Adult post-traumatic radioulnar synostosis

Feline radial and ulnar diaphyseal fractures: a retrospective study of 49 cases comparing single bone fixation and dual bone fixation

OBJECTIVES

The objectives of this study were to report the complications in radial and ulnar diaphyseal fractures in cats and to compare the differences in outcome between single and dual bone internal fixation.

METHODS

Medical records between 2004 and 2022 were searched retrospectively for cats with antebrachial diaphyseal fractures treated with internal bone-plate fixation. In total, 49 cases were included from six referral hospitals, including one teaching hospital. Patient information was collated, including fracture configuration, location, repair method and clinical outcome as assessed by veterinary physical examination, radiography and owner questionnaire.

RESULTS

A total of 47 cats (mean age 4.2 years) were included. Fractures were located distally (24/49, 49%), proximally (13/49, 26.5%) and mid-diaphyseally (12/49, 24.5%). Dual bone fixation was used in 13/49 (26.5%) cases, with only 1/13 (7.7%) having major complications. By comparison, 4/36 (11.1%) of single plated fractures had major complications. Single bone fixation was 14.25 times more likely (95% confidence interval [CI] 2.07-97.99) to have a successful outcome (veterinarian-assigned score of 0) compared with dual bone fixation (P = 0.007). When evaluating owner-assessed outcomes, single bone fixation was 9.4 times more likely (95% CI 1.4-61.96) to have a successful outcome (owner score of 0) compared with dual bone fixation (P = 0.019).

CONCLUSIONS AND RELEVANCE

Fractures that were repaired with single bone fixation had a greater chance of a better outcome. Although the difference was not significant, there was a higher major complication rate and a lower minor complication rate for cases treated with single bone fixation compared with dual bone fixation. The majority of fractures were located in the distal diaphysis. Comminution of the fracture and concurrent orthopaedic issues did not significantly affect the outcome. Further prospective studies with standardised follow-up, radiographic assessment, surgeon and implants are required to truly assess the difference between dual and single bone fixation.

Proximal radioulnar synostosis following Monteggia fracture-dislocation: a case report

Introduction and importance

Radioulnar synostosis is a rare complication of a forearm fracture that restricts pronation-supination. This study presents a case of proximal radioulnar synostosis in an adult male after Monteggia fracture-dislocation who had a loss of pronation and supination movements.

Case presentation

Herein, we report a case of proximal radioulnar synostosis in a 43-year-old man who presented with loss of pronation and supination of the right forearm that restricted his daily activities. He had a history of Monteggia fracture-dislocation 9 months back, which was managed with open reduction and internal fixation with a dynamic compression plate. Plain radiography and computed tomography of the right forearm after 9 months of operation showed an implant in situ with proximal radioulnar synostosis. Implant removal was performed and the excess fibro-osseous connection in the proximal radius and ulna was removed.

Clinical discussion

Forearm injuries that affect the interosseous membrane may result in radioulnar synostosis. Trauma and treatment-related factors increase the risk of radioulnar synostosis. The fibro-osseous fusion between the forearm bones restricts the pronation and supination movements.

Conclusion

Loss of pronation-supination following forearm fracture should raise suspicion of radioulnar synostosis.

Complications and Revision Surgery of Forearm Fractures

Nonunion or malunion of forearm fractures may result in restricted range of motion or persistent pain, leading to limitations in activities of daily living. Complications may also present in the form of ectopic bone growth or persistent infections. A systematic method to evaluate complications resulting from forearm fractures is helpful to both determine the cause for the failure and plan for adequate reconstruction.

Management of Isolated Ulnar Shaft Fractures

» Most isolated ulnar shaft fractures are stable and heal without complication regardless of treatment protocol.» Casting above the elbow may create unwanted stiffness without enhancing union rates.» Defining unstable fractures and determining which injuries would benefit from operative management remain a challenge.» Recent development of intramedullary devices has shown promise in preliminary studies, but more vigorous investigation is needed to determine their role.

Rare complication of open reduction and internal fixation of fracture distal radius: A case report of distal radioulnar synostosis- letter to editor

We read the article "Rare complication of open reduction and internal fixation of fracture distal radius: A case report of distal radioulnar synostosis" by Ahmed Elmahdi [1], with a lot of interest. We commend the authors efforts in describing a rare case of distal radioulnar synostosis after open reduction and internal fixation for distal radius fracture. It is the purpose of this letter-to-the-editor to express our opinion, which is based on the research that has been published, which indicates that our opinion is supported by the research.

Proximal Ulnar Osteotomy as a Treatment for Humeral Intracondylar Fissure in a Shetland Sheepdog

A seven-month-old male Shetland Sheepdog was presented for assessment of thoracic limb lameness of 3 weeks duration. Orthopaedic examination revealed severe discomfort in elbow extension, bilaterally. CT-scan confirmed presence of a complete humeral intracondylar fissure (HIF), bilaterally, and arthroscopic examination of both elbows confirmed the presence of the cartilaginous lesion previously reported in dogs suffering from HIF. A staged oblique proximal ulnar osteotomy was performed to address the humero-anconeal incongruency believed to be the cause of HIF formation. Orthopaedic examination performed 5 weeks after each surgical procedure confirmed that pain previously present on elbow manipulation had subsided. Follow-up examination performed 8 months after the second surgery revealed the dog to be sound at walking on the thoracic limbs with no discomfort present on elbow manipulation. Repeated CT scan confirmed complete healing of both HIFs. This is the first report documenting the presence of HIF in a Shetland sheepdog and complete healing of both HIFs following a proximal ulnar osteotomy.

Resection of Posttraumatic Rib Synostoses Resolves Pulmonary Insufficiency: A Case Report

CASE

A 30-year-old woman underwent open reduction and internal fixation for multiple segmental rib fractures status post a motor vehicle collision. A year later, the patient presented with extensive intercostal heterotopic ossification associated with multilevel, hemithoracic, rib synostoses compromising her ventilation. The patient subsequently underwent synostoses excision and hardware removal. Pulmonary function tests (PFT), imaging, and patient-reported outcome scores demonstrate resolution of impairment.

CONCLUSION

Resection of multilevel, intercostal, rib synostoses provided an effective treatment for pulmonary restrictive disorder secondary to traumatic rib synostosis. This is the first patient with documentation of prereconstructive and postreconstructive PFTs for chest wall synostosis excision.

Post-traumatic Radioulnar Synostosis in Distal Forearm Fractures in Children: A Report of 2 Cases

CASES

Two pediatric cases of post-traumatic distal radioulnar synostosis are reported, accompanied by a literature review summarizing evidence on the management of these conditions. Radioulnar synostosis is a rare complication of distal forearm fractures, which impairs upper-extremity function. The numerous surgical procedures that have been described to treat this condition in adults typically involve synostosis resection and an interposition graft to reduce recurrence. The optimal treatment in children has not been established.

CONCLUSIONS

Post-traumatic radioulnar synostoses are rare conditions in pediatric patients who can be successfully treated with surgical excision of the synostoses and without the use of interposition grafting.

Release of Extensive Post Traumatic Radio-Ulnar Synostosis with Vascularized Free Flap Interposition

Radioulnar synostosis is a rare complication after a forearm or elbow injury. The severity of initial trauma, associated head injury along with timing and the type of surgical treatment have been implicated in the formation of extra bone leading to synostosis. Surgical intervention is the standard treatment and is recommended after the maturation of synostotic bone. Surgery involves resection of the extra bone with or without tissue interposition. Materials used for interposition may include synthetic materials, allografts, and vascularized and non-vascularized autologous tissue superiority of one material over the other has not been demonstrated. Reported is a case of extensive soft-tissue defect and severe type II synostosis, with a relevant review of the literature. Level of Evidence Level IV.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00395-5.

Chronic dysphagia caused by Laryngo-vertebral Synostosis after anterior fusion for cervical spine trauma: a case report

BACKGROUND

Anterior cervical spine surgery is often associated with postoperative dysphagia, but chronic dysphagia caused by laryngo-vertebral synostosis is extremely rare. We report a case of chronic dysphagia caused by synostosis between the cricoid cartilage and cervical spine after anterior surgery for cervical spine trauma.

CASE PRESENTATIONS

We present a case of a 39-year-old man who had sustained complex spine trauma at C5-6 associated with complete spinal cord injury at the age of 22; the patient presented with a 5-year history of chronic dysphagia. Computed tomography demonstrated posterior shift of the esophagus as well as calcification of the cricoid cartilage and its fusion to the right anterior tubercle of the C5 vertebra. A barium swallow study demonstrated significant barium aspiration into the airway and no laryngeal elevation. The patient underwent resection of the bony bridge and omohyoid muscle flap insertion. His symptoms ameliorated after surgery.

CONCLUSION

Synostosis between the cricoid cartilage and cervical spine may occur associated with cervical spine trauma and causes chronic dysphagia. Resection of the fused part can improve dysphagia caused by this rare condition and omohyoid muscle flap might be a good option to prevent recurrence.

Use of Acellular Dermal Matrix to Prevent Recurrence of Radioulnar Heterotopic Ossification

Radioulnar heterotopic ossification is a rare occurrence found in approximately 2% of all forearm injuries. Treatment is complicated by relatively high recurrence rates. Strategies to decrease recurrence have included the range of motion exercises and the interposition of inert or autogenous barriers. We report on the interposition of human acellular dermal matrix (ADM) for the treatment of distal radioulnar synostosis. We report a novel technique for the treatment of distal radioulnar heterotopic ossification. After resection, ADM in a cigar-shaped construct is interposed between the radius and ulna. Patients are followed clinically and radiographically. Two female patients were treated. Both patients had significant improvement in the range of motion in supination and pronation of the affected wrist postoperatively with an average follow-up of 36 months. There were no postoperative complications. Neither patient had recurrent disease. We describe the successful treatment of 2 patients with distal radioulnar heterotopic ossification with the use of human ADM. The ADM provides a barrier between the radius and ulna to prevent the recurrent formation of heterotopic ossification. ADM usage results in no donor site morbidity and is theoretically more resistant to infection when compared with nonbiologic barriers such as silicone and Integra. This technique is a simple, safe, and effective way to treat and prevent the recurrence of radioulnar heterotopic ossification.

Union Rates and Reported Range of Motion Are Acceptable After Open Forearm Fractures in Military Combatants

BACKGROUND

High-energy open forearm fractures are unique injuries frequently complicated by neurovascular and soft tissue injuries. Few studies have evaluated the factors associated with nonunion and loss of motion after these injuries, particularly in the setting of blast injuries.

QUESTIONS/PURPOSES

(1) In military service members with high-energy open forearm fractures, what proportion achieved primary or secondary union? (2) What is the pronation-supination arc of motion as stratified by the presence or absence of heterotopic ossification (HO) and synostosis? (3) What are the risks of heterotopic ossification and synostosis? (4) What factors may be associated with forearm fracture nonunion?

METHODS

A retrospective study of all open forearm fractures treated at a tertiary military referral center from January 2004 to December 2014 was performed. In all, 76 patients were identified and three were excluded, leaving 73 patients for inclusion. All 73 patients had serial radiographs to assess for HO and union. Only 64 patients had rotational range of motion (ROM) data. All patients returned to the operating room at least once after initial irrigation and débridement to ensure the soft tissue envelope was stable before definitive fixation. The indication for repeat irrigation and débridement was determined by clinical appearance. Patient demographics, fracture and soft tissue injury patterns, surgical treatments, neurovascular status at the time of injury, incidence of infection, heterotopic ossification (defined as the presence of heterotopic bone visible on serial radiographs), radioulnar synostosis, bony status after initial definitive treatment (union, nonunion, or amputation), and forearm rotation at final followup were retrospectively obtained from chart review by someone other than the operating surgeon. Seventy-six open forearm fractures in 76 patients were reviewed; 73 patients were examined for osseous union as three went on to early amputation, and 64 patients had forearm ROM data available for analysis. Union was determined by earliest radiology or orthopaedic staff official dictation stating the fracture was healed. Nonunion was defined as the clinical determination by the orthopaedist for a repeat procedure to achieve bony union. Secondary union was defined as union after reoperation to achieve bony union, and final union was defined as overall percentage of patients who were healed at final followup. Of the patients analyzed for union, 20 had less than 1 year of followup, and of these, none had nonunion. Of the patients analyzed for ROM, eight patients had less than 6 months of followup (range, 84-176 days). Of these, one patient had decreased ROM, none had a synostosis, and the remaining had > 140° of motion.

RESULTS

Initial treatment resulted in primary union in 62 of 73 patients (85%); secondary union was achieved in eight of 11 patients (73%); and final union was achieved in 70 of 73 patients (96%). Although pronation-supination arc in patients without HO was 140° ± 35°, a limited pronation-supination arc was primarily associated with synostosis (arc: 40° ± 40°; mean difference from patients without HO: 103° [95% confidence interval {CI}, 77°-129°], p < 0.001); patients with HO but without synostosis had fewer limitations to ROM than those with synostosis (arc: 110° ± 80°, mean difference: 77° [35°-119°], p < 0.001). Heterotopic ossification developed in 40 of 73 patients (55%), including a radioulnar synostosis in 14 patients (19%). Bone loss at the fracture site (relative risk (RR) 6.2; 95% CI, 1.8-21) and healing complicated by infection (RR, 9.9; 95% CI, 4.9-20) were associated with the development of nonunion after initial treatment. Other potential factors such as smoking status, vascular injury, both-bone involvement, need for free flap coverage and blast mechanism were not associated.

CONCLUSIONS

Despite a high-energy mechanism of injury and high rate of soft tissue defects, the ultimate probability of fracture union in our series was high with a low infection risk. Nonunions were associated with bone loss and deep infection. Functional motion was achieved in most patients despite increased burden of HO and synostosis compared with civilian populations. However, if synostosis did not develop, HO itself did not appear to interfere with functional ROM. Future investigations may provide improved decision-making tools for timing of fixation and prophylactic means against HO synostosis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Posttraumatic Proximal Radioulnar Synostosis after Closed Reduction for a Radial Neck and Olecranon Fracture

Posttraumatic proximal radioulnar synostosis (PPRUS) is a severe complication of radial head and neck fractures known to occur after severe injury or operative fixation. Cases of PPRUS occurring after minimally displaced, nonoperatively treated radial neck injuries are, by contrast, extremely rare. 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.

Optimal management of post-traumatic radioulnar synostosis

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. For most types of synostosis, surgical resection with interposition graft is recommended. The types of materials used include synthetic, allograft, and vascularized and non-vascularized materials, but currently there is no consensus on which is the most preferable. Adjuvant therapy is not considered necessary for all cases but can be beneficial in patients with high risk factors such as recurrence or traumatic brain injury. Postoperative rehabilitation should be performed early to maintain range of motion.

Combined physeal fractures of the distal radius and ulna: complications associated with K-wire fixation and long-term prognosis in six cats

Objectives The objective was to describe the complications and long-term outcome associated with Kirschner (K)-wire fixation of combined distal radial and ulnar physeal fractures in six cats. Methods Medical records (2002-2014) of six referral institutions were searched for cats with combined distal radial and ulnar physeal fractures. Cases with complete clinical files, radiographs and surgical records were retrospectively reviewed. Long-term outcome was assessed via telephone interviews using an owner questionnaire. Results Complete files were available for 6/9 identified cases (cases 1-6). All fractures were classified as Salter-Harris type I or II. Five cases underwent open reduction and internal fixation via cross-pinning of the distal radius and intramedullary pinning of the ulna (cases 1-3); fixation of the distal radial and ulnar physes with one K-wire each (case 4); and K-wire fixation of the radial physis in combination with two transulnoradial K-wires (case 5). One case underwent closed reduction and percutaneous cross-pinning of the distal radius under fluoroscopic guidance (case 6). The complications encountered were: reduced radiocarpal range of motion (ROM) (cases 1, 3, 4, 5); implant loosening/migration (cases 1, 2, 5); and radioulnar synostosis (case 4). None of the cats developed angular limb deformity. Long-term outcome (12 months to 7 years after surgery) was graded as 'excellent' by the owners in all cases. Conclusions and relevance Prognosis is favourable for feline combined distal radial and ulnar physeal fractures following K-wire fixation in cats over 7 months of age. Implant removal after bony union is recommended to minimise reduction in ROM and to prevent implant loosening/migration.

The Adipofascial Radial Artery Perforator Flap: A Versatile Reconstructive Option in Upper Limb Surgery

BACKGROUND

Flaps have been used in upper limb surgery for varied indications including coverage of soft tissue defects, interposition and to provide a pliable bed for gliding structures among others.

METHODS

We report our use of the radial artery perforator based adipofascial flap in nine patients, five with rigid radioulnar synostosis, three with recalcitrant carpal tunnel syndrome and one with a soft tissue defect.

RESULTS

All our patients with radioulnar synostosis regained good functional rotations of the forearm with no recurrence at follow up. The patients with recalcitrant carpal tunnel also had resolution of symptoms with no recurrence. The flap healed well in all the patients.

CONCLUSIONS

We propose this flap as a viable, versatile reconstructive option for the hand and upper limb.

Surgical Treatment of Posttraumatic Radioulnar Synostosis

Radioulnar synostosis is a rare complication of forearm fractures. The formation of a bony bridge induces functional disability due to limitation of the pronosupination. Although the etiology of posttraumatic synostosis is unknown, it seems that the incidence is higher in patients who have suffered a concomitant neurological or burn trauma, and extensive soft tissue injury, mainly due to high-energy impact. Surgical treatment, such as reinsertion of distal biceps tendon into the radius, seems to be another possible factor. The aim of the surgical treatment is to remove the bony bridge and restore complete range of movement (ROM), thus preventing recurrence. Literature does not indicate a preferred type of surgical procedure for the aforementioned complication; however, it has been shown that surgical interposition of inert material reduces the formation rate of recurrent bony bridge. We describe a surgical technique in two cases in which the radius and ulna were wrapped with allogenic, cadaver fascia lata graft to prevent bony bridge formation. The data from 2 years of follow-up are reported, indicating full restoration of ROM and no recurrence of synostosis.