Session VI Upper Extremity

The Operative Management of Post-Traumatic Proximal Radioulnar Synostosis

Jesse B. Jupiter, MD, David Ring, MD, Leonard Goldstock, MD

Massachusetts General Hospital, Boston, MA

Hypothesis: Post-traumatic radioulnar synostosis can be surgically removed with restoration of forearm rotation without the need for radiation or indomethacin to prevent recurrence.

Conclusion: A functional range of forearm rotation can be predictably gained by operative excision, early mobilization without recurrence, and without irradiation or Indocin.

Material and Methods: A prospective study was established in 1989 to treat consecutive patients with post-traumatic radioulnar synostosis by operative resection without adjuvant radiation or Indocin. The same operative protocol of resection, cauterization of the bony surfaces, bone wax, and a free fat graft were used in each case. Inclusion criteria was a post -traumatic bony synostosis, either alone or associated with extensive peri-articular heterotopic bone around the elbow. Excluded were patients with head trauma and lack of return of cognitive or motor function and patients with congenital synostosis. Seventeen adult patients (18 limbs) were treated (15 males and 2 females). The average age was 37 years and the dominant limb was involved in 11. The original injury was an elbow fracture-dislocation in 16 and biceps repair in 2. Twelve limbs had had more than 1 operative treatment and 3 had prior infection. All had complete absence of forearm rotation and average elbow flexion-extension was 84°/30° with complete ankylosis in 7.

Results: At an average follow-up of 23 months (range, 8-60 mos.), all but one patient regained a functional arc of forearm rotation, with an average pronation of 60° and supination of 50°. Average elbow flexion-extension was 123°/23°. No patient developed recurrence of the bony synostosis. Only one patient, who was placed in a hinged distractor for restoration of elbow flexion-extension, failed to regain functional motion. Complications included transient ulnar neuritis in 2 patients who had concomitant elbow capsulectomy. All patients previously employed returned to work, although some functional limitation was noted in all.

Significance: The pessimism surrounding operative excision of forearm or elbow bony anklyosis should be re-evaluated, and earlier excision is warranted to increase functional recovery and limit the extent and duration of the disability.