Article ID: WMC00596 ISSN

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1 Article ID: WMC00596 ISSN "Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft" Author(s):Dr. Bhavuk Garg, Prof. Prakash Kotwal Corresponding Author: Dr. Bhavuk Garg, Senior Research Associate, AIIMS - India Submitting Author: Dr. Bhavuk Garg, Senior Research Associate, AIIMS - India Article ID: WMC00596 Article Type: Case Report Submitted on:11-sep-2010, 08:07:01 AM GMT Article URL: Subject Categories:ORTHOPAEDICS Keywords:Radio-Ulnar Synostosis, Damru Published on: 12-Sep-2010, 12:21:16 AM GMT How to cite the article:garg B, Kotwal P. \"Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft\". WebmedCentral:ORTHOPAEDICS 2010;1(9):WMC00596 Source(s) of Funding: None Competing Interests: None Webmedcentral > Case Report Page 1 of 9

2 \"Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft\" Abstract Case Report(s) Radioulnar synostosis is a well recognized and disabling complication of fractures of forearm bones; however it is very rare following single forearm bone fracture. Excision of synostosis alone carries a high potential for recurrence. Therefore interposition of varieties of foreign or biologic materials has been recommended. We describe a patient with a fixed type II diaphyseal radioulnar synostosis following an isolated fracture of ulna treated with radical bony excision and tensor fascia lata graft interposition. Introduction Synostosis or cross-union between the radius and ulna resulting in complete loss of supination and pronation is a well recognized complication of fractures of forearm bones, which significantly impairs the ability to perform many activities of daily life (Vince and Miller, 1987). It is very uncommon following a single forearm bone fracture where overuse of injured extremity can lead to exuberant callus formation leading to synostosis between radius and ulna (Posman and Little, 1986). Excision of synostosis alone carries a high potential for recurrence. Therefore interposition of varieties of foreign or biologic materials including bone wax, silicone, muscle, fat, and fascia has been recommended. Additionally use of nonsteroidal anti-inflammatory medicines and postoperative radiotherapy has also been reported to decrease the chances of recurrence (Jones et al, 2004). We describe a patient with a fixed type II diaphyseal radioulnar synostosis following an isolated fracture of ulna treated with radical bony excision and tensor fascia lata graft interposition. A 23 years old laborer sustained an isolated fracture of the right distal ulna on following a fall from bicycle, which was immobilized in an above elbow plaster cast by a local practitioner. Patient removed the cast himself after 10 days and continued to work. Patient presented to us after six months of injury with range of motion of 50 pronation to 300 supination and normal wrist and elbow movements. X-rays (Fig 1.) revealed a radio-ulnar synostosis involving distal 1/3rd of the right forearm. On 5th January 2006, the synostosis was excised and a tensor fascia lata graft harvested from patient s left thigh was interposed between the radius and ulna. Surgery was conducted under general anaesthesia and above elbow tourniquet control. A volar approach was used and care was taken for minimal soft tissue dissection. (Fig. 2) The synostosis was excised with the help of osteotomes and roungers. A tensor fascia lata graft, measuring 8 x 4 cm. was taken from the opposite thigh and wrapped circumferentially around the ulna and ends were sutured with 2-0 vicryl. Full pronation and supination was achieved under anaesthesia. Tourniquet was deflated and hemostasis achieved. Wound was closed in layers and a compression bandage was applied. Patient was started on physiotherapy from the next morning with a unique Indian musical instrument called Damru (Fig. 3) which is played by repeated supination, pronation movement of forearm. After 3 months, patient s range of motion was 700pronation to 900supination (Fig. 4). This range of motion was same at his last follow up on 15th May Radiographs showed no evidence of recurrence. Discussion Post traumatic radio-ulnar synostosis is a rare Webmedcentral > Case Report Page 2 of 9

3 complication of forearm bone fracture and is even rarer after isolated fracture of single bone forearm (Posman and Little, 1986). A number of risk factors have been implicated following fracture of both bones of forearm, including both fractures at the same level, severe trauma with marked soft tissue damage, open reduction and internal fixation of both fractures through single incision, delayed open reduction and internal fixation and closed head injury leading to an increased propensity towards heterotopic bone formation. Only a few cases have been described in literature following isolated fracture of distal ulna and the usual factor implicated is overuse of the injured extremity leading to exuberant callus formation, further leading to synostosis. This exuberant callus may also result from subperiosteal hemorrhage, simultaneous tear of the periosteum of radius or it may actually represent a myositis ossificans of the interosseous muscles. It is often very difficult to assess the degree of soft tissue injury as displacement of ulna is prevented by intact radius(posman and Little, 1986). Vince and Miller (Vince and Miller, 1987) classified radio-ulnar synostosis according to their location- Type I Distal intraarticular area of radius and ulna synostosis, which classically follows both bone forearm fracture at same level, can also occur following single bone forearm fracture. This complication was treated by excision of the mass with interposition of tensor fascia lata. In the postoperative rehabilitation, a unique Indian instrument called Damru is a useful adjunct. References 1. Friedrich JB, Hanel DP, Chilcote H et al. The use of tensor fascia lata interposition grafts for the treatment of posttraumatic radioulnar synostosis. J Hand Surg [Am] May-Jun;31(5): Jones NF, Esmail A, Shin EK. Treatment of radioulnar synostosis by radical excision and interposition of a radial forearm adipofascial flap. J Hand Surg [Am] Nov;29(6): Posman CL, Little RE. Radioulnar synostosis following an isolated fracture of the ulnar shaft. A case report. Clin Orthop Relat Res Dec;(213): Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am Jun;69(5): Type II Middle third and distal third nonarticular area of radius and ulna Type III Proximal third of radius and ulna However they did not discuss the rationale for their grading system. Most of the recent literature on the treatment of post traumatic radio-ulnar synostosis has advocated excision of synostosis followed by interposition of either foreign or biologic material. Non-biologic materials have been superseded by the use of fascia, fat and muscle as they prevent scar formation better than any foreign material. In our case, we used the tensor fascia lata graft (Friedrich et al, 2006) as it is easy to harvest and there is less donor site morbidity. Whatever may be the interposition material, early postoperative mobilization is the key to success. The value of continuous passive motion, low dose postoperative radiation and bisphosphonates remains to be determined, but they should probably be considered as adjutants. In our case, Damru, a unique Indian musical instrument proved to be very useful. Recurrence more than 6 months after excision is unusual. Conclusion This case report emphasizes the fact that radioulnar Webmedcentral > Case Report Page 3 of 9

4 Illustrations Illustration 1 Preoperative X-rays showing radio-ulnar synostosis involving distal 1/3rd of the right forearm Illustration 2. Intraoperative photograph showing radio-ulnar synostosis involving distal 1/3rd of the right forea Webmedcentral > Case Report Page 4 of 9

5 Illustration 3 A unique Indian musical instrument called 'Damru' which is played by repeated supination, pronation Illustration 4 Final range of motion Webmedcentral > Case Report Page 5 of 9

6 Reviews Review 1 Review Title: i like this article... Posted by Dr. Vaibhav Jain on 31 Dec :14:31 PM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Yes 3 Is this a new and original contribution? Yes 4 Does this paper exemplify an awareness of other research on the topic? Yes 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? Yes 8 Is the quality of the diction satisfactory? Yes 9 Are the illustrations and tables necessary and acceptable? Yes 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 9 Comment: i like this article very much, its very informative... Competing interests: no... Invited by the author to make a review on this article? : No Experience and credentials in the specific area of science: little experience... Publications in the same or a related area of science: No How to cite: Jain V.i like this article...[review of the article '"Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft" ' by ].WebmedCentral 1970;1(12):REVIEW_REF_NUM313 Yes Webmedcentral > Case Report Page 6 of 9

7 Review 2 Review Title: review: radio-ulnar synostosis Posted by Sumit Batra on 18 Nov :41:00 PM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Yes 3 Is this a new and original contribution? Yes 4 Does this paper exemplify an awareness of other research on the topic? Yes 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? No 8 Is the quality of the diction satisfactory? Yes 9 Are the illustrations and tables necessary and acceptable? Yes 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 6 Comment: a few language modifications may be made to improve the quality of written english. pronation and supination movements have been recorded from 5 degrees pronation to 30 degrees supination but the mark of degrees has not been printed as superscript. this may be modified. No Competing interests: no Invited by the author to make a review on this article? : Yes Experience and credentials in the specific area of science: it is a very rare condition and i have seen only a few cases of radio-ulnar synostosis. Publications in the same or a related area of science: No How to cite: Batra S.review: radio-ulnar synostosis [Review of the article '"Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft" ' by ].WebmedCentral 1970;1(11):REVIEW_REF_NUM146 Webmedcentral > Case Report Page 7 of 9

8 Review 3 Review Title: Interesting case of Synostosis after a single bone fracture Posted by Lalit Sharma on 12 Nov :08:00 PM GMT 1 Is the subject of the article within the scope of the subject category? Yes 2 Are the interpretations / conclusions sound and justified by the data? Yes 3 Is this a new and original contribution? Yes 4 Does this paper exemplify an awareness of other research on the topic? Yes 5 Are structure and length satisfactory? Yes 6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? 7 Can you suggest any reductions in the paper, or deletions of parts? No 8 Is the quality of the diction satisfactory? Yes 9 Are the illustrations and tables necessary and acceptable? Yes 10 Are the references adequate and are they all necessary? Yes 11 Are the keywords and abstract or summary informative? Yes Rating: 8 Comment: No This is an innovative use of an indian musical instrument. Although, Radio-ulnar synostosis is a common presentation, however, following a single bone fracture is very rare, which makes this case interesting. Competing interests: no Invited by the author to make a review on this article? : Yes Experience and credentials in the specific area of science: I have seen many case of Post-tramatic synostosis of forearm bones, but all were after a both bone fracture. Publications in the same or a related area of science: No How to cite: Sharma L.Interesting case of Synostosis after a single bone fracture[review of the article '"Radio-Ulnar Synostosis Following Isolated Fracture Of Shaft Of Ulna And Its Treatment By Radical Excision And Interposition Of Tensor Fascia Lata Graft" ' by ].WebmedCentral 1970;1(11):REVIEW_REF_NUM136 Webmedcentral > Case Report Page 8 of 9

9 Disclaimer This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party. Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website. Webmedcentral > Case Report Page 9 of 9