve
at risk.
Fig. 3. A 70-year-old female was referred
to our clinic due to reduction loss of
closed reduction and K-wire fixation at 4
weeks after initial treatment. Therefore,
we used the Darrach procedure for a
concomitant distal ulnar metaphyseal
fracture. (A) Preoperative radiograph of
the wrist. (B) Immediate postoperative
radiograph.
Various methods of distal ulna fracture fixation
have been described, including the use of K-wires, ten-
sion banding, intraosseous wiring, and plate-screw
constructs.14) We usually use a mini-locking plate as
an internal fixator for this fracture, because this plate
type can provide enough mechanical strength to sustain
screw pull-out despite of purchase of the distal fracture
fragment with only two screws. A recently introduced
low-profile mini-locking plate might be suitable for this
region (Fig. 2). Ring et al.13) reported satisfactory results
for 24 patients with an unstable fracture of the distal
ulna treated using mini-condylar blade plates; one pa-
tient went on to nonunion and 7 patients required plate
removal due to prominence. Dennison14) described satis-
factory results for 5 patients treated for an unstable frac-
ture of the distal ulna using 2.0 mm mini-locking plates.
According the Gartland and Werley scoring system, four
patients achieved an excellent and one patient a good
result after an average follow-up of 12 months, and no
patient experienced non-union or required plate removal
due to hardware irritation.
Salvage procedures
When the distal ulna fracture is highly comminuted,
operative fixation may be difficult or impossible. In
these situations, salvage procedures including Darrach
(Fig. 3), Suave-Kapandji, or ulnar head replacement may
produce better results than internal fixation.16)
In select cases, salvage operations may be appropri-
ate at the time of initial management. Ruchelsman et
al.15) reported on a series of 11 consecutive patients that
underwent primary resection of the distal ulna at the
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Jae Kwang Kim, et al. Distal Ulnar Fracture

time of distal radius fracture fixation. After an average
follow-up of 42 months, 7 patients achieved an excellent
and 4 a good result according to Gartland and Werley
scores, and no patient required secondary surgery. Arora
et al. performed primary Sauve-Kapandji procedures
to treat comminuted distal radial fractures with com-
bined significant shortening and comminuted distal
ulnar fractures in 11 elderly women. After an average of
46 months of follow-up, clinical outcomes rated using
Green and Obrien scores were excellent for 8, good for 2,
and fair for 1, and there were no cases of distal radius or
ulnar non-union. The use of a primary ulnar head pros-
thesis following ulnar head resection has not gained wide
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stable fixation of an accompanying distal radius fracture
using a locking plate (Fig. 4).
Namba et al.18) treated distal radial fractures with
fixation of volar locking plate and distal ulnar fracture
with cast immobilization in 14 patients of mean age of
74 years. All patients were excellent or good on modi-
fied Gartland and Werley scores, and all fracture sites
displayed union, and no instability of the distal radio-
ulnar joint was encountered at an average of 18 months
after surgery. Cha et al.19) compared a non-operative
method and one third tubular plate fixation for unstable
distal ulnar metaphyseal fractures after stable distal
radius fracture fixation using a locking plate, and con-

acceptance due to the relative success of the Darrach cluded unstable distal ulnar metaphyseal fractures can be
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procedure.16) However, secondary ulnar head prosthesis
placement after failed ulnar head resection arthroplasty
has been reported to improve pain scores, satisfaction,
range of motion, and grip strength.17)
Skillful neglect
Because surgical treatments of comminuted osteopo-
rotic distal ulnar metaphyseal fractures cannot achieve
effective fixation but rather produce some complications,
some authors have suggested nonoperative treatment can
substitute for operative treatment in cases of unstable
osteoporotic distal ulnar metaphyseal fracture following
successfully treated conservatively if the accompanying
distal radius fracture is stably fixed.
ULNAR HEAD FRACTURE
(INTRA-ARTICUCLAR FRACTURE ALONE)
Because the occurrence of ulnar head fracture alone
is quite rare in trauma cases, no comparative study has
been conducted on combined distal radius fracture and
ulnar head fracture. However, case reports on the treat-
ment of isolated ulnar head fracture using headless
cannulated screws have been issued.20,21) Accordingly,

A B C

Fig. 4. A 68-year-old female patient who received conservative treatment for a concomitant distal ulnar metaphyseal fracture. (A) Preoperative
radiograph of the wrist. (B) Radiograph taken immediately after surgery. (C) Radiograph taken at one year after surgery (Reprinted with permission from
Kim JK, Kim JO, Yun YH. Treatment of ulnar fractures combined with distal radius fracture. J Korean Orthop Assoc. 2013 Apr;48(2):151-156.).
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The Journal of Hand Surgery (Asian-Pacific Volume) • Vol. 21, No. 2, 2016 • www.jhs-ap.org
accompanying ulnar head fracture can be treated conser-
vatively when an ulnar head fracture shows no displace-
ment and using headless cannulated screws when this
fracture shows displacement after distal radius fracture
has been addressed.
ULNAR STYLOID FRACTURE
Ulnar styloid fractures accompany 50% or more of
distal radius fractures.6) Although about 50–70% of ul-
nar styloid fractures result in non-union treated by con-
servative methods, most of them are asymptomatic.22)
However, ulnar styloid non-union resulted in pain at the
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non-union site, ulnocarpal impaction, or extender carpi
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ulnaris tendinitis in a few of case reports,6,23) which can
all be treated by excision of the styloid fragment. In ad-
dition, it has to be borne in mind ulnar styloid fractures
can potentially lead to DRUJ instability when a dis-
placed fracture involves the ulnar styloid base or fovea.
Reported results disagree regarding the effect of an
accompanying ulnar styloid fracture on the outcome of
distal radius fracture.24) However, studies that have sug-
gested ulnar styloid fracture has an adverse effect on
accompanying distal radius fracture outcomes did not
show that ulnar styloid fracture fixation provides better
outcomes.25-29) Advances in plate technology can main-
tain initial reduction statuses of distal radius fractures
and displaced ulnar styloid fractures can be reduced dur-
ing open reduction of distal radius fractures.24) Recent
studies support the idea that most ulnar styloid fractures
do not affect objective or subjective clinical outcomes,
particularly when the distal radius is treated by open re-
duction and plate fixation.24,30-32)
We examine the DRUJ stability intraoperatively after
fixation of distal radius fracture as follows. The distal
radius is grasped by the examiner with the forearm in a
neutral position, and the distal ulna, which is fixed by
the examiner’s other hand, is then moved in dorsal and
volar directions with respect to the radius and compared
with the contralateral side.33) This test is performed with
the forearm in neutral rotation, pronation, and supina-
tion. Intraoperative DRUJ instability is determined to be
present when the distal ulna swayed with little end point
resistance (clunk feeling) comparing to contralateral
side.30,34) When the DRUJ is stable, we do not perform
operative fixation of the ulnar styloid, but do adopt im-
mobilization for 2 or 4 weeks regardless of degree of
displacement or fragment size.35) If the DRUJ is unstable
in one or two positions of forearm rotation, we immobi-
lize the forearm in a stable position for 4 or 6 weeks.33)
However, if the DRUJ is unstable in all positions of
forearm rotation, which is extremely rare in cases of dis-
tal radius fracture, we may perform open reduction and
internal fixation for an ulnar styloid fracture.
The operative method commonly used for ulnar sty-
loid fracture is tension band wiring, but when surgery is
performed for an ulnar styloid fracture, it should be kept
in mind that surgery would be associated with risk of
hardware prominence, irritation of the dorsal branch of
the ulnar nerve, scarring, and longer operative times.16)
CONCLUSION
Accompanying distal ulnar fracture may affect the
outcomes of distal radius fracture by disturbing the con-
gruity and stability of the DRUJ. When confronted with
distal ulnar fracture combined with distal radius fracture,
the distal radius fracture should be addressed first, and
then decisions made regarding the treatment of the distal
ulnar fracture. When we choose the treatment option for
the accompanying distal radius fracture, considerations
should be given to fracture’s factors (location and sever-
ity), patient’s factors (age, work, and demand), and sur-
geon’s factors (experience and facility).
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