forearm reconstruction after sequalae of chronic osteomyelitis in children

1. FOREARM RECONSTRUCTION
AFTER SEQUELAE OF
CHRONIC OSTEOMYELITIS

2. INTRODUCTION
 Radius & ulna- rare sites for haematogenous
osteomyelitis in children (<3%)
 More rarely can be following forearm
fracture, child abuse, animal bites and
venous cannulation
 Occasionally, part of multifocal sepsis
 The infection usually involves the
metaphyses and can destroy the whole bone
 Primary epiphyseal involvement has also
been reported
 Periosteal stripping and thrombosis of the
nutrient vessels result in bone destruction
and pus formation

3. PRESENTATION
 The acute infection presents with
 fever,
 pain,
 swelling,
 pseudoparalysis and
 occasionally, a compartment syndrome.
 Chronicity may occur resulting in a
 pathological fracture,
 sequestrum formation,
 discharging sinuses and
 pseudarthrosis.

4. COMPLICATIONS & DEFORMITIES
 Weakness of grip, shortening and a cosmetic
deformity - due to continuing growth of the intact
bone.
 Osteomyelitis of radius with large defect ->
overgrowth of ulna -> dislocation of the distal
radioulnar joint, radial deviation of the hand and
weakness of grip.
 Radial club hand type of deformity may occur with
extensive defects
 Defects of the ulna shaft can result in cubitus varus
deformity, curvature of the intact radius and
consequent dislocation of the radial head resulting in
instability of the elbow and a cosmetic deformity
 Posterior interosseous palsy may result
 Deficiency of the proximal radius results in a cubitus
valgus deformity and curvature of the ulna

5. METHODS USED TO RECONSTRUCT THE
FOREARM
 Cancellous bone grafting
 Strut grafts for shaft defects
 Radioulnar synostosis for larger defects with
joint involvement
 Carpal transposition to the ulna for radial
club hand type deformity
 Vascularised bone grafting
 Lengthening techniques

6.  Grafting of bone defects depends on
 length of the defect,
 quality of the underlying bone,
 soft tissue cover
 experience of the surgeon
 Radical eradication of sequestrum,
granulation tissue and residual pus, followed
by antibiotic bead insertion is first step in
selected cases

7. FREE FIBULAR GRAFT
JBJS Br. 2005
Infection -29%
Non Union- 25%

8. NON-VASCULARISED STRUT GRAFTS
 technically much easier.
 may take many months to incorporate
 lose strength
 susceptible to fracture
 high infection rate (when used for
osteomyelitis)
 Resorption of the graft
 development of compartment syndrome
 nerve damage and muscle tethering

9.  Donor site morbidity
 valgus tilting of the ankle due to proximal
migration of the lateral malleous.

10. VASCULARISED GRAFTS
 incorporated sooner
 technically demandinghigh thrombosis
rate of graft vessels

13.  Primary bony union was achieved in all 10 patients
(100%)
 no significant difference between vascularized
grafts and non-vascularized grafts
 the method of stabilization between the plate and
other type of fixation had no significant effect on
bony healing

14. ONEBONE FOREARM
 When there is massive bone defect
 loss of the articulating surface
 technically impossible to place a graft
 Radioulnar transposition
 Loss of rotation of the elbow is compensated
for successfully by shoulder rotation.
 Correction of the deviation of the hand onto
a solid forearm gives a much stronger grip
 Elbow flexion and wrist movements are not
impaired
 Longitudinal growth continues and
improvement in cosmesis occurs

15. VARIOUS METHODS
 Radiou ulnar synostosis- requirement - intact
radiocarpal and humeroulnar joints
 catgut sutures
 cerclage wires
 sidetoside cross union with screws or K wires
 plating and intramedullary pinning of both
shafts
 works well with distal ulna defects or large
proximal radial defects

20. S

23. CONCLUSION
1. When indications are appropriate, creation of a one-bone forearm normalizes elbow and
wrist function, corrects forearm malalignment, and improves forearm growth potential.
2. Concurrent proximal ulnar–radial fusion should be considered during the surgical removal
of the distal ulna for any reason.
3. The procedure is appropriately applied to many underlying conditions.
4. The surgical technique will depend upon which anatomic parts are available for use. The
procedure works best when the proximal ulna and distal radius are available. This
preserves elbow and wrist stability and function.
5. Preservation of a normal distal radial physis allows normal growth and minimizes inherent
relative shortening.
6. The younger the patient at the time of fusion, the better the growth.
7. Gradual subluxation and dislocation of the radial head render its articular surface unsuitable
for rereduction against the humeral capitellum.
8. Surgical reduction of a dislocated radial head associated with an absent or deficient distal
ulna will be unsuccessful (cases 1 and 2).
9. The only disadvantage of ulnar–radial fusion is the loss of forearm rotation.
10. Since all cases in this study and those reported in the literature were unilateral, fusion in a
position of mild forearm pronation is optimal. This will facilitate computer keyboarding.

24. RADIAL CLUB HAND LIKE DEFORMITY

27. CONCLUDED
 Operative reconstruction in acquired clubhand is difficult
 Significant deformity can be present
 Aim – cosmetic improvement with stable wrist and
forearm
 Maintainance of growth
 Choice of surgery depends on what remains
 If diaphysis and distal radius epiphysis is involved,
centralization of carpus on remaining ulna
 If distal radial epiphysis intact,
 Small gap- interposition grafting
 Large gap- Single bone forearm
 Wrist arthrodesis- salvage procedure
 Circular ext fixator- correct deformity, gain length,
transport bone