SCIENTIFIC ARTICLE

The Effects of Ulnar Styloid Fractures on Patients

Sustaining Distal Radius Fractures
Parham Daneshvar, MD, Robert Chan, MD, Joy MacDermid, PhD, Ruby Grewal, MD

Purpose To determine if ulnar styloid fractures (USF) affect clinical outcome following distal
radius fracture (DRF) in adults under 65 years of age.
Methods This study involved 312 patients (aged 18e64) with surgically and nonsurgically
treated DRFs. Patients were followed prospectively at baseline and 3, 6, and 12 months. The
primary outcome was the Patient-Rated Wrist Evaluation (PRWE), and secondary outcomes
were range of motion and grip strength. The USFs were classified by location (tip, middle,
and base) and union status.
Results There were 170 patients with isolated DRFs and 142 with associated USF (64 tip, 32
middle, and 46 base fractures). The mean age of the entire cohort was 48 years with 218 (70%)
women. All USFs were treated nonoperatively. There was a trend of higher PRWE scores in
DRFs associated with USFs compared to isolated DRFs throughout the study. Associated ulnar
styloid base fractures had higher but clinically insignificant PRWE scores than isolated DRFs
at 6 and 12 months. Patients with an associated USF had a slower recovery of wrist flexion
and grip strength compared to isolated DRF, but values were comparable at 12 months. United
USFs and nonunited USFs had similar PRWE scores at all time points.
Conclusions Adults under 65 years old with DRFs and associated USFs initially have greater
pain and disability than those with isolated DRFs; however, this difference dissipated over
time and was not significant at one year. No long-term differences in measured impairments
were observed, but the presence of an associated USF resulted in a slower recovery of grip
strength and wrist flexion. Presence of a USF nonunion did not significantly affect outcomes.
(J Hand Surg Am. 2014;39(10):1915e1920. Copyright Ó 2014 by the American Society for
Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Prognostic II.
Key words Distal radius fracture, functional outcome, patient-related wrist evaluation, ulnar
styloid fracture.

U
LNAR STYLOID FRACTURES (USFS)are commonly
associated with fractures of the distal radius.
Although there are numerous reports looking at
distal radius alignment as a determinant of outcome,1e27
From the Hand and Upper Limb Centre, St. Joseph’s Health Centre, London, Ontario,
Canada.
Received for publication January 31, 2013; accepted in revised form May 30, 2014.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Parham Daneshvar, MD, 1189 Melville Street, Unit 2901,
Vancouver, BC V6E 4T8; e-mail: pdane050@uottawa.ca.
0363-5023/14/3910-0004$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2014.05.032
there have been few reports on the contribution
of USFs to patient-reported pain and disability
following this injury.28e32 Previous studies have
demonstrated that the ulnar styloid is an important
attachment site for components of the triangular
fibrocartilage complex, with the dorsal and volar
radioulnar ligaments being major stabilizers of the
distal radioulnar joint (DRUJ) and attaching to the
fovea and the base of the ulnar styloid.33e37 This may
have implications on DRUJ stability, and fractures
through the base of the ulnar styloid and peripheral
tears of the TFCC may increase the risk of DRUJ
instability.28,38 Despite a rationale that suggests
ulnar styloid fracture may worsen prognosis for full

Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 1915

1916 FUNCTIONAL OUTCOME OF ULNAR STYLOID FRACTURES
TABLE 1. Patient Demographics
USF (n ¼ 142)
Age (y) 48  14 (1864)
Males (no. [%]) 43 (30%)
Dominant hand injured (no. [%]) 73 (52%)
Workers’ compensation claim (no. [%]) 9 (43%)
AO classification (no. [%])
A 94 (45%)
B 11 (48%)
C 37 (49%)
Surgical treatment for DRF 57 (38%)
functional recovery, most studies report a negligible
impact on outcomes.38e42
Previous studies may not have identified an asso-
ciation between USF and outcomes because they
may have been underpowered (Kim, n ¼ 70; Zenke,
n ¼ 118),31,32,43 and possibly because the previous
studies included elderly patients in whom it has been
shown that radiographic parameters do not relate to
outcomes (ie, age range: Kim 17-88, Souer 18-83,
Zenke 25-94).27 Additionally, if a less responsive
outcome measure is used, such as the Disabilities of
the Arm, Shoulder, and Hand (DASH) score, differ-
ences may not be detected when one exists.44
The purpose of this study was to determine whether
associated ulnar styloid fractures had a clinical effect
on patients less than 65 years old with either surgically
or nonesurgically treated DRFs. In this study the
Patient-Rated Wrist Evaluation (PRWE) score was
used to assess outcome, as it has been shown to be
highly responsive in this population.44,45 In addition,
we attempt to reduce bias by including participants
treated surgically and nonsurgically. By focusing on a
population less than 65 years old, we could evaluate
the role of ulnar styloid fractures in a population in
whom radiographic parameters have been shown to
influence outcomes.27 Our primary outcome was the
PRWE at one year. Secondary outcomes included
range of motion, grip strength, and their association
with radiographic variables such as union and location
of the USF.
We hypothesized that patients with associated
USFs would have longer recovery periods and higher
reported pain and disability.
MATERIALS AND METHODS
This was a retrospective observational study of pro-
spectively collected data involving 312 patients aged
J Hand Surg Am. r Vol. 39, October 2014
No USF (n ¼ 170) P Value
49  11 (2264) .96
51 (30%) .88
71 (43%) .78
12 (57%) .59
.91
113 (55%)
12 (52%)
39 (51%)
44 (26%) .10
18 to 64 years old who presented to a single tertiary
care center between 2004 to 2008 with a distal radius
fracture under the care of 1 of 9 fellowship-trained
hand surgeons. Only patients enrolled in the pro-
spective database with minimum one-year follow-up
were included. Participants provided informed con-
sent to have their information entered in the database.
Ethics approval was obtained from the ethics board to
use the data for this study. The follow-up protocol
involved clinic visits and outcome measurements at
3, 6, and 12 months.
In this cohort of 312 patients, 170 had isolated
DRFs and 142 had associated USFs. The patient
characteristics, fracture type, and DRF treatment for
those with and without USF were similar (Table 1).
Twenty-one patients were on Workers’ Compensation:
9 in the USF group and 12 in the isolated DRF group.
At the initial visit, all patient demographic data
were obtained. At each visit, patients were asked to
complete the PRWE. This questionnaire was used as it
evaluates both pain and disability. In addition, a
trained research assistant measured wrist range of
motion using the N-K Computerized Hand Evaluation
System (NK Biotechnical Corporation, Minneapolis,
MN) and determined the grip strength (NK Digit grip
dynamometer) at 3, 6, and 12 months post injury.
Radiographs were reviewed by 2 fellowship-trained
hand surgeons. Dorsal/volar angulation, radial incli-
nation, articular involvement, presence and location
of ulnar styloid fracture (tip, middle, or base), and type
of distal radius fracture (based on AO classification)
were noted. Patients with associated ulnar head
fractures were excluded from this study. We defined
an acceptable reduction of the distal radius fracture as
> 15 radial inclination, < 10 dorsal tilt, and ulnar
variance < þ3 mm.27
Outcomes were compared between patients with
and without an associated USF. For those with an
 FUNCTIONAL OUTCOME OF ULNAR STYLOID FRACTURES
FIGURE 1: Patient-related wrist evaluation scores for patients with and without ulnar styloid fractures including standard deviation bars.
*Statistical significance.
associated USF, we assessed whether there were any
differences in outcomes based on location and union
of the USF. A 2-tailed Student t test was used to
compare mean scores between groups, and analysis
of variance testing when greater than 2 groups were
involved. A P value of < .05 was considered sig-
nificant in this study.
RESULTS
Patient demographics
Patient demographics are demonstrated in Table 1. In
the USF group, 64 (45%) had fractures at the tip, 32
(23%) in the middle, and 46 (32%) at the base of the
ulnar styloid. Radiographic union of the ulnar styloid
was seen in 42 (34%) of the USFs. Of the tip frac-
tures, 33% healed, 35% of mid ulnar styloid fractures
healed, and 42% of base fractures healed. All USFs
were treated nonsurgically. None of the patients
were found to have significant DRUJ instability on
examination at one year.
Outcomes with and without USF
Based on PRWE scores, patients with associated
USFs had more pain and disability compared to those
with isolated DRFs at all time intervals (Fig. 1), with
differences most notable at baseline and 3 months.
The PRWE score in the USF group was 20% higher
at baseline, 26% at 3 months, 24% at 6 months, and
33% at 12 months compared with the isolated DRF
group; however, these differences were not clinically
significant (Fig. 1). At 12 months, a statistical
J Hand Surg Am.
1917
difference between PRWE scores (USF: 20  20; no
USF: 15  16, P ¼ .03) persisted; but this difference
in PRWE scores (< 5 points) was not clinically
significant.
When assessing the subset of questions related to
pain in the PRWE, a trend was demonstrated toward
increased pain in patients with associated USFs;
however, this was not statistically significant at any
of the time intervals.
Recovery of wrist flexion and grip strength was
slower for patients with associated USFs. Grip
strength was significantly lower for patients with
associated USF at 3 months (17  9 kg vs 20 kg 
12, P ¼ .02) with isolated DRFs patients having 22%
greater grip strength, but this difference was not
present from 6 months on. Wrist flexion was signif-
icantly reduced with USF at both 3 (42  18 vs 49
 14, P ¼ .03) and 6 months (50  19, vs 55  17,
P ¼ .04), with no differences seen at 12 months
(55  16, vs 57  12).
Outcomes of different levels of USF
An increase in the mean PRWE score at 6 and
12 months was seen for patients with base USFs
compared to isolated DRFs with P values of .03 and
.04, respectively (Table 2); however, this difference
did not reach clinical significance. There were no other
clinically significant differences seen when comparing
different levels of USF. When comparing tip and base
fractures at one year, the latter had a PRWE score that
was 9 points greater with a P value of .06.
r Vol. 39, October 2014
1918 FUNCTIONAL OUTCOME OF ULNAR STYLOID FRACTURES

TABLE 2. PRWE Scores comparing No USF With Different Levels of USF

Location of Ulnar Styloid Fracture
No USF Tip Middle Base
PRWE SD SD P SD P SD P

Baseline 64 18 75 12 .08 72 20 .28 76 12 .11

3 Months 30 22 38 23 .12 43 25 .03 37 24 .07
6 Months 22 20 27 18 .21 22 22 .86 30 23 .03
12 Months 15 16 15 13 .24 19 24 .11 24 23 .04

Bold P values are significant.

SD, standard deviation.

FIGURE 2: Patient-related wrist evaluation scores for united and nonunited ulnar styloid fractures including standard deviation bars.
*Statistical significance.

When assessing wrist motion and grip strength
in patients with different levels of USF no statistical
difference was seen. No correlation was found be-
tween the type of DRF and level of USF sustained.
Outcomes of USF union versus USF nonunion
In the patients with USF, nonunion did not adversely
influence functional outcomes. The improvement in
PRWE scores over time for both groups is illustrated
in Figure 2.
There were some differences in mean wrist motion
and grip strength, with the USF nonunion group per-
forming better at every instance at which differences
were present. At 3 months, wrist flexion (34  27 vs
46  13 , P ¼ .02), extension (42  14 vs 50 
12 , P ¼ .03) and pronation (67  9 vs 72  10 ,
P ¼ .04). At 6 months, the only differences were seen
in supination (60  22 vs 70  12 , P ¼ .01) and
grip strength (20 kg  9 vs 24 kg  10, P ¼ .04). At
12 months, the only difference seen was in radial de-
viation (14  5 vs 18  8 , P ¼ .02).
DISCUSSION
This study found that USFs associated with DRFs
resulted in more physical impairments, disability, and
possibly pain during the first 3 months of recovery for
adult patients under 65 years old. The effect of a USF
on pain and disability tended to dissipate over time.
Although not statistically significant, at one year after
injury, patients with an ulnar styloid base fracture had
more impairment than those with no USF, and there
was a trend towards poorer functional outcome for
base fractures compared to tip fractures.
This study demonstrated results similar to previous
studies. Souer et al30 reviewed 76 surgically treated
DRF patients ranging in age from 18 to 83 years old.

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 FUNCTIONAL OUTCOME OF ULNAR STYLOID FRACTURES
They found no difference in DASH and Short Form-
36 scores, pain, grip strength, and range of motion
between this population and a matched cohort of
patients without USF up to 2 years after injury. Zenke
et al31 reported on 118 patients, 25 to 94 years of age,
with volar locking plate fixation and found no dif-
ference in functional outcome using the DASH. Kim
et al studied 138 patients aged 17 to 88 with DRFs.43
They found no significant difference in the functional
outcome (using Modified Mayo Wrist Score and
DASH), grip strength, or range of motion after a
minimum of 1year follow-up.
This study used a large sample size of a working-
age population whereas similar studies have included
more heterogeneous and smaller numbers of patients
(30, 31, and 43). Younger adults are more physically
active, and when considering DRFs, this population
is more sensitive to malalignment and associated soft
tissue injury than older individuals.27. When consid-
ering that previous studies included older individuals,
in whom the effect of radiographic parameters would
be expected to have minimal impact, and had smaller
overall samples sizes, the effective numbers in each
subgroup may have been underpowered to find clin-
ically important differences.
In this study we used the PRWE as the primary
outcome score, which is more responsive to change
in patients with DRF than the DASH.44,45 Further-
more, the PRWE has an embedded pain scale that
comprises 50% of the score, whereas the DASH
emphasizes function with minimal emphasis on pain.
If the impact of a USF is to increase pain, the PRWE
would be more likely to detect this difference.
Consistent with previous studies,46e48 we found
that patients had high pain and disability close to the
time of injury, which improved markedly by 3 months.
By 12 months the PRWE score improved consider-
ably. The gradual improvement of wrist range of
motion and grip strength was also expected. The fact
that supination and pronation both failed to recover
also is consistent with previous studies.47
The presence of a USF may be considered as a
marker of additional bone and soft tissue injury,
which could result in greater disability. The mean
PRWE score was shown to be higher for individuals
with associated USF at all points in time, but this
was only clinically significant at baseline and notable
at 3 months. Subgroup analysis of the different levels
of USF also failed to prove any clinical significance,
although there was a trend towards worst outcome
with ulnar base fractures. When comparing ulnar
styloid base fractures to tip fractures at one year, the
base fractures had a PRWE score 9 points worse than
J Hand Surg Am.
1919
the latter; however, this was not clinically or statis-
tically significant.
In terms of wrist motion, patients with USFs
associated with DRFs exhibited more limitations at 3
and 6 months. These differences were between 4-7 ,
which is unlikely to represent a clinically important
difference. For the entire cohort, differences became
nonsignificant by 12 months. Grip strength was signif-
icantly worse in the presence of a USF during the first 3
months but this difference also dissipated by 12 months.
Patients with united USFs reported similar disability
compared to patients with nonunited fractures at all
time points. Wrist motion and grip strength were better
with a nonunited USF. The reason for this statistically
significant finding is not known. This could possibly be
due to a malunion of the USF along with its associated
soft tissue injury, leading to altered biomechanics of
the wrist.
This study is a retrospective cohort study, thereby
having some inherent limitations. The amount of USF
displacement was not assessed in this study, as we are
unaware of a validated method of quantifying this.
Another limitation of this study is that some may not
consider a 13-point difference in PRWE score as
clinically important, as some authors suggest that 14
(95% confidence interval 8-20) is the minimal clini-
cally important difference in PRWE,49 whereas others
consider 10 to be the minimal clinically important
difference.50 In addition, hand dominance was not
accounted for when assessing grip strength, which
may pose a limitation. Another potential weakness of
this study was that only patients in our database who
had at least one year follow-up were included, and this
poses a potential selection bias.
A number of design issues contribute to our ability
to demonstrate the deleterious impact of a USF. Our
limitation to adults under the age of 65 allowed us
to focus on patients who have higher functional
demand. Using the PRWE score, which is a more
wrist-specific clinical measurement tool than other
measures, provided a valid assessment function. In
addition, the large sample size in this study made it
well powered to demonstrate meaningful results for
the primary outcome.
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