I have a painful wrist problem called impaction syndrome. The X-rays showed that the tip of my ulnar bone is too long so it’s smacking up against the bones in the wrist. The first surgeon I saw says she can shave down the tip of that bone or remove part of it or all of it. The second surgeon I went to said, no he would just remove a piece of the bone and collapse it down so it would be more natural. Do you think it matters how it is done?

It sounds like you have a condition called ulnar styloid impaction syndrome by its full name. This refers to a condition causing wrist pain because there is a short ulna (one of the two bones of the forearm) and a long styloid.

The styloid is a piece of bone at the end of the ulna that makes the ulna look longer on one side compared to the other. The styloid is a normal feature of the ulnar bone but when it is too long, it presses against the bones of the wrist. In particular, the triquetrum bone in the wrist gets compressed.

The contact point between the too-long tip of the ulnar styloid and the triquetrum (wrist) bone starts to get inflamed and swell up. There can be bone bruising and bone edema as well. Pain along the ulnar side of the wrist is a hallmark finding. But the diagnosis can be difficult to make. Imaging studies such as MRIs and CT arthrography may be needed to see if there is any soft tissue damage that could cause the same or similar symptoms.

Treatment ranges from conservative (nonoperative) care with antiinflammatories and hand therapy to surgery. There are several different types of surgical procedures that can be used.

As the first surgeon mentioned, the surgeon can shave down (decompress) or remove the styloid tip (stylectomy) altogether. Whether a partial or complete stylectomy is done, the surgeon makes every effort to save the ligaments holding everything together.

Surgeons may try other approaches such as the osteotomy procedure suggested by the second surgeon you saw. In any osteotomy procedure, the surgeon cuts out a wedge- or pie-shaped piece of bone from the styloid side of a bone.

Removing this piece of bone allows the surgeon to collapse the remaining pieces of the bone together, effectively shortening the bone while still preserving the natural shape of the bone. With ulnar impaction syndrome, an oblique osteotomy may be preferred. An oblique osteotomy procedure is done at an angle (on the diagonal) rather than straight across. After the piece of bone is removed, a pin is used to hold everything together until healing occurs.

A recent series study of five patients who had an oblique ulnar styloid osteotomy (OUSO) for the treatment of ulnar styloid impaction syndrome showed that this can be a successful and effective approach. Patients must be selected carefully to make sure the diagnosis is accurate.

If there is soft tissue damage from ligamentous instability, an osteotomy may not be the best choice. For those individuals with intact ligament attachments, the oblique osteotomy does not disrupt but rather preserves the soft tissues and maintains joint stability. That is a unique and important feature of this particular procedure.

Whichever surgeon you choose to go with just make sure you are a good candidate for the procedure recommended. Don’t hesitate to ask what makes the proposed surgery the best choice for you. You can also ask how many of these procedures the surgeon has performed, the success and failure rates, and any complications you might experience. Comparing the information about these two proposed procedures may help you solve the question of which one is best for you.