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RADIOULNAR SYNOSTOSIS POSTTRAUMATIC

Introduction

Radioulnar synostosis is defined as bony or fibrous fusion of the radius and ulna resulting in complete loss of pronation and supination. It is a rare complication of forearm fractures and causes serious disability.1,2 It is typically a result of violation of the interosseous membrane. Surgical treatment is generally recommended; however, the outcome may vary depending on the location of synostosis and the surgical technique utilized.3 Recurrence of synostosis may occur after surgical treatment. Posttraumatic radio ulnar synostosis must be differentiated from congenital radioulanar synostosis.

Pathophysiology

- Post traumatic radio-ulnar synostosis can be the result of the trauma itself or the treatment modality.  With respect to the trauma itself, the energy of the fracture, the fracture pattern and the extent of soft tissue damage all play a role.  With respect to the treatment modality, surgical interventions that lend themselves to extensive soft tissue dissection or violation of the interosseous membrane trigger a healing response which results in fibrous or osseous formation leading to a synostosis

  • Related to forearm fractures1
    • Monteggia fractures
    • Fractures of radius and ulna at the same level
    • Open fracture
    • Soft tissue lesion
    • Comminuted fracture
    • Associated brain injury
    • Bone fragments on the interosseous membrane
  • Related to the treatment of the forearm1
    • Excessively delayed surgery
    • Prolonged immobilization
    • Delayed rehabilitation
    • Synthesis of radius and ulna using single (Boyd) approach
    • Lengthy cortical screws extending into the interosseous membrane
    • Primary bone graft
  • Viance Classification2
    • Type I: fusion in the distal articular part of radius and ulna
    • Type II: fusion in the middle third or non-articular part of radius and ulna
    • Type III: fusion in the proximal third of radius and ulna
      • IIIA: distal to the bicipital tuberosity
      • IIIB: at the radial head and the proximal radioulnar joint
      • IIIC: contiguous with heterotopic bone that extends across the elbow joint to the distal aspects of the humerus
Hastings and Graham Classification
TypeTreatment
Humero-ulnar jointArthroplasty
Proximal radio-ulnar jointRadial head resection vs. arthroplasty
Bicipetal tuberosityResection and interposition
ShaftResection and interposition
Pronator quadratusSuave Kapanji
Distal radioulnar joint (DRUJ)Darrach

 

Related Anatomy

  • Forearm Anatomy3
    • Radius
    • Ulna
    • Humerus
    • Wrist Joint
  • Radius
  • Ulna
  • Carpal bones
  • Proximal radioulnar joint
  • Distal radioulnar joint
  • Radioulnar syndesmosis
  • Interosseous membrane
  • Nerves
    • Interosseous nerves
    • Radial nerve
    • Medial nerve
  • Muscles
    • Supinator muscle
    • Brachioradialis muscle
  • Radial artery

Incidence and Related Conditions

  • The exact incidence is unknown
  • Estimated to result in 1.2% to 6.6% of patients with forearm fractures treated with compression plating
  • Higher incidence of 18% observed in patients with head injuries

Differential Diagnosis

  • Congenital radioulnar synostosis
  • DRUJ contracture
  • Elbow contracture
  • Prior history of dual incision or posterior approach of distal biceps tendon resection
ICD-10 Codes

  • RADIOULNAR SYNOSTOSIS POSTTRAUMATIC

    Diagnostic Guide Name

    RADIOULNAR SYNOSTOSIS POSTTRAUMATIC

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    RADIOULNAR SYNOSTOSIS POSTTRAUMATIC M21.832M21.831 

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Traumatic Radioulnar Synostosis
  • Viance Type III post-traumatic radioulnar synostosis
    Viance Type III post-traumatic radioulnar synostosis
Symptoms
Limited forearm rotation
Pain with rotation in partial synostosis
Pain is typically absent in complete synostosis
Elbow flexion/extension is typically preserved unless ulno-humeral or radio-humeral synostosis is present
Typical History

A 47-year-old male roof construction worker presented with complete loss of forearm rotation. He sustained a fall from height one year ago, with injuries to the head and fractures in the forearm. He had undergone an open reduction and internal fixation of the fracture at the time of injury and experienced chronic fatigue, altered perception, memory lapses and fits of anger since the initial injury. A Type 2 Vince and Miller radioulnar synostosis was observed in plain X-rays 1 year after the surgery.3. 

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative
  • Recurrence after multiple surgical management attempts
  • Not willing to accept the risk of surgery
  • Normal forearm function
Operative

-          Timing: Recommendations vary, with most authors suggesting to wait 6-12 months after initial surgery to allow synostosis to mature or “cool down” to minimize risk of recurrence after resection.  Serial bone scans may help to identify the optimal timing of the surgery

  • Excision of the synostosis with:
    • Optional interposition of soft tissue6,7 or synthetic material to prevent recurrence and scar tissue formation
      • Interposition materials used: fat, fascia, muscle, bone wax, silicone, and polyethylene
      • Fascia lata graft interposition – best reported results for ROM, significant donor site morbidity
      •  Anconeus interposition – limited to proximal synostoses only
      • Local adipofascial flaps
  • Excision of the proximal radius/ radial head arthroplasty
  • Darrach or Suave-Kapanji
  • Insertion of a screw to distract the radius from the ulna
  • Rotational osteotomy of the radius to improve function
  • Post-surgical prophylaxis for preventing recurrence3,5
    • Recommended for patients with head trauma
    • NSAIDs
    • Radiation therapy
Complications
  • Neurovascular injury
  • Infection
  • Fracture
  • Incomplete restoration of the pronation/supination arc
  • Recurrence of the synostosis
 
Outcomes
  • Varying degree of improvement in function
  • Recurrence rate is 6–35% after primary resection depending on the location of the injury, surgical technique used, and associated brain injury3
Key Educational Points
  • Removal of the synostosis can be accomplished, but unfortunately, the improvement in active supination/pronation is usually small.
  • Proximal surgical corrections of severe case of radioulnar synotosis can have severe complications, therefore proceed with caution and properly educate the patient.
  • Surgery is not indicated for cosmesis alone.
References

Cited

  1. Dohn P, Khiami F, Rolland E, Goubier JN. Adult post-traumatic radioulnar synostosis. Orthop Traumatol Surg Res 2012;98(6):709–14. PMID: 23000035
  2. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am 1987;69(5):640–53. PMID: 3110165
  3. Bergeron SG, Desy NM, Bernstein M, Harvey EJ. Management of posttraumatic radioulnar synostosis. J Am Acad Orthop Surg 2012;20(7):450–8. PMID: 22751164
  4. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint Surg Am 1998;80(2):248–57. PMID: 9486731
  5. Kamrani RS, Ahangar P, Nabian MH, et al. Proximal radial diaphyseal segment resection for posttraumatic proximal radioulnar synostosis: a prospective study of 15 cases. J Shoulder Elbow Surg 2014;23(6):855–60. PMID: 24768222
  6. Daluiski A, Schreiber JJ, Paul S, Hotchkiss RN. Outcomes of anconeus interposition for proximal radioulnar synostosis. J Shoulder Elbow Surg 2014;23(12):1882–7. PMID: 25304042
  7. Samson D, Power D, Tan S. Adipofascial radial artery perforator flap interposition to treat post-traumatic  radioulnar synostosis in a patient with head injury. BMJ Case Rep 2015 Epub. PMID: 25725026

New Articles

  1. Kamrani RS, Ahangar P, Nabian MH, et al. Proximal radial diaphyseal segment resection for posttraumatic proximal radioulnar synostosis: a prospective study of 15 cases. J Shoulder Elbow Surg 2014;23(6):855–60. PMID: 24768222
  2. Daluiski A, Schreiber JJ, Paul S, Hotchkiss RN. Outcomes of anconeus interposition for proximal radioulnar synostosis. J Shoulder Elbow Surg 2014;23(12):1882–7. PMID: 25304042
  3. Samson D, Power D, Tan S. Adipofascial radial artery perforator flap interposition to treat post-traumatic radioulnar synostosis in a patient with head injury. BMJ Case Rep 2015 Epub. PMID: 25725026

Reviews

  1. Dohn P, Khiami F, Rolland E, Goubier JN. Adult post-traumatic radioulnar synostosis. Orthop Traumatol Surg Res 2012;98(6):709–14. PMID: 23000035
  2. Bergeron SG, Desy NM, Bernstein M, Harvey EJ. Management of posttraumatic radioulnar synostosis. J Am Acad Orthop Surg 2012;20(7):450–8. PMID: 22751164

Classics

  1. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am 1987;69(5):640–53. PMID: 3110165
  2. Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint Surg Am 1998;80(2):248–57. PMID: 9486731
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