Radial head and neck fractures represent up to 14% of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient. In up to 39% of proximal radius fractures, there is a concomitant fracture, which can easily be overlooked on the initial standard radiographs. The treatment options for proximal radius fractures in children range from non-surgical treatment, such as immobilization alone and closed reduction followed by immobilization, to more invasive options, including closed reduction with percutaneous pinning and open reduction with internal fixation. The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient; an angulation of less than 30 degrees and translation of less than 50% is generally accepted, whereas a higher degree of displacement is considered an indication for surgical intervention. Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures, range of motion and complications compared to severely displaced fractures requiring surgical intervention. With proper management, good to excellent results are achieved in most cases, and long-term sequelae are rare. However, severe complications do occur, including radio-ulnar synostosis, osteonecrosis, rotational impairment, and premature physeal closure with a malformation of the radial head as a result, especially after more invasive procedures. Adequate follow-up is therefore warranted.

Proximal radioulnar synostosis is a complication after elbow injuries. Various treatment methods have been reported and are associated with unpredictable outcomes. In a prospective study, we evaluated the medium-term effects of proximal radial resection on wrist and elbow function and forearm rotation in 15 cases.

We treated 15 patients with posttraumatic proximal radioulnar synostosis by resection of 1 cm of the proximal radial diaphysis. On the preoperative examination and last follow-up, the Mayo Elbow Performance Score, grip force, visual analog scale for elbow and wrist score, radiographic ulnar variance changes, and elbow range of motion were measured. The Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score and the general satisfaction of the patients were assessed at the final follow-up.

The mean duration of follow-up was 31 ± 13 months. The mean active postoperative supination/pronation arc was 101° ± 45°. The mean increase measured in the ulnar variance at the final follow-up was 3.3 ± 1.5 mm (P = .02). The mean final QuickDASH score was 13.3 ± 12.1. The preoperative and final Mayo scores were 57 ± 10 and 91 ± 7, respectively (P = .01). The general satisfaction with the results of the operation was 86.6%.

We suggest that proximal radial resection for the treatment of posttraumatic proximal radioulnar synostosis shows acceptable results in adults regarding the recovery of range of motion and patient satisfaction. This technique might be considered as a salvage procedure, particularly in cases with previous failed heterotopic resection at the proximal radioulnar joint, resulting in disturbed anatomy.

Level IV, case series, treatment study.

The posttraumatic proximal cross-union of the forearm in childhood is a rare complication after radial head, neck or proximal forearm fractures and elbow dislocations. There is no standardized treatment. Several surgical procedures with or without interposition techniques are described in the literature. The aim of this study was to analyze all children with cross-unions who underwent surgery over the last 15 years. From 1998 to 2013, 8 children with a posttraumatic proximal cross-union of the forearm (Type 3 according to Vince and Miller) received surgical treatment with resection of the cross-union or radial head. Mean age at the time of initial trauma was 9.0±2.56 years (range 6-14 years), age at the time of surgery was 11.9±3.09 years (range 7-16 years). Mean time of resection of the crossunion was 23.2 months. Follow-up time was 10.6 months (range 1-36 months). Five patients had a resection of the cross-union without any interposition techniques, in 2 cases with an additional arthrolysis of the elbow. One patient had an interposition of a local fascia flap. In 2 cases, a primary excision of the radial head, six and seven years, respectively, after trauma, was performed. All patients, except one, had non-steroidal antiinflammatory drugs therapy after surgery. A post-operative irradiation was performed in 3 cases. The mean postoperative range of motion for pronation/supination was 36/0/53°. Controversy remains about the best procedure to adopt for posttraumatic cross-union in childhood. After analysis of our data and the literature, we recommend the resection of the crossunion within 6-24 months of occurrence without necessarily using any interposition techniques. All patients reported an improvement with regard to ordinary activities. In cases of long-term cross-union for several years with ankylosis of the elbow and bony deformities of the proximal radius, an excision of the radial head as salvage procedure is recommended.

Posttraumatic radioulnar synostosis results in functional loss of forearm rotation. Treatment preference is to excise the synostosis when associated fractures have healed or when the process is radiographically static. Interposition material is used in the region of the proximal radioulnar joint or when the medullary canal of the radius or ulna is breached. Irradiation is limited to lesions at or proximal to the radial tuberosity. Postoperative management includes resting splint that holds the extremity in the extremes of forearm rotation, and intermittent active and passive range of motion exercises. Anti-inflammatory medications are used only during hospitalization. Results have shown a good functional arc of pronosupination, and no recurrence, especially when the process is limited to the midforearm.

We report on four children in whom a proximally based, posterior interosseous artery adipofascial flap was used as an adjunct to surgical resection of synostoses of the forearm and elbow. Three traumatic radio-ulnar and one congenital humero-radial synostoses were treated. The postoperative pronation to supination arc of motion was excellent in all of the traumatic cases and fair in the congenital case.

There is no agreement on the ideal treatment of traumatic radioulnar synostosis, especially the type of interposition material to be used. The purpose of this study is to report our experience with synostosis resection and interposition of tensor fascia lata grafts.

A chart review was conducted for all patients treated for posttraumatic radioulnar synostosis between 2000 and 2004. Demographic data, mechanism of injury, length of time to synostosis resection, range-of-motion, patient satisfaction, and postoperative complications were analyzed.

Thirteen patients were identified for this study. The mean preoperative pronation was 14 degrees and the mean postoperative pronation was 62 degrees. The mean preoperative supination was 4 degrees and the mean postoperative supination was 62 degrees. The mean follow-up time was 30 months.

These results indicate that synostosis resection with tensor fascia lata graft interposition is an effective technique for the treatment of posttraumatic radioulnar synostosis.

Therapeutic, Level IV.

Heterotopic ossification about the elbow joint can lead to considerable functional disability, including the loss of forearm rotation. Many procedures have been described for the treatment of proximal radioulnar synostosis. Varying degrees of success have been achieved with regard to the improvement of the flexion arc, but less success has been reported in terms of the restoration of forearm rotation. The success of treatment is associated with the extent of heterotopic ossification, soft-tissue scarring, and anatomical distortion. A new and simple technique to address the unresectable proximal radioulnar synostosis is described.

Seven patients were managed with a partial proximal radial resection distal to the synostosis and were followed for an average of eighty months (range, twenty-four to 144 months).

Forearm rotation improved from an average fixed pronation of 5 degrees to an average arc of 98 degrees (range, 40 degrees to 175 degrees ). The average functional score improved from 57 points preoperatively to 81 points at the time of the final review. Complications included reankylosis at the site of the resection and ulnar-nerve sensory neurapraxia in one patient each.

Resection of a 1-cm-thick section of the proximal part of the radial shaft provides a safe and reliable method of improving forearm rotation in patients with heterotopic ossification of the elbow. A single technical factor that seems to positively influence the result is the application of bone wax at the resection site. This simple procedure is ideally suited for patients who have a proximal radioulnar synostosis that (1) is too extensive to allow a safe and discrete resection, (2) involves the articular surface, and (3) is associated with an anatomical deformity.