Study shows earlier return of function, fewer complications

In adults, isolated ulnar shaft fractures (IUSF) associated with a direct blow—also known as “nightstick fractures”—are uncommon, and opinions on treatment regimens vary widely.

“The majority of ulnar nightstick fractures are treated nonsurgically,” said Clifford B. Jones, MD. “Historically, benign neglect or nonsurgical treatment produced good results with early return to function and high healing rates.”

In comparing surgical and nonsurgical outcomes for these fractures, however, Dr. Jones and his fellow researchers found that nonsurgical treatment of IUSF is prone to complications and is associated with malunion and nonunion (Table 1). Their data also revealed that surgical treatment with rigid plate fixation and early range of motion leads to earlier return of function.

The cohorts
The retrospective analysis included 70 consecutive patients diagnosed with IUSF who were treated at a Level I teaching trauma center between 2002 and 2008. Surgeon discretion determined treatment; therefore, the simplest nondisplaced fractures were commonly treated nonsurgically. The average follow-up was 12 months.

The surgical cohort consisted of 37 patients (19 males; 18 females), with a mean age of 46 years (range: 19 to 86 years). Treatment methods included standard and locking plates. Most patients (43.4 percent) were treated with 2.7 mm DC-plates. Surgery on closed fractures was performed, on average, after a trial immobilization period of 3 days.

The nonsurgical cohort included 33 patients (15 males; 18 females) with similar demographics. Patients were treated with a brace (36.4 percent), long-arm cast (30.3 percent), short-arm cast (21.2 percent), or sling (12.1 percent). Within the nonsurgical cohort, 20 patients (60.6 percent) had sustained isolated ulnar fractures.

Injuries in both treatment groups were primarily midshaft fractures resulting from high-energy injuries (85.7 percent), low-energy falls (11.4 percent), and sports injuries (2.9 percent); 14 percent of the injuries were open fractures. Of the 70 patients, 13 had sustained multiple injuries, in addition to the ulnar fracture.

Interpreting the data
Researchers reported that clinical results and functional outcomes, including healing time, range of motion, level of activity, and pain were similar in the two treatment groups and that most patients achieved full recovery. Pain, however, was related to an inferior functional result. Age, body mass index, gender, treatment, and injury severity did not relate or independently contribute to these clinical or functional outcomes.

Complications of malunion and nonunion were influenced by fracture location and angulation, respectively. Proximal fractures contributed to the development of malunion (p = 0.002), but not to nonunion, which was defined as angulation equal to or greater than 10 degrees at final follow-up (Fig. 1). Nonunion was also associated with age (older than 50 years), female gender, and noncompliance with weight-bearing restrictions (Fig. 2).

Malunion and nonunion were major contributors to morbidity and were more predominant in the nonsurgical treatment group. Nonsurgical treatment was also associated with higher incidences of treatment conversion and secondary displacements ( > 2 mm).

“When looked at retrospectively, the results of nonsurgical treatment were far from good,” Dr. Jones said. “Patients treated in this fashion had the highest rate of nonunion and complications with angulation, pain, and delayed surgery—which delays recovery.”

Surgical treatment with rigid plate fixation and early range of motion resulted in a shorter period of cast immobilization and an earlier return to weight bearing, and led to reduced patient morbidity.

The researchers admit that the study’s subgroup analysis was underpowered and that randomization in predefined groups of surgical or nonsurgical treatment is preferred. They also recommend caution in generalizing the results, because this was a single center study involving patients of lower socioeconomic status with a high loss of follow-up.

“Results of 70 Consecutive Ulnar Nightstick Fractures” was presented by Marlon O. Coulibaly, MD, at the 2010 annual meeting of the Orthopaedic Trauma Association (OTA). Other coauthors of the paper include Debra L. Sietsema, PhD; James R. Ringler, MD; and Terrence J. Endres, MD.

Bottom line

• Isolated ulnar shaft fractures may be treated surgically or nonsurgically.
• This small, retrospective study found nonsurgical treatment is prone to more complications.
• It also found that surgical treatment with rigid plate fixation and early range of motion is associated with an earlier return to function.

Disclosures: Drs. Jones and Endres—AONA; Dr. Sietsema—Eli Lilly, Inc.; the other authors report no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org