**Ulna Fracture in Adults: Non-Operative vs. Operative Treatment and Modern Fixation Techniques**
Ulna Fracture in Adults: Non-Operative Treatment
Ulna fractures—whether isolated (nightstick fractures) or part of complex forearm injuries—are common orthopedic injuries in adults. While some heal well with conservative care, others demand surgical intervention to restore forearm rotation, grip strength, and daily function. This comprehensive review compares **non-operative and operative approaches** for adult ulna fractures and details the **most effective fixation methods** used today—helping patients and clinicians make informed, evidence-based decisions.
---
### Understanding Ulna Fractures: Types and Mechanisms
The ulna is the stabilizing bone of the forearm, running from the elbow to the wrist. Fractures commonly occur due to:
- **Direct blows** (e.g., “nightstick fracture” – isolated midshaft ulna fracture from blocking a strike)
- **Falls on an outstretched hand** (often with radius involvement)
- **High-energy trauma** (motor vehicle accidents, sports injuries)
Fractures are classified by:
- **Location**: proximal (olecranon), shaft, or distal (ulnar styloid)
- **Pattern**: transverse, oblique, spiral, or comminuted
- **Association**: isolated vs. **Monteggia injury** (ulna fracture + radial head dislocation)
Treatment hinges on **displacement, stability, and associated injuries**.
---
### Non-Operative Treatment: When It Works
Non-surgical management is appropriate for:
- **Isolated, non-displaced or minimally displaced ulna shaft fractures** (<50% displacement, <10° angulation)
- **Stable fractures with intact proximal/distal radioulnar joints**
- **Low-demand or elderly patients** with comorbidities
#### Protocol:
- **Long arm cast or functional brace** for 4–6 weeks
- **Early elbow and wrist motion** (within pain limits) to prevent stiffness
- **Serial X-rays** at 1, 2, and 6 weeks to monitor alignment
#### Outcomes:
- Union rates exceed **90%** in stable, non-displaced fractures
- Most patients regain near-normal forearm rotation and grip strength
#### Risks of Non-Operative Care:
- **Malunion**: Angulation or shortening → loss of forearm rotation (pronation/supination)
- **Nonunion**: Rare in isolated fractures (<5%) but higher in smokers or diabetics
- **Chronic pain or weakness** if alignment is poor
> ⚠️ **Red Flag**: Any ulna fracture with **elbow or wrist instability** requires urgent evaluation for **Monteggia or Essex-Lopresti injury**—both surgical emergencies.
---
### Operative Indications: When Surgery Is Essential
Surgical fixation is recommended for:
- **Displaced ulna shaft fractures** (>50% displacement or >10° angulation)
- **Open fractures**
- **Floating elbow or forearm** (concomitant humerus or radius fracture)
- **Neurovascular compromise**
- **Polytrauma patients** needing early mobilization
- **Failed conservative treatment** (progressive displacement)
Surgery restores anatomy, prevents malunion, and enables faster functional recovery.
---
### Surgical Fixation Methods: Options and Outcomes
#### 1. **Compression Plating (3.5 mm DCP or LCP)**
- **Gold standard** for most displaced ulna shaft fractures
- **Technique**: Open reduction + plate applied to the **subcutaneous border** (posterior aspect)
- **Advantages**:
- Anatomical reduction
- Immediate stability
- Early mobilization
- **Plate Types**:
- **Dynamic Compression Plate (DCP)**: Allows interfragmentary compression
- **Locking Compression Plate (LCP)**: Superior in osteoporotic bone or comminuted fractures
- **Outcomes**: Union rates >95%, with full forearm rotation in 85–90% of cases
#### 2. **Intramedullary Nailing**
- **Indications**: Simple transverse or short oblique midshaft fractures
- **Technique**: Minimally invasive; nail inserted through olecranon or distal ulna
- **Advantages**:
- Less soft tissue dissection
- Lower infection risk
- Cosmetic benefit (small incisions)
- **Limitations**:
- Poor control of rotation in oblique/comminuted fractures
- Risk of elbow stiffness if entry point is intra-articular
- **Best for**: Young, active patients with simple fracture patterns
#### 3. **Minimally Invasive Plate Osteosynthesis (MIPO)**
- **Technique**: Plate inserted through small incisions, reduced percutaneously
- **Advantages**:
- Preserves fracture hematoma and blood supply
- Reduces risk of nonunion
- Less postoperative pain
- **Ideal for**: Comminuted fractures where soft tissue preservation is critical
#### 4. **External Fixation (Temporary or Definitive)**
- **Indications**:
- Severe open fractures with soft tissue loss
- Temporary stabilization in polytrauma
- **Limitations**: Pin-site infections, poor patient compliance, limited stability
- **Rarely used definitively** for isolated ulna fractures
---
### Complications: A Comparative Overview
| Complication | Non-Operative | Operative |
|-------------|----------------|-----------|
| **Nonunion** | 5–10% (displaced) | <2% |
| **Malunion** | Common (angulation) | Rare with plating |
| **Infection** | None | 1–3% (higher in open fractures) |
| **Hardware irritation** | None | 10–15% (often requires removal) |
| **Nerve injury** | Rare | Ulnar nerve risk (proximal fractures) |
| **Stiffness** | Elbow/wrist if immobilized too long | Rare with early motion |
> 💡 **Key Insight**: Hardware removal is needed in **15–20% of plated ulna fractures** due to subcutaneous prominence—but this rarely affects long-term function.
---
### Rehabilitation Protocol
- **Non-Operative**:
- Cast/brace × 4–6 weeks
- Passive elbow/wrist motion after 1–2 weeks
- Strengthening at 6–8 weeks
- Full activity by 12 weeks
- **Operative**:
- Sling × 1 week
- **Elbow and wrist motion within 3–5 days**
- Light strengthening at 6 weeks
- Return to manual labor/sports at 10–12 weeks
Surgical patients typically regain **forearm rotation 4–6 weeks faster** than non-operative counterparts.
---
### Evidence-Based Recommendations
- **Isolated, non-displaced ulna fracture**: Non-operative care is safe and effective.
- **Displaced shaft fracture**: **Compression plating** offers the best functional outcomes.
- **Comminuted fractures**: **LCP or MIPO** preserves biology and ensures stability.
- **Proximal (olecranon) fractures**: Tension band wiring or plate fixation based on pattern.
- **Distal ulna fractures**: Often managed non-operatively unless part of DRUJ instability.
A 2022 meta-analysis in *Injury* confirmed that **operative fixation of displaced ulna fractures significantly improves union rates, reduces malunion, and accelerates return to work**—with acceptable complication profiles.
---
### Final Thoughts
Ulna fractures in adults require a **tailored approach** based on fracture pattern, patient demands, and associated injuries. While conservative treatment suffices for stable injuries, **surgical fixation is superior for displaced or unstable fractures**—restoring anatomy, function, and quality of life.
At BoneFractures.org, we believe that informed decisions—guided by evidence, expertise, and patient goals—lead to the best recovery outcomes.
*— Written by Dr. Attia, Orthopedic consultant*
*Published on BoneFractures.org – Your trusted source for evidence-based fracture care and recovery.*
---
