scenario based presentation on radio-ulnar synostosis

1. Presented by :
Ahmed Reda Noaman
Orthopedic Surgery Resident (R3)
Abdallah Jomaa El Azanki
Orthopedic Surgery As. Lecturer
Mansoura Orthopedic Club
Cedar Tree of
Lebanon
Radio-Ulnar Synostosis
Scenario Based Presentation
JAN 2019

2.  Male , 44 years old
 Shoe maker
 Complaint : Inability to rotate his forearm
R

3. History :
 RTA in 2016
 Open GII fracture RT Proximal Ulna Plating ( MUH-ER )
 Delayed fixation 10 days after the admission
 AES for 2 months Post-Operative

4. Examination:
 Shoulder:
Decreased ER
Elbow :
FLEX & EXT NAD
IR & ER NON
 Wrist / Hand :
NAD

5. X-rays

6. CAT Scan

7. Presentation

8. Definition
 Bony bridge between the radius & ulna
Embryology
 Forearm begins as a single cartilaginous anlage and divides from distal to
proximal into the radius and ulna in the 7th week in uterus
 Failure of differentiation results in synostosis in proximal aspect of the forearm

9. Epidemiology (congenital )
 Male > female (3:2)
 60% Bilateral
 30% associated with other syndromes
 20% with positive family history

10. Synostosis
History
Congenital Acquired
Trauma ?!
Details matters

11. 1. Both bone forearm fractures - same level ??
2. Open fracture ??
3. Significant soft-tissue lesion ??
4. Comminuted fracture??
5. High energy fracture (MOT) ??
6. Associated head trauma ??
7. Bone fragments on the interosseous membrane ??
8. Monteggia fracture ?!
Preop. Hx Investigation (8Q) :
Single bone (ulna #)
Open G||
Not Evident
Suspecting simple or wedge #
RTA, with multi-trauma Hx
Query , Couldn't go to Archive
NO
Possible , by card U/3 ulna!!
Vince KG et al, 1987

12. 1. One incision for both radius & ulna ?!
2. Surgery Delay (> 2 weeks) ?!
3. Any screws penetrate interosseous membrane?
4. Bone grafting ??
5. Prolonged immobilization ??
Postop. Hx Investigation (5Q) :
1 inc. for ULNA
Surgery 10 days after admission
NO
3 proximal Screws
BIG YES, 2 months in AES
Vince KG et al, 1987

13. How to manage ?!

15. Vince & Miller Classification for the Post-Traumatic
R-U Synostosis
IIIA S.at the level of or distal to the bic. Tuber.
IIIB S. at the radial H. & the proximal radioulnar
Joint
IIIC heterotopic bone that extends across the
elbow
Our Case

16. Extra points with Hx:
 Hand dominance
 Occupation
 Recreational activities ( patient’s expectations and functional demands )
Position of the forearm :
 Fixed pronation ( associated with much less function)
 Fixed supination
Our Case
Most positional and functional tasks can be achieved within a
rotation arc of 100° (50° of pronation and 50° of supination)
Morrey et al 1981

17.  Low-demand patients
 Recurrence following multiple attempts at resection
 Unable to tolerate additional procedures
 Functional forearm position
 Unwilling to accept the risks of surgery.
Nonsurgical management candidates

18. When to Excise?
 Historically, it was advised to monitor the synostosis until
maturation before performing resection.
 Maturation was assessed with serial bone scans and
alkaline phosphatase levels
 Best results been obtained when resection is performed
between 1 and 2 years after injury

19.  It is no longer advisable to wait (12 months) to confirm
that the synostosis has fully matured
 Early resection ( between 6 and 12 months ) has been
performed safely without an increase in recurrence
 Use the approach that allows for the safest and most
direct access to the synostosis.

20. Distal synostoses:
Interval btw FCU & ECU muscles is used. Care is required
to avoid the superficial sensory branch of the ulnar nerve.
Diaphyseal radioulnar synostoses Excision is performed using
the volar Henry approach.
Proximal based synostoses Excised using the lateral Kocher
interval ( anconeus and ECU). Care to avoid injury to the posterior
interosseous nerve.

21. Principles of surgery:
 Removal of hardware
 Complete synostosis excision (cartilaginous & osseous )
 With / without interposition of biologic or synthetic materials

22.  Synthetic and biologic interposition is to prevent recurrence
and minimize scar formation.
 Materials used
 Fascia
 Muscle
 Bone wax
 Silicone
 Polyethylene
Free nonvascularized fat interposition is no longer
recommended because of the risk of dislodgment.

23.  Fascia Lata interposition after synostos
 Mean improvement in forearm rotation of 115°
 Mean follow-up of 30 months
 Allograft fascia lata is preferred
Friedrich JB et al 2006

24. Prophylaxis after S. excision
 Indomethacin 25 mg three times per day for 6 weeks
 Radiation therapy (external beam radiation therapy dose is typically a
single fraction of 7 Gy)
 Early Rehabilitation

25. Rehabilitation
 Active and passive ROM exercises are begun on the first
day postoperative under the supervision of a therapist.
 Bracing

26. After primary resection 6% to 35% of patients
Degree of soft-tissue trauma (prior recurrence)
Associated traumatic brain injury
Recurrence
 Patients with recurrent synostosis
 Pedicled vascularized flexor carpi ulnaris
 Brachioradialis muscle flap
 Vascularized Fascias
 Wrapped around the bone, and sutured onto itself
Fernandez DL et al, 2004

27.  Post-traumatic radioulnar synostosis is an uncommon complication
following injury to the forearm and elbow.
 Literature consists mostly of level IV retrospective case studies and
case reports.
 Predisposing risk factors are related to either the initial injury or the
surgical technique.
TAKE HOME MESSAGE

28.  Initial management should be focused on maintaining
adjacent joint motion and preventing soft-tissue contractures.
 Nonsurgical measures should not be prolonged in patients with
joint ankylosis
 Preoperative imaging should include plain radiographs and a CAT
scan to appreciate the complex anatomy & H.O maturation

29. THANK YOU