[Surgical treatment of the ulnar styloid process using an angle-stable hook plate in fractures and symptomatic nonunions]

Is surgery superior for distal ulna fractures? a comprehensive systematic review and meta-analysis

BACKGROUND

The management of distal ulna fractures remains a subject of considerable debate within orthopedic practice. This systematic review and meta-analysis aims to evaluate the efficacy of surgical versus non-surgical management strategies for distal ulna fractures and their impact on functional outcomes.

METHODS

This study followed PRISMA guidelines and involved a systematic search of databases like PubMed, Scopus, and Web of Science for relevant studies published in English up to December 2023. The search included keywords such as "ulnar styloid fracture", "non-surgical management", "surgical management", and "treatment outcomes". Studies were selected based on predefined inclusion and exclusion criteria, and data were extracted on patient demographics, fracture characteristics, treatment details, functional outcomes, patient-reported outcomes, complications, and follow-up duration. The methodological quality of included studies was assessed using the GRADE system. The meta-analysis used standardized mean differences for continuous outcomes and log odds ratios for dichotomous outcomes.

RESULTS

The initial search yielded 1253 studies, which were narrowed down to 12 studies suitable for review after removing duplicates and irrelevant articles. These studies included a total of 709 patients, with 422 receiving non-surgical management and 287 undergoing surgical treatment. The results showed no significant differences in grip strength, DASH score, or VAS score between surgical and non-surgical management. However, a higher union rate was observed with surgical management.

LIMITATIONS

The moderate quality of the included studies and the moderate to high heterogeneity among them are noted as limitations, indicating a need for more standardized research methodologies in this area.

CONCLUSIONS

While surgical management may offer a higher union rate, the choice of treatment should be individualized, balancing the potential benefits against the risks of surgery, as ORIF implants are typically associated with higher ulnar-sided pain rates and limited ulnar deviation due to implant prominence. Future research should focus on standardizing study designs to improve the quality of evidence in the management of distal ulna fractures.

LEVEL OF EVIDENCE I

Evidence from a meta-analysis and systematic review from all relevant studies.

Surgical fixation of distal ulna neck and head fractures

OBJECTIVES

Distal ulna plate fixation for ulnar neck and head fractures (excluding ulnar styloid fractures) aims to anatomically reduce the distal ulna fracture (DUF) by open reduction and internal fixation, while obtaining a stable construct allowing functional rehabilitation without need for cast immobilization.

INDICATIONS

Severe displacement, angulation or translation, as well as unstable or intra-articular fractures. Furthermore, multiple trauma or young patients in need of quick functional rehabilitation.

CONTRAINDICATIONS

Inability to surgically address concomitant ipsilateral extremity fractures, thus, limiting early active rehabilitation. Stable, nondisplaced fractures. Need for bridging plate or external fixator of distal radiocarpal joint.

SURGICAL TECHNIQUE

An ulnar approach, with a straight incision between the extensor and flexor carpi ulnaris. Preservation of the dorsal branch of the ulnar nerve. Reduction and plate fixation with avoidance of plate impingement in the articular zone.

POSTOPERATIVE MANAGEMENT

Postoperatively, an elastic bandage is applied for the first 24-48 h. In isolated DUF with stable fixation, a postoperative splint is often unnecessary and should be avoided. For the first four weeks, only light weightbearing of everyday activities is allowed to protect the osteosynthesis. Thereafter, heavier weightbearing and activities are allowed and can be increased as tolerated.

RESULTS

The best available evidence likely shows that for younger patients with a DUF, with or without concomitant distal radius fractures, open reduction and internal fixation can be safely achieved with good functional outcome and acceptable union and complication rates as long as proper technique is ensured.