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Radioulnar Synostosis Treatment & Management

  • Author: Raymond Wurapa, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: May 19, 2016
 

Approach Considerations

Indications for surgical treatment of congenital radioulnar synostosis remain somewhat controversial but are related to bilaterality and to the degree of deformity. Patients with neutral rotation, mild pronation, or rare supination positions can compensate somewhat with ipsilateral shoulder motion. Wrist hypermobility allows further functional compensation. Severe pronation deformities (specifically, >60º) cause significant functional difficulty, especially with activities requiring supination. Therefore, indications for surgery must be based more on individual functional limitations than on absolute forearm position.

It is recommended that surgery be performed in childhood before patients reach school age. In patients with symptomatic subluxation of the radial head, the radial head may be excised at maturity. Appropriate workup includes plain radiography performed in orthogonal planes (eg, posteroanterior [PA] and lateral views).

The indication for surgery in posttraumatic radioulnar synostosis is functional limitation of forearm rotation. This limitation must be assessed on an individual basis. An appropriate workup includes taking plain radiographs in orthogonal (eg, PA and lateral) planes.

Surgery should be performed after the synostosis has matured and distinct radiographic borders are observed, so as to decrease the likelihood that the synostosis will recur. Waiting more than 3 years, however, has adversely affects final outcome, probably because of soft-tissue contracture. A 100º arc of motion is desired so that the patient can perform all activities of daily living, and a 60º arc is required to perform most activities of daily living without assistance.

The only contraindication for surgical correction is the presence of milder deformity in an older patient, if the patient has only minimal functional deficit and has already made adjustments in his/her activities to accommodate the synostosis.

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Surgical Therapy

Attempts to achieve and maintain motion at the synostosis site usually are not successful. Synostosis typically recurs despite excision, the use of various medications, or the interposition of silicone, fat, or muscle. However, success has been reported with excision of the bony bridge and the interposition of vascularized fat graft, with an average rotation range of 74º being maintained at 2 years after surgery.[22]

Some mobilization procedures are combined with tendon transfers to achieve supination. The flexor carpi ulnaris can be transferred dorsally around the ulna, and the extensor carpi radialis longus can be transferred to the volar aspect of the wrist. Overall, the preferred surgical procedure has been osteotomy and derotation through the fusion mass, along with fixation with transcutaneous pins.[23, 24, 25]

The optimal position of correction varies according to the degree of involvement, the bilaterality of the synostosis, and the amount of compensatory shoulder or radiocarpal motion that the patient has. Severe deformities do not allow one-stage correction, because of the tension on vascular and fibrous structures. Gradual correction using a multiplanar external fixator decreases the risk of neurovascular compromise and allows the patient to select the most functional position.

Reports of the optimal correction position vary. In general, neutral rotation is used for unilateral deformities; for bilateral deformities, one side is placed in 20-30º of pronation and the other in 20-30º of supination.[26] Shortening of the forearm to decrease the risk of neurovascular compromise has also been recommended.

A long arm cast with 90º of elbow flexion is utilized postoperatively for 8 weeks. Transcutaneous pins are recommended for fixation after derotation. Unlike techniques that require open operative exposure, this pinning can easily be reversed if postoperative vascular compromise develops.[7, 27]

Simcock et al described the use of derotational osteotomy to treat 31 forearms in 26 children with congenital radioulnar synostosis and functional limitations.[28]  In all cases, union was successfully achieved by 8 weeks. No instances of compartment syndrome, vascular compromise, or loss of fixation occurred. The overall rate of complications was 12%, including two transient anterior interosseous nerve palsies (both in patients with rotational corrections >80º), one transient radial nerve palsy, and one symptomatic muscle herniation.

Hwang et al studied the use of one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection to treat congenital radioulnar synostosis in 25 patients (28 forearms).[29] In group 1, the ulnar osteotomy was stabilized with an intramedullary pin, whereas in group 2, no fixation was used. Surgical outcomes did not differ significantly between the two groups. The authors concluded that one-stage rotational osteotomy of the proximal third of the ulna and distal third of the radius with segmental bone resection is simple and safe in this setting and that internal fixation at the osteotomy site seems to be unnecessary.

In contrast to surgery for congenital radioulnar synostosis, surgery for the posttraumatic form of the condition restores motion through excision of the synostosis area.[4, 5, 30] Numerous interposition materials—including fat, muscle, fascia, silicone, and cellophane—have been proposed for use after resection to prevent a recurrence of synostosis, but these have met with varying degrees of success. Kelikian and Doumanian developed a metallic swivel prosthesis to restore motion, but no large series has been reported that supports its effectiveness.[31]

The goal of treatment, regardless of what interpositional material is used, involves resection of the entire bony synostosis. Careful dissection with minimal periosteal disruption prevents the further stimulation of bone, limiting recurrence. Identification and protection of neurovascular structures is essential, and the final range of motion should be assessed intraoperatively. Minimal postoperative immobilization is recommended.

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Complications

Although the surgical procedure that is used to treat congenital radioulnar synostosis is not exceedingly difficult, it is associated with significant complications,[32] including neurovascular compromise and recurrence of ankylosis. The limiting factor for derotation is soft-tissue contracture and neurovascular compromise. Simmons et al recommended that derotations of more than 85º be performed in two stages.[21] A low threshold for fasciotomies should be maintained for suspected compartment syndromes.

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Contributor Information and Disclosures
Author

Raymond Wurapa, MD Consulting Surgeon in Orthopedics, Orthopedic ONE

Raymond Wurapa, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Medical Association, American Society for Surgery of the Hand, Ohio State Medical Association, Ohio Orthopaedic Society, Columbus Orthopaedic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

N Ake Nystrom, MD, PhD Associate Professor of Orthopedic Surgery and Plastic Surgery, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

A Lee Osterman, MD Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

References
  1. Wang E, Wenger DR, Zhang L, Zhao Q, Ji S, Li J. The mechanism of acute elbow flexion contracture in children with congenital proximal radioulnar synostosis. J Pediatr Orthop. 2010 Apr-May. 30(3):277-81. [Medline].

  2. Shinohara T, Horii E, Tatebe M, Yamamoto M, Okui N, Hirata H. Painful snapping elbow in patients with congenital radioulnar synostosis: report of two cases. J Hand Surg Am. 2010 Aug. 35(8):1336-9. [Medline].

  3. Sachar K, Akelman E, Ehrlich MG. Radioulnar synostosis. Hand Clin. 1994 Aug. 10(3):399-404. [Medline].

  4. Hanel DP, Pfaeffle HJ, Ayalla A. Management of posttraumatic metadiaphyseal radioulnar synostosis. Hand Clin. 2007 May. 23(2):227-34, vi-vii. [Medline].

  5. Watson FM Jr, Eaton RG. Post-traumatic radio-ulnar synostosis. J Trauma. 1978 Jun. 18(6):467-8. [Medline].

  6. Mital MA. Congenital radioulnar synostosis and congenital dislocation of the radial head. Orthop Clin North Am. 1976 Apr. 7(2):375-83. [Medline].

  7. Dawson HG. A congenital deformity of the forearm and its operative treatment. Br Med J. 1912. 2:833-5.

  8. Hansen OH, Andersen NO. Congenital radio-ulnar synostosis. Report of 37 cases. Acta Orthop Scand. 1970. 41(3):225-30. [Medline].

  9. Kelikian H. Congenital deformities of the hand and forearm. Philadelphia, Pa: WB Saunders; 1974.

  10. Lewis WH. The development of the arm in man. Am J Anat. 1901. 1:145-83.

  11. Miura T, Nakamura R, Suzuki M. Congenital radio-ulnar synostosis. J Hand Surg [Br]. 1984 Jun. 9(2):153-5. [Medline].

  12. Spritz RA. Familial radioulnar synostosis. J Med Genet. 1978 Apr. 15(2):160-2. [Medline].

  13. Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg. 1991. 110(3):142-5. [Medline].

  14. Henket M, van Duijn PJ, Doornberg JN, et al. A comparison of proximal radioulnar synostosis excision after trauma and distal biceps reattachment. J Shoulder Elbow Surg. 2007 Sep-Oct. 16(5):626-30. [Medline].

  15. Garland DE, Dowling V. Forearm fractures in the head-injured adult. Clin Orthop Relat Res. 1983 Jun. (176):190-6. [Medline].

  16. Sauder DJ, Athwal GS. Management of isolated ulnar shaft fractures. Hand Clin. 2007 May. 23(2):179-84, vi. [Medline].

  17. Cleary JE, Omer GE. Congenital proximal radio-ulnar synostosis. Natural history and functional assessment. J Bone Joint Surg Am. 1985 Apr. 67(4):539-45. [Medline].

  18. Jaffer Z, Nelson M, Beighton P. Bone fusion in the foetal alcohol syndrome. J Bone Joint Surg Br. 1981. 63B(4):569-71. [Medline]. [Full Text].

  19. Giuffre L, Corsello G, Giuffre M, et al. New syndrome: autosomal dominant microcephaly and radio-ulnar synostosis. Am J Med Genet. 1994 Jul 1. 51(3):266-9. [Medline].

  20. Wilkie DP. Congenital radio-ulnar synostosis. Br J Surg. 1914. 1:366-75.

  21. Simmons BP, Southmayd WW, Riseborough EJ. Congenital radioulnar synostosis. J Hand Surg [Am]. 1983 Nov. 8(6):829-38. [Medline].

  22. Sonderegger J, Gidwani S, Ross M. Preventing recurrence of radioulnar synostosis with pedicled adipofascial flaps. J Hand Surg Eur Vol. 2011 Oct 10. [Medline].

  23. Ogino T, Hikino K. Congenital radio-ulnar synostosis: compensatory rotation around the wrist and rotation osteotomy. J Hand Surg [Br]. 1987 Jun. 12(2):173-8. [Medline].

  24. Khalil I, Vizkelety T. Osteotomy of the synostosis mass for the treatment of congenital radio-ulnar synostosis. Arch Orthop Trauma Surg. 1993. 113(1):20-2. [Medline].

  25. El-Adl W. Two-stage double-level rotational osteotomy in the treatment of congenital radioulnar synostosis. Acta Orthop Belg. 2007 Dec. 73(6):704-9. [Medline].

  26. Green WT, Mital MA. Congenital radio-ulnar synostosis: surgical treatment. J Bone Joint Surg Am. 1979 Jul. 61(5):738-43. [Medline].

  27. Smith RJ, Lipke RW. Treatment of congenital deformities of the hand and forearm (second of two parts). N Engl J Med. 1979 Feb 22. 300(8):402-7. [Medline].

  28. Simcock X, Shah AS, Waters PM, Bae DS. Safety and Efficacy of Derotational Osteotomy for Congenital Radioulnar Synostosis. J Pediatr Orthop. 2015 Dec. 35 (8):838-43. [Medline].

  29. Hwang JH, Kim HW, Lee DH, Chung JH, Park H. One-stage rotational osteotomy for congenital radioulnar synostosis. J Hand Surg Eur Vol. 2015 Oct. 40 (8):855-61. [Medline].

  30. Failla JM, Amadio PC, Morrey BF. Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment. J Bone Joint Surg Am. 1989 Sep. 71(8):1208-13. [Medline].

  31. Kelikian H, Doumanian A. Swivel for proximal radioulnar synostosis. J Bone Joint Surg. 1957. 39:945-51.

  32. Hankin FM, Smith PA, Kling TF Jr, et al. Ulnar nerve palsy following rotational osteotomy of congenital radioulnar synostosis. J Pediatr Orthop. 1987 Jan-Feb. 7(1):103-6. [Medline].

 
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Radioulnar synostosis occurs as either congenital or posttraumatic condition.
Degree of fusion in radioulnar synostosis varies and may or may not involve radial head.
 
 
 
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