638483

research-article2016
JHS0010.1177/1753193416638483Journal of Hand Surgery (European Volume)Nunez et al.

Full length article

JHS(E)
The Journal of Hand Surgery

Treatment of symptomatic non-unions (European Volume)

2017, Vol. 42E(4) 382­–388
© The Author(s) 2016
of the base of the ulnar styloid with plate Reprints and permissions:
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osteosynthesis DOI: 10.1177/1753193416638483

https://doi.org/10.1177/1753193416638483
journals.sagepub.com/home/jhs

F. A. Nunez Jr1, T. D. Luo1 and F. A. Nunez Sr2

Abstract
The purpose of this prospective case series was to assess the efficacy of plate osteosynthesis using a low
profile distal ulna plate for the management of persistently symptomatic non-unions of the base of the ulnar
styloid. Six consecutive patients underwent resection of the non-union and plate osteosynthesis with a 2.0 mm
distal ulna hook plate. Post-operative measurements of mean pain scores, QuickDASH scores, grip strength,
and range of motion parameters showed significant improvements compared with the pre-operative values.
No complications were reported at a mean follow-up of 25 months. The present study presents an alternative
method for treating symptomatic ulnar styloid non-unions that provides stable fixation with low risk of implant
removal.

Level of Evidence: Therapeutic IV

Keywords
Ulnar styloid non-union, ulnar styloid fracture, distal radioulnar joint instability, ulnar-sided wrist pain

Date received: 3rd November 2015; revised: 2nd February 2016; accepted: 4th February 2016

Introduction
Ulnar styloid fractures are common injuries that are
usually associated with distal radial fractures, or less
commonly occur as isolated injuries caused by a
direct blow (Hauck et al., 1996). The ulnar styloid
serves as attachment for the extensor carpi ulnaris
(ECU) tendon sheath, ulnocarpal ligaments, and the
triangular fibrocartilage complex (TFCC). Most of
these attachments are at the base of the styloid and
therefore fractures distal to the base do not cause
instability of the distal radioulnar joint (DRUJ)
(Linscheid, 1992; Palmer and Werner, 1981;
Zimmerman and Jupiter, 2014). Most ulnar styloid
fractures heal or become asymptomatic non-unions.
Recent evidence suggests that ulnar styloid fractures
that are unrepaired or develop non-union have no
effect on the outcome of distal radial fracture (Buijze
and Ring, 2010; Souer et al., 2009).
Ulnar styloid non-unions are classified based on
the stability of the DRUJ (stable in type 1 and unstable
treatment of type 2 non-unions has been described
using tension band fixation, compression screw fixa-
tion, or excision of the styloid with repair of the TFCC.
The latter relies exclusively on ligamentous healing
to bone as the only stabilizer of the DRUJ (Burgess
and Watson, 1988; Hauck et al., 1996; Protopsaltis
and Ruch, 2010).
There continues to be divided opinion among
experts on whether ulnar styloid fractures and non-
unions should be addressed surgically (Buijze and
Ring, 2010; Hauck et al., 1996; Lindau et al., 2000; May
et al., 2002; Roysam, 1993; Souer et al., 2009; Stoffelen
et al., 1998; Zenke et al., 2009). Based on a review of
available reports in PubMed®, no prospective studies
1WakeForest Baptist Medical Center, Medical Center Blvd,
Winston Salem, NC, USA
2Centro Medico Guerra Mendez, Valencia, Venezuela

in type 2) (Hauck et al., 1996). Symptomatic type 1

Corresponding author:
non-unions are traditionally treated with excision of F. A. Nunez Jr, Wake Forest Baptist Medical Center, Medical
the styloid with or without reinsertion of the radioul- Center Blvd, Winston Salem, NC 27157, USA.
nar ligaments to the base of the distal ulna. Surgical Email: fnunez@wakehealth.edu
Nunez et al. 383
Figure 1.  Posteroanterior and lateral wrist radiograph showing a non-union of the base of the ulnar styloid.
have yet analysed the treatment of persistently symp-
tomatic non-unions of the base of the ulnar styloid. We
report a prospective case series of patients with per-
sistently symptomatic (painful or unstable) non-unions
at the base of the ulnar styloid despite non-operative
treatment and who underwent plate osteosynthesis.
The purpose of this study was to assess the relief of
symptoms and hand function after plate fixation.
Methods
Ethical committee approval was obtained from the
participating institution. All patients with a persis-
tently symptomatic non-union of the base of the ulnar
styloid (with persistent pain or DRUJ instability for at
least 6 months after injury) were invited to participate
(Figure 1). Patients were excluded if they had an inci-
dental finding of an asymptomatic ulnar non-union of
the base of the styloid or had a non-union of the tip of
the ulnar styloid. Patients who met the inclusion cri-
teria were offered osteosynthesis using a distal ulna
hook plate and possible TFCC repair. Patients who
declined this option were offered continued conserv-
ative management or ulnar styloid resection with or
without TFCC repair.
DRUJ instability was assessed by physical exami-
nation using the Shuck test and compared with the
contralateral wrist (Figure 2 and Video S1, available
online). Wrists were classified as either stable or
unstable without further grading. In order to qualify
as persistently symptomatic, the patients must have
received conservative management for 6  months,
consisting of wrist immobilization for 8 weeks with a
removable splint, with or without combined local
anaesthetic/steroid injections (maximum of two).
Non-union of the ulnar styloid was diagnosed with
plain posteroanterior wrist radiographs with the
forearm in neutral rotation. Other imaging was not
obtained before surgery since there would be direct
visualization of the TFCC and wrist ligaments at
operation. Cigarette smokers were included in the
study only if they had stopped smoking for 1 month
before the date of surgery.
Demographics
Between 2008 and 2015, seven patients were referred
to the senior author (F. A. N. Snr) with non-unions of
the base of the ulnar styloid. Patients who had
received conservative management as described
above for more than 6 months without success were
offered surgical intervention. In one patient, the pre-
vious management was not well documented, and
therefore standard conservative measures were
offered for 6 months. This patient elected for surgery
4 months later owing to the severity of pain and insta-
bility and was excluded from the study. The remain-
ing six patients underwent operative osteosynthesis
using a 2.0-mm LC distal ulna plate (Synthes, West
Chester, PA). No patients refused surgery.
The senior author carried out all the operations.
Follow-up visits were scheduled at 2 weeks, 6 weeks,
384 The Journal of Hand Surgery (Eur) 42(4)
Figure 2.  Physical examination demonstrating instability of the DRUJ.
3 months, 6 months, and 12 months. Patients were
allowed unrestricted activity when examination of the
non-union site was painless with active range of
motion and to palpation. Post-operative radiographs
were obtained at 6 weeks and at the time of starting
full activity to confirm bridging bony trabeculae
across the non-union.
Study design
The study was a prospective case series. The pri-
mary outcome measure was post-operative pain
ratings based on a 10-point visual analogue scale.
Secondary outcome measures included range of
motion of the wrist and forearm, grip strength, and
the quick Disabilities of the Arm, Shoulder, and
Hand (QuickDASH) score. Pre-operative scores were
obtained 1  week before surgery. Post-operative
scores were obtained 6  months after operation.
Non-union, mal-union, infection, or complications
associated with the implant, such as pain or tendo-
nitis, were recorded.
Statistical analysis
The paired Student’s t-test was used to compare the
pre-operative and post-operative visual analogue
pain scales, QuickDASH scores, ranges of motion of
the wrist and forearm, and grip strength. Statistical
significance was set at p ⩽ 0.05.
Surgical technique
With the patient positioned supine and the elbow
flexed, a direct approach to the distal ulnar metaphy-
sis was made as previously described for the use of
this implant (Nunez et al., 2012, 2013). In brief, a 6 to
8-cm longitudinal ulnar-sided incision was made
starting at the tip of the ulnar styloid and continued
proximally. The dorsal cutaneous branch of the ulnar
nerve was identified and protected. The ulna was
exposed subperiosteally by sharp dissection between
the flexor carpi ulnaris and extensor carpi ulnaris.
Once the non-union was exposed, the sclerotic
edges at the site of the non-union and any interposed
soft tissue were excised. Special attention was given
to the radioulnar ligaments and their insertion on the
ulnar styloid. Once the TFCC attachment to the non-
united styloid fragment was confirmed, the non-
union was resected. An oscillating saw with profuse
irrigation was used to start the cuts and then a small
osteotome was used to resect the proximal end of the
non-union to allow the ulnar styloid to be fixed more
proximally. This did not affect the ulnar variance
because the ulna itself was not shortened. This part
of the procedure allowed tightening of the TFCC and
more uniform bone contact for compression (Figure
3). The hooks of the plate were then engaged on the
tip of the styloid and a locking drill guide was attached
to the plate to use as a handle. Once reduction was
achieved, a 2.0-mm non-locking self-tapping cortical
Nunez et al. 385

Figure 3.  Illustration showing re-tensioning of the TFCC. By resecting the non-union and fixing the ulnar styloid slightly
more proximally, the superficial limbs of the TFCC (green) are re-tensioned and provide a buttress to the deep limbs (blue).

Figure 4.  Intraoperative fluoroscopic images showing plate osteosynthesis of a non-union of the base of the ulnar styloid.

screw was inserted eccentrically into the oblong hole
of the shaft to achieve axial compression of the non-
union. Two more non-locking screws were then
inserted, one proximal and one distal to the oblong
hole. Alternatively, if the direction of the non-union
allowed interfragmentary compression, one screw
was inserted between the distal hooks of the plate
from the styloid tip and directed proximally (Figure 4).
If the foveal fibres were detached, they were reat-
tached using a 4-0 non-absorbable braided suture.
The sutures were tunnelled from the fovea to the
neck of the ulna where they were tied.
A soft dressing and short arm plaster splint was
applied after surgery. The plaster was removed 5 days
after surgery in all patients to allow unrestricted range
of motion. Early mobilization has not been shown to
result in DRUJ instability (Andersson et al., 2017; Gong
et al., 2015). Patients were provided with a removable
wrist splint, which was used for comfort for 3 weeks
after surgery or as needed. Patients were instructed to
remove the splint at least 3 times per day and to carry
out motion exercises to avoid stiffness. Patients were
advised to avoid heavy lifting and manual labour for
6 weeks, but otherwise had no restrictions in activity.
386 The Journal of Hand Surgery (Eur) 42(4)
Table 1.  Pre-operative and post-operative measurements.
Measurement Before (range)
Pain score 7.3 (6–10)
QuickDASH 70 (52–98)
Grip strength 28(4–40)
Flexion 66 (60–85)
Extension 58 (43–80)
Pronation 43 (30–60)
Supination 44 (30–70)
p-values in bold represent statistical significance (p < 0.05).
All patients were referred to hand therapy 7 days after
surgery, at which time the sutures were removed.
Patients were cleared for full activity at 12 weeks or
earlier if they were pain free and demonstrated a sta-
ble DRUJ on clinical examination.
Results
Three patients had sustained extra-articular frac-
tures of the distal radius and fractures of the base of
the ulnar styloid and were treated with anterior plat-
ing for the radius. There was no documented inter-
vention for the fracture of the ulna. One patient had
an extra-articular distal radial fracture and a fracture
of the base of the ulnar styloid treated with cast
immobilization. Two patients sustained isolated frac-
tures of the base of the ulnar styloid. The average age
at the time of surgery was 27 years (range 23–37). All
patients were employed at time of injury (four labour-
ers, one engineer, one physician). The average fol-
low-up was 25 months (range 6–49).
The mean time from the injury until surgical inter-
vention was 20 months (range 8–34). All operations
resulted in healing of the non-united segment with-
out complications. There were no infections, delayed
healing, or mal-union. All patients had a stable DRUJ
during the immediate post-operative period, and this
remained unchanged until final follow-up (Video S2).
All post-operative outcome measurements demon-
strated statistically significant improvements com-
pared with the pre-operative measurements (Table 1).
Patients were released for unrestricted activity and
cleared for return to work at a mean time of 9 weeks
(range 6–12) based on radiographic evidence of heal-
ing. No patients had pain that required removal of the
plate.
Discussion
Fractures of the base of the ulnar styloid are often
associated with distal radial fractures, but there is no
clear consensus regarding their optimal management
After (range) t-test (p-value) Mean of differences
(95% confidence interval)
0.3 (0–2) 10.3 (<0.001) −7.0 (−5.2 to −8.8)
12 (2–36) 7.9 (<0.001) −58 (−39 to −76)
37 (15–45) 3.1 (0.01) 9 ( −1 to 16)
73 (65–85) 2.2 (0.04) 7 (−1 to 15)
70 (60–90) 2.2 (0.04) 12 (−21 to 26)
67 (60–80) 3.1 (0.01) 24 (−4 to 43)
72 (55–85) 3.6 (0.008) 28 (8 to 47)
(May et al., 2002). These fractures are rarely treated
surgically because they often heal or go on to develop
asymptomatic non-union. Symptomatic non-union of
the ulnar styloid is uncommon. This is supported by
the current study (seven patients in a 7-year span) and
the original series by Hauck et al. (20 patients over a
13-year span) (1996).
Some authors suggest that there is no correlation
between non-union and wrist pain, and that even
painful ulnar styloid non-unions become painless by
1 year after the injury (Buijze and Ring, 2010;
Daneshvar et al., 2014; Kramer et al., 2013; Wijffels
and Ring, 2011; Wijffels et al., 2014; Zenke et al.,
2009). However, these studies did not make an ana-
tomical description of the injury, address DRUJ insta-
bility, or classify the type of non-union into those of
the base and tip, which have different anatomical and
function implications. Most patients with painful non-
unions of the ulnar styloid may be able to continue
conservative measures in anticipation that the pain
will subside within 1 year of the injury. However, some
patients require the use of their hands for manual
labour and cannot afford to wait that long. Our series
included four labourers who were unable to work
because of pain.
Excision of a large ulnar styloid non-union with
repair of the TFCC not only has the disadvantage of
relying on ligament healing rather than bone, but
also requires forearm immobilization for 4–6 weeks
(Protopsaltis and Ruch, 2010). In the series by Hauck
et al. (1996), the fracture healed in all patients who
underwent open reduction and internal fixation, but
they continued to have persistent post-operative
pain, which subsided after the removal of implants.
Prominence of the implant is not uncommon after
fixation of the ulnar styloid (Hauck et al., 1996;
Shirakawa and Shirota, 2013). No patients in our
series required removal of the plate during a mean
follow-up of 25 months. This might be credited to two
factors: shortening obtained by resection of the non-
union might provide space for the hooks of the plate
and avoid irritation of the ECU sheath; and proper use
Nunez et al. 387
Figure 5. Showing the use of the plate on an unusually
small ulnar styloid.
of the ‘safe zone’ as described in a recent cadaveric
study (Hazel et al., 2015). We have previously reported
a low need for removal after using a similar surgical
technique for ulnocarpal abutment syndrome (Nunez
et al., 2012).
It is important to clarify that we do not dispute that
most ulnar styloid fractures either heal or develop
asymptomatic non-union, nor are we advocating that
more ulnar styloid fractures or non-unions should be
treated surgically at an early stage. We believe the
indication for operation is a non-union of the base of
the ulnar styloid associated with persistent ulnar-
sided symptoms that have failed to respond to con-
servative management. The patient must have clear
understanding of the complex nature of ulnar-sided
wrist pain and that predictable pain relief or func-
tional improvement, although likely (given our data),
is not guaranteed.
The surgical technique allows stable fixation with
interfragmentary and axial compression to improve
healing potential. Resection of the non-union allows
slight shortening of the styloid for optimized TFCC
tensioning and does not significantly alter ulnar vari-
ance. Although the implant is manufactured in a sin-
gle size, we believe it is suitable for most ulnar
styloids regardless of size (Figure 5).
There are several limitations to our study. None of
the patients were followed from the initial injury and
there was no control group or randomization to con-
servative or surgical treatment. Therefore, the pro-
spective nature does not add significant strength to
the study. The stability of the DRUJ was assessed on
physical exam, which may be subjective in nature. A
recent cadaver study established an in vivo method of
objectively measuring DRUJ translation to quantify
instability (Pickering et al., 2016). However, based on
our patients’ symptoms and history, we do not believe
the lack of formal measurement of the DRUJ would
have changed the diagnosis or excluded any patients
from the cohort. All patients underwent plate osteo-
synthesis, which is the preferred treatment method
of the senior author. This brings bias to the study;
however, we do not have a conflict of interest.
Treatment by plate osteosynthesis increases cost.
However, more anatomical implants, such as the
ones used in this study, may potentially offset this by
reducing the need for removal. Techniques that use
tension band and screw fixation often require a sec-
ond operation for their removal. The study is limited
by the small sample size. Future studies to compare
different treatments with adequately powered sam-
ple sizes may be feasible in a multicentre setting.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Ethical approval
Ethics committee approval was obtained from the partici-
pating institutions.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
Supplementary material
Supplementary videos are available at jhs.sagepub.com/
supplemental.
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