Very rare complication for radial head fracture and even other trauma (elbow dislocation, radius/cubitus shaft fracture,…)
Lost of range of motion and specifiquely for pronosupine
Lot of treatment in litterature as:
- preventive irradiation
- resection without interposition
- resection/interposition
- resection wo interposition + irradiation
- resection/interposition + irradiation
Still no consensus
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Posttraumatic radio ulnar synostosis
1. Post-traumatic synostosis
of the proximal radio-
ulnar joint: About one case
and review of the
litterature
R. Acquaviva, M.Hallez, R. Elbaum
CHIREC orthopaedic group
Brussel,Belgium
2. The only man who
never makes mistakes is
the one who does
nothing.
THEODORE ROOSEVELT
(1858 - 1919)
3. Introduction
Very rare complication for radial head fracture and
even other trauma (elbow dislocation,
radius/cubitus shaft fracture,…) or after forearm
osteotomy
Lost of range of motion (Prosupination)
Lot of treatment in litterature as:
- preventive irradiation
- resection without interposition
- resection/interposition
- resection wo interposition + irradiation
- resection/interposition + irradiation
Still no consensus
4. Case report
Zoe 8 years old
Radial head
fracture at the
age of 7 years
old (08/2015)
Fracture: Salter–
Harris 2-3
Conservative
treatment
started at
trauma date
5. First visit on
01/09/2016
Pain in the forearm and the elbow
Limited ROM
Functional disability to draw and write
Limitation PS 30/0/30
Extension -30°
Elective pain on radial head
13. Post-operative follow-up
1 w post-op : wound
control + BAB
3 w post-op: remove
cast + self kine
7 w post-op:
• - PS > 60/45
• - Rx showing resection
zone
• - start kine
17. Anterior approach (Henry)
Abord antérieur du coude selon Henry avec bifurcation
dans l’interligne du coude. Mise en évidence du brachial antérieur et du long
supinateur. Ligature des différents vaisseaux superficiels. Mise en évidence du
nerf radial qui sera laqué. On se dirige progressivement vers l’interligne
articulaire radio-ulnaire proximal. Désinsertion du court supinateur et
ouverture de la capsule articulaire. Mise en
évidence de la tête radiale. On visualise une zone protubérante au niveau de
la région sigmoïdienne entre l’ulna et le radius.
18. LAST FU
11/2018
No pain
Complete RTS (Ballet)
No limitation at school
PS 45/0/60
Temporary paraparesy in the radial
territory (Extensor)
20. PPRUS
Classification
Vince and Miller classification
Vince K. G., Miller J. E. Cross union complicating fracture of
the forearm. The Journal of Bone & Joint Surgery—American
Volume. 1987;69:640–653.
21. PPRUS
Etiology
Proximal Radial or Ulnar fracture or dislocations
After closed or open reduction
Periostal interpositions
Surgical approach with traumatisation of the tissue
Repeated manipulation
Excessive callus formation
• Isolated fractures of the proximal end of the radius in children epidemiology, treatment and
prognosis.
Henrikson B Acta Orthop Scand. 1969; 40(2):246-60.
• Injuries involving the proximal radial epiphysis.
O'Brien PIClin Orthop Relat Res. 1965 Jul-Aug; 41():51-8.
• Severe fracture of the neck of the radius in children.
Dougall AJ J R Coll Surg Edinb. 1969 Jul; 14(4):220-5.
• Radioulnar synostosis following proximal radial fracture in child.
Roy DR Orthop Rev. 1986 Feb; 15(2):89-94.
22. PPRUS
Epidemiology
1969
• Acta Orthop Scand. 1969;40(2):246-60. Isolated fractures of the
proximal end of the radius in children epidemiology, treatment and
prognosis. Henrikson B.
1982
• Ogden JA. Skeletal injury in the child. Philadelphia: Lea and Febiger
1997
• von Laer L, Pirwitz A, Vocke AK. Posttraumatic problem cases involving
the elbow in children. Orthopade 1997;26:1030-6
2012
• Wierer M, Huber-Wagner S, Mutschler W. Post-traumatic proximal
radioulnar synostosis. Surgical technique and review of the literature.
Unfallchirurgie 2012;115:451-6
1900
• Mouchet A. Les fractures du col du radius. Chirurgie 1900;21:596-622
23. Case Rep Orthop. 2018 Feb 19;2018
Posttraumatic Proximal Radioulnar Synostosis
after Closed Reduction for a Radial Neck and
Olecranon Fracture.
Keller PR, Cole HA, Stutz CM, Schoenecker JG
Here, we present a pediatric case of PPRUS
that developed after a nonoperatively
treated minimally displaced radial neck
fracture with concomitant olecranon
fracture. While more cases are needed to
establish the association between this
pattern of injury and PPRUS, we
recommend that when encountering
patients with a minimally displaced radial
neck fracture and a concomitant elbow
injury, the rare possibility of developing
proximal radioulnar synostosis should be
considered.
24. PPRUS
Treatment
option
Roy DR. Radioulnar synostosis following proximal radial fracture in child. Orthop Rev 1986;15:89-94
Aner A, Singer M, Feldbrin Z, et al. Surgical treatment of posttraumatic radioulnar synostosis in
children. J Pediatr Orthop 2002;22:598-600
Kamineni S, Maritz NG, Morrey BF. Proximal radial resection for posttraumatic radioulnar
synostosis: a new technique to improve forearm rotation. J Bone Joint Surg Am 2002;84-A:745-51
Proubasta IR, Lluch A. Proximal radioulnar synostosis treated by interpositional silicone
arthroplasty. A case report. Int Orthop 1995;19:242-4
Abrams RA, Simmons BP, Brown RA, Botte MJ. Treatment of posttraumatic radioulnar synostosis
with excision and low-dose radiation. J Hand Surg Am 1993;18:703-7
Friedrich JB, Hanel DP, Chilcote H, Katolik LI. The use of tensor fascia lata interposition grafts for the
treatment of posttraumatic radioulnar synostosis. J Hand Surg Am 2006;31:785-93
25. Orthop Res Rev. 2017 Dec
Optimal management of
post-traumatic radioulnar
synostosis.
Osterman AL, Arief MS.
Post-traumatic radioulnar synostosis is a rare complication after
forearm or elbow injury that can result in loss of motion and
significant disability. Risk factors include aspects of the initial
trauma and of the surgical treatment of that trauma. Surgical
intervention for synostosis is the standard of care and is
determined based on the location of the bony bridge. Surgical
timing is recommended between 6 months and 2 years with
recent advocacy for the 6- to 12-month period after radiographs
demonstrate bony maturation but early enough to prevent
further stiffness and contractures.
26. Aktuelle Traumatol. 1986
Feb;16(1):13-6.
[Post-traumatic radio-ulnar
synostoses in childhood].
Bätz W, Hofmann-v Kap-
herr S, Pistor G.
This article reports on five children treated
surgically during 1973-1975 for posttraumatic
radioulnar synostosis.
The article presents the technique of surgical
treatment of proximal radioulnar synostosis with
Lyodura sheathing.
Follow-up examination showed good results in
two children, a moderate result in one, and poor
results of surgery in two cases.
Improved results may be expected from further
improvement of the surgical method, such as
resection of the bicipital tuberosity (tuberositas
radii) or from additional partial sheathing of the
ulna at the side facing the radius.
27. Aust N Z J Surg. 1993 Dec
Post-traumatic radio-ulnar
synostosis treated by surgical
excision and adjunctive
radiotherapy.
Thurston AJ, Spry NA.
The management of three cases of traumatic
radio-ulnar synostosis involved surgical excision of
the synostotic bone followed by radiotherapy.
Irradiation was commenced on the first
postoperative day and was continued daily.
No acute side effects were observed. All three
patients regained a good, functional range of
forearm rotation with no evidence of recurrence
of the synostosis after 2 years.
28. J Bone Joint Surg Am. 2002 May.
Proximal radial resection for
posttraumatic radioulnar synostosis:
a new technique to improve forearm
rotation.
Kamineni S, Maritz NG, Morrey BF.
Resection of a 1-cm-thick section of the proximal
part of the radial shaft provides a safe and reliable
method of improving forearm rotation in patients
with heterotopic ossification of the elbow.
A single technical factor that seems to positively
influence the result is the application of bone wax
at the resection site.
This simple procedure is ideally suited for patients
who have a proximal radioulnar synostosis that (1)
is too extensive to allow a safe and discrete
resection, (2) involves the articular surface, and (3)
is associated with an anatomical deformity.
29. J Pediatr Orthop. 2002 Sep-
Oct;22(5):598-600.
Surgical treatment of
posttraumatic radioulnar
synostosis in children.
Aner A, Singer M, Feldbrin Z,
Rzetelny V, Bar-On E.
The authors describe two children who
underwent surgical treatment of radioulnar
synostosis. One case involved simple excision; the
other, excision and interposition of Gore-Tex
vascular graft material. In a review of the
literature, no other report of the latter type of
surgical treatment was found. A discussion of the
literature concerning this rare complication in
children and the current surgical treatment
options are included.
30. Conclusion
The Posttraumatic Proximal
Cross-union of the Forearm in
Childhood: What is
Recommended?
Marcel Dudda, Tobias
Fehmer, Thomas A. Schildhauer,
and Christiane Kruppa
Orthop Rev (Pavia). 2013 Jun.
Postoperative cross-unions are rarely seen in the
pediatric population and there is no consensus as to
treatment.
Compared to the adult population, worse results in
pediatric diaphyseal (Type 2) cross-unions are
reported.
We suggest resection within 6-24 months without
necessarily an interposition technique.
For delayed treatment, resection of the radial head as
salvage procedure can be performed.
We advocate postoperative oral therapy with NSAID in
all patients and irradiation in cases of delayed
treatment of cross-unions;
All patients should be treated with intensive
physiotherapy and continuative postoperative follow up
to prevent a loss of range of motion.
Ladies and Gentlemen, Dear Colleague,
I would like thanks the organising comitee and especially Dr Zorman and Molenaers for this intersting Congress about Complications in Orthopaedics
As we know, complications in orthopaedics related to surgery or to the pathology represent a source of anxiety and worry for all the surgons, especially when the lawyers get involved.
Especially in Paediatric Orthopaedics where our action have a consequence in the very long term of our patient.
But as Theodore Roosvelt have sayed …
Many complication after elbow fracture are describe but posttraumatic Radio Ulnar synostosis are very rare and often unpredictible.
It is caracterised by a loss of motion in the elbow ans specifically by loss pf Prosupination
Many treatment are proposed in the littérature but because of this rare condition, there is no consensus
, Zoe; is a 8 year old girl who present at our clinic 1 year after an radial head fracture on his left elbow.
She complaint of Pain in the forearm and the elbow
and especially when she was writing or drawing
She had limitation in Prosupination and in extension
The Xray done in Romania showed a proximal coalition of the radioulnar joint
Unfortunally I could’nt get this X-Ray
A Ct Scan with 3D Reconstruction showed this complete coalition between the sigmoidienne fossette of the ulna distally and proximal part of the radius under the epiphysis.
There is also a fusion of the epiphyseal nucleus of the radial head, small,
On the MRI the upper part of the radius appears enlarged and largely fused with the ulna. The fusion between the radius and the ulna
is about 12 mm in height. This injury is made proximally to the bicipital tuberosity
In front of the complain of the patient, the disability and the delay between the first trauma and the coalition ,Surgery was proposed.
We perform the resection of the synostosis by a Boyd approach and interposition of Fascia lata.
In postop we prescribe NSAI therapy and active mobilisation after cast .
Here on the Perop view, you can see the radiohumeral joint after detaching the epitrochlean muscle and opening the capsula
Boyd approach was choosed to avoid neurovascular damage
By this approach we could reach almost all the coalition and you can see on the right image the margin of the bony coalition.
First the resection was done with muller cissels and then with a little bur
Here is the bony coalition resected
On this video you cans see the moblity obtain after resection
After 3week of immobilisation in a sling ,she start selfkine ans active mobilisation
At 7W post op Prosupination was 60/45
XRAY showed the almost complete resection
4mo postop there is a growth disturbance on the radial proximal epiphysis
Unfortunatly 6 mo lather we assist to partial recurrence of the synostosis especially on tne anterior part .
So we decide after discussion a lot with the parent about the neuro vascular risk , to complete the resection by an anterior approach
On last FU Zoe has improved his mobility. She return to sport.
As we could expect ,she present a temporary paraparesy in the radial teritory .
PPRUS in children is a rare condition and not so easy to manage.
Litterature is not so profuse and we have try to do a global review about this complication
Vince and Miller published in 1987 a classification about posttraumatic coalition of the PRUJ for adult.
In our case it was a type 3, the most unfrequent type.
Concerning etiology ,many condition and agravating factor are proposed.
It can occure after Radio Ulnar fracture or dislocation like the Monteggia Type.
Closed or openreduction are equally involved but surgical approach with tissue injuries can increase bony formation.
If there is a periostal interposition or after repeated manipulation
Excessive callus formation that occures frequently in children fracture may also be an etiology
PPRUS represent 2% of adult population with forearm fracture but there is not a precise incidence in childhood but it is very law
The first report of PPRUS in children was performed by Mouchet in 1900
Few case were reported since this in the littérature.
Recently Keller and coll published one case exactly the same than ours and recommend…
Concerning management of PPRUS in children , littérature is not so profuse and i will present some article concerning this subject
In 1986 five case of PPRUS treated with Lyodura interposition.
They suggested that resection of bicipital tuberosity or sheating of the ulna may improved the result
Thurston in 1993 published 3 case of PPRUS treat by adjunctive radiotherapy starting in the first postoperative day.
There was no evidence of recurrence after 2 years
Kamieni and coll describe a technique resecting a 1cm thick section of the radial sahft to improve forearm rotation.
According to him this procedure is indicated when the PPRUS is to extensive and involve the articular surface.
In 2002 Aner and coll describe 2 case using in one , interposition of gore tex between the resected coalition.