Resect Ulnar Styloid Fracture with Repair of Triangular Fibrocartilage Complex

Symptomatic nonunion of the ulnar styloid with and without instability of the distal radioulnar joint (DRUJ)
Patients should be warned of persistent instability of the DRUJ in spite of triangular fibrocartilage complex (TFCC) repair.

Zigzag incision along ulnar border of the hand and wrist. The incision begins 1 cm distal to the ulnar styloid and extends to the subcutaneous border of the ulna, palmar to the extensor carpi ulnaris (ECU) tendon sheath (Fig. 14-1).

Figure 14-1

Avoid the dorsal cutaneous branch of ulnar nerve that passes obliquely between the ulnar styloid and pisiform.

Expose with subperiosteal dissection the ulnar aspect of the ulnar head and metaphysis. Do not open the ECU subsheath.
Open the ulnar aspect of the ulnocarpal joint capsule.
Expose and resect the nonunited ulnar styloid (Fig. 14-2).
Assess the stability of the DRUJ with the forearm in neutral, supination, and pronation.
If the styloid fragment is small and DRUJ is stable in all positions close the capsule and skin.
If the styloid fragment is large or if the DRUJ is lax, use a no. 15 blade knife to create a plane between the TFCC and the head and the TFCC and the joint capsule.
Place two throws with a 2-0 PDS suture on a UCL needle through the ulnar margin of the TFCC (Fig. 14-3).
Remove a 21 gauge needle from its plastic hub and place into a drill chuck. Drill the needle from the ulnar aspect of the ulnar metaphysis into the fovea of the distal ulna (Fig. 14-4A,B).
Pass the suture through the needle and retrieve at the level of the metaphysis (Fig. 14-4B).
Tie the suture ends with the forearm in neutral rotation. Use the same suture to close the joint capsule.
Close subcutaneous tissue and skin.