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Treatment of traumatic radioulnar synostosis by excision, with interposition of a posterior interosseous island forearm flap
T R E A T M E N T OF T R A U M A T I C R A D I O U L N A R S Y N O S T O S I S BY E X C I S I O N , W I T H I N T E R P O S I T I O N OF A P O S T E R I O R INTEROSSEOUS ISLAND FOREARM FLAP M. SUGIMOTO, K. MASADA, H. OHNO and T. HOSOYA
From the Department of Orthopaedic Surgery, Himeji Red Cross Hospital, Hyogo, and the Department of Physical Therapy, Osaka Prefectural College of Health Sciences, Osaka, Japan A 21-year-old man had proximal radioulnar synostosis 10 months after fracture of the proximal radius and the ulna. The bony bridge was excised and a direct posterior interosseous island flap was interposed as a biological barrier. One year after surgery, the range of forearm rotation was 65 ° . There was no radiographic evidence of recurrence.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 3:393 395 Post-traumatic radioulnar synostosis is a well recognized but poorly defined complication of forearm fractures. It results in an inability to perform many activities because of restriction of forearm rotation. Treatment has mainly consisted of excision of the bony bridge and interposition of biological or foreign material including fat(Yon-Hing and Tschang, 1983), muscle(Breit, 1983), and silicone sheet(Carstam and Eiken, 1971; Corless, 1977; Garland and Dowling, 1983; Watson and Eaton, 1978). Recurrence of the bony bridge is not consistently prevented by these methods.
proximally and subcutaneous tissue was placed between the radius and ulna (Fig 2b). Intraoperative rotation of the forearm was 5° of pronation and 65 ° of supination. The wound was closed directly using the skin paddle as a monitor, demonstrating survival. One year after operation there was pronation to 10° (Fig 3a), and 55 ° of supination (Fig 3b). There was no radiographic evidence of recurrence (Fig 4). DISCUSSION
The incidence of post-traumatic radioulnar synostosis has been estimated to be 2%, but may be higher in Monteggia fractures where it has been estimated to be 3.6%(Vince and Miller, 1987). In association with a head injury, the cross-union rate is 33% in complicated forearm fractures(Garland and DoMing, 1983). Other risk factors for the occurrence of radioulnar synostosis include severe local trauma, fractures of both bones at the same level, open fractures, fractures with infection, and open reduction and fixation through one incision. Vince and Miller(1987) presented separate series of radioulnar synostosis excision in children and adults. In the adult series, there was recurrence in 24% after separation, and a rotational arc of 30° or more was restored in only 53% of the 17 cases. Several published case reports have demonstrated successful restoration
CASE R E P O R T
A 20-year-old man sustained closed fractures of the radius and ulna in a motor vehicle accident. Radiographs revealed a comminuted fracture of the proximal ulna and transverse fractures of the middle third of the radius and ulna. Anterior dislocation of the radial head was also noted. Open reduction and internal fixation were delayed because of incomplete spinal cord injury at the T4 and T5 level. Spinal cord damage recovered uneventfully and operation was performed 36 days after injury. Plates and screws were used for the fractures of the middle third of the radius and ulna. Tension band wiring was used for the fracture of the proximal ulna. Seven months after operation, clinical examination revealed limitation of forearm rotation. The forearm was fixed in a neutral position, whereas the elbow had 0 ° to 140° of extension and flexion. Radiographs revealed radioulnar synostosis at the level of the proximal third of the radius and the ulna (Fig 1). One year and 3 months after injury, the bony bridge was excised through a posterior approach with interposition of a posterior interosseous island flap. The 10 x 3 cm flap was designed on the distal third of the forearm, and included the septum between extensor digitorum and extensor digiti minimi that contains the posterior interosseous artery. It was elevated as described by Masquelet and Penteado(1992; Fig2a). After the flap was isolated on its direct pedicte, the distal part of the skin was excised leaving a small proximal part as a monitor. The flap was rotated
Fig 1
393
Ten months after operation. A bony bridge has developed between the radius and ulna.
394
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 21B No. 3 JUNE 1996
(a) The flap has been raised, including the septum between extensor digitorum communis and extensor digiti minimi that contains the posterior interosseous artery. (b) Subcutaneous tissue is placed between the radius and ulna(arrow).
of motion after radioulnar synostosis excision with the insertion of muscle(Breit, 1983), fat(Yong-Hing and Tschang, 1983), or silicone rubber(Carstam and Eiken, 1971; Corless, 1977; Garland and Dowling, 1983; Watson and Eaton, 1978) as physical barriers to recurrence. These methods, however, cannot completely prevent recurrence after synostosis excision. Since silicone rubber sheeting is not approved as a permanent implant, it should be removed subsequently. This requires a second procedure with a further risk of synostosis recurrence. Failla et al (1989) reported that no patient had a good or excellent result with biological interpositional material. Interposition of muscle introduces further surgical trauma with scarring and may compromise the function of the interposed muscle. Abrams et al (1993) reported two cases of post-traumatic radioulnar synostosis treated by excision and low-dose irradiation. Cullen et al (1994) also reported the usefulness of low-dose irradiation. Although no untoward effects have so far been reported when this has been used, the long-term effects remain unclear. When vascularized subcutaneous tissue is interposed
Fig 3
One year after operation, there was pronation to 10° (a) and 55 ° of supination(b).
Fig 4
One year after operation. There was no evidence of recurrence.
between the radius and ulna, it is not replaced by scar tissue. A free subcutaneous flap is technically difficult, and takes a long time to perform. We have found the posterior interosseous flap first reported by Zancolli and Angrigiani (1988) to be useful as interposition material. References ABRAMS R A, SIMMONS B P, BROWN R A and BOTTE M J (1993). Treatment of post-traumatic radioulnar synostosis with excision and lowdose radiation. Journal of Hand Surgery, 18A: 703-707. BREIT R (1983). Post-traumatic radioulnar synostosis. Clinical Orthopaedics and Related Research, 174: 149-152. CARSTAM N and EIKEN O (1971 ). The use of silastic sheet in hand surgery.
R A D I O U L N A R SYNOSTOSIS Scandinavian Journal of Plastic and Reconstructive Surgery and H a n d Surgery, 5: 57-61. CORLESS J R (1977). Post-traumatic radioulnar synostosis. Journal of Bone and Joint Surgery, 59B: 510. C U L L E N J P, P E L L E G R I N I V P, M I L L E R R J and JONES J A (1994). Treatment of traumatic radionlnar synostosis by excision and postoperative low-dose irradiation. Journal of H a n d Surgery, 19A: 394 401. FAILLA J M, A M A D I O P C and M O R R E Y B F (1989). Post-traumatic proximal radioulnar synostosis: results of surgical treatment. Journal of Bone and Joint Surgery, 71A: 1208 1213. G A R L A N D D E and D O W L I N G V (I983). Forearm fractures in the headinjured adult. Clinical Orthopaedics and Related Research, t76: 190-196. M A S Q U E L E T A C and PENTEADO C V. The Posterior Interosseous Flap. In: Gilbert A, Masquelet A C, and Hentz V R (Eds.): Pedicle Flaps of the Upper Limb, London, Dunitz, 1992:111-118.
395 VINCE K G and MILLER J E (1987). Cross-union complicating fracture of the forearm: part I: adults. Journal of Bone and Joint Surgery, 69A: 640-53. WATSON F M and EATON R G (1978). Post-traumatic radioulnar synostosis. Journal of Trauma, 18: 467-468. Y O N G - H I N G K and T C H A N G S P K (1983). Traumatic radioulnar synostosis treated by excision and a free fat transplant: a report of two cases. Journal of Bone and Joint Surgery, 65B: 433-435. Z A N C O L L I E A and A N G R I G I A N I C (1988). Posterior interosseous island forearm flap. Journal of H a n d Surgery, 13B: 130 135.
Accepted: 20 July]i995 Mimlo Sugimoto, MD, Department of Pathology, OSAKA University Medical School, 2-2, Yamadaoka, Suita, 565, Japan. © 1996 The British Society for Surgery of the Hand
From the Department of Orthopaedic Surgery, Himeji Red Cross Hospital, Hyogo, and the Department of Physical Therapy, Osaka Prefectural College of Health Sciences, Osaka, Japan A 21-year-old man had proximal radioulnar synostosis 10 months after fracture of the proximal radius and the ulna. The bony bridge was excised and a direct posterior interosseous island flap was interposed as a biological barrier. One year after surgery, the range of forearm rotation was 65 ° . There was no radiographic evidence of recurrence.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 3:393 395 Post-traumatic radioulnar synostosis is a well recognized but poorly defined complication of forearm fractures. It results in an inability to perform many activities because of restriction of forearm rotation. Treatment has mainly consisted of excision of the bony bridge and interposition of biological or foreign material including fat(Yon-Hing and Tschang, 1983), muscle(Breit, 1983), and silicone sheet(Carstam and Eiken, 1971; Corless, 1977; Garland and Dowling, 1983; Watson and Eaton, 1978). Recurrence of the bony bridge is not consistently prevented by these methods.
proximally and subcutaneous tissue was placed between the radius and ulna (Fig 2b). Intraoperative rotation of the forearm was 5° of pronation and 65 ° of supination. The wound was closed directly using the skin paddle as a monitor, demonstrating survival. One year after operation there was pronation to 10° (Fig 3a), and 55 ° of supination (Fig 3b). There was no radiographic evidence of recurrence (Fig 4). DISCUSSION
The incidence of post-traumatic radioulnar synostosis has been estimated to be 2%, but may be higher in Monteggia fractures where it has been estimated to be 3.6%(Vince and Miller, 1987). In association with a head injury, the cross-union rate is 33% in complicated forearm fractures(Garland and DoMing, 1983). Other risk factors for the occurrence of radioulnar synostosis include severe local trauma, fractures of both bones at the same level, open fractures, fractures with infection, and open reduction and fixation through one incision. Vince and Miller(1987) presented separate series of radioulnar synostosis excision in children and adults. In the adult series, there was recurrence in 24% after separation, and a rotational arc of 30° or more was restored in only 53% of the 17 cases. Several published case reports have demonstrated successful restoration
CASE R E P O R T
A 20-year-old man sustained closed fractures of the radius and ulna in a motor vehicle accident. Radiographs revealed a comminuted fracture of the proximal ulna and transverse fractures of the middle third of the radius and ulna. Anterior dislocation of the radial head was also noted. Open reduction and internal fixation were delayed because of incomplete spinal cord injury at the T4 and T5 level. Spinal cord damage recovered uneventfully and operation was performed 36 days after injury. Plates and screws were used for the fractures of the middle third of the radius and ulna. Tension band wiring was used for the fracture of the proximal ulna. Seven months after operation, clinical examination revealed limitation of forearm rotation. The forearm was fixed in a neutral position, whereas the elbow had 0 ° to 140° of extension and flexion. Radiographs revealed radioulnar synostosis at the level of the proximal third of the radius and the ulna (Fig 1). One year and 3 months after injury, the bony bridge was excised through a posterior approach with interposition of a posterior interosseous island flap. The 10 x 3 cm flap was designed on the distal third of the forearm, and included the septum between extensor digitorum and extensor digiti minimi that contains the posterior interosseous artery. It was elevated as described by Masquelet and Penteado(1992; Fig2a). After the flap was isolated on its direct pedicte, the distal part of the skin was excised leaving a small proximal part as a monitor. The flap was rotated
Fig 1
393
Ten months after operation. A bony bridge has developed between the radius and ulna.
394
Fig 2
THE JOURNAL OF HAND SURGERY VOL. 21B No. 3 JUNE 1996
(a) The flap has been raised, including the septum between extensor digitorum communis and extensor digiti minimi that contains the posterior interosseous artery. (b) Subcutaneous tissue is placed between the radius and ulna(arrow).
of motion after radioulnar synostosis excision with the insertion of muscle(Breit, 1983), fat(Yong-Hing and Tschang, 1983), or silicone rubber(Carstam and Eiken, 1971; Corless, 1977; Garland and Dowling, 1983; Watson and Eaton, 1978) as physical barriers to recurrence. These methods, however, cannot completely prevent recurrence after synostosis excision. Since silicone rubber sheeting is not approved as a permanent implant, it should be removed subsequently. This requires a second procedure with a further risk of synostosis recurrence. Failla et al (1989) reported that no patient had a good or excellent result with biological interpositional material. Interposition of muscle introduces further surgical trauma with scarring and may compromise the function of the interposed muscle. Abrams et al (1993) reported two cases of post-traumatic radioulnar synostosis treated by excision and low-dose irradiation. Cullen et al (1994) also reported the usefulness of low-dose irradiation. Although no untoward effects have so far been reported when this has been used, the long-term effects remain unclear. When vascularized subcutaneous tissue is interposed
Fig 3
One year after operation, there was pronation to 10° (a) and 55 ° of supination(b).
Fig 4
One year after operation. There was no evidence of recurrence.
between the radius and ulna, it is not replaced by scar tissue. A free subcutaneous flap is technically difficult, and takes a long time to perform. We have found the posterior interosseous flap first reported by Zancolli and Angrigiani (1988) to be useful as interposition material. References ABRAMS R A, SIMMONS B P, BROWN R A and BOTTE M J (1993). Treatment of post-traumatic radioulnar synostosis with excision and lowdose radiation. Journal of Hand Surgery, 18A: 703-707. BREIT R (1983). Post-traumatic radioulnar synostosis. Clinical Orthopaedics and Related Research, 174: 149-152. CARSTAM N and EIKEN O (1971 ). The use of silastic sheet in hand surgery.
R A D I O U L N A R SYNOSTOSIS Scandinavian Journal of Plastic and Reconstructive Surgery and H a n d Surgery, 5: 57-61. CORLESS J R (1977). Post-traumatic radioulnar synostosis. Journal of Bone and Joint Surgery, 59B: 510. C U L L E N J P, P E L L E G R I N I V P, M I L L E R R J and JONES J A (1994). Treatment of traumatic radionlnar synostosis by excision and postoperative low-dose irradiation. Journal of H a n d Surgery, 19A: 394 401. FAILLA J M, A M A D I O P C and M O R R E Y B F (1989). Post-traumatic proximal radioulnar synostosis: results of surgical treatment. Journal of Bone and Joint Surgery, 71A: 1208 1213. G A R L A N D D E and D O W L I N G V (I983). Forearm fractures in the headinjured adult. Clinical Orthopaedics and Related Research, t76: 190-196. M A S Q U E L E T A C and PENTEADO C V. The Posterior Interosseous Flap. In: Gilbert A, Masquelet A C, and Hentz V R (Eds.): Pedicle Flaps of the Upper Limb, London, Dunitz, 1992:111-118.
395 VINCE K G and MILLER J E (1987). Cross-union complicating fracture of the forearm: part I: adults. Journal of Bone and Joint Surgery, 69A: 640-53. WATSON F M and EATON R G (1978). Post-traumatic radioulnar synostosis. Journal of Trauma, 18: 467-468. Y O N G - H I N G K and T C H A N G S P K (1983). Traumatic radioulnar synostosis treated by excision and a free fat transplant: a report of two cases. Journal of Bone and Joint Surgery, 65B: 433-435. Z A N C O L L I E A and A N G R I G I A N I C (1988). Posterior interosseous island forearm flap. Journal of H a n d Surgery, 13B: 130 135.
Accepted: 20 July]i995 Mimlo Sugimoto, MD, Department of Pathology, OSAKA University Medical School, 2-2, Yamadaoka, Suita, 565, Japan. © 1996 The British Society for Surgery of the Hand