Surgical Treatment of Posttraumatic Radioulnar Synostosis in Children *Alan Aner, M.D., *Menachem Singer, M.D., *Zeev Feldbrin, M.D., *Valentin Rzetelny, M.D., and †Elhanan Bar-On, M.D. Study conducted at Wolfson Medical Center, Holon, Israel Summary: The authors describe two children who underwent surgical treatment of radioulnar synostosis. One case involved simple excision; the other, excision and interposition of Gore- Tex vascular graft material. In a review of the literature, no other report of the latter type of surgical treatment was found. A discussion of the literature concerning this rare complication in children and the current surgical treatment options are in- cluded. Key Words: Children—Fracture—Posttraumatic— Radioulnar—Resection—Synostosis. Radioulnar synostosis is a rare but well-recognized complication of both adult and pediatric forearm frac- tures. In children, however, it is significantly less com- mon, with a higher recurrence rate after excision, than in the adult population. Current techniques commonly used in an attempt to prevent recurrence of the synostosis after surgical removal include nonsurgical procedures, such as radiotherapy, or surgical intervention, such as interposi- tion of soft tissue (fat or muscle) or biomaterials (silicone or absorbable gel transosseous screw). Derotation oste- otomies were performed to improve function without ad- dressing the main pathology. We describe two children who underwent successful excision for radioulnar synostosis. One case involved simple excision; the other, excision of the synostosis, followed by wrapping the proximal ulna with Gore-Tex vascular graft. To the best of our knowledge, this is the first reported instance of the use of a Gore-Tex vascular graft for this purpose. CASE REPORTS Patient 1 A 9-year-old boy was admitted to the emergency room with a displaced midshaft fracture of his right radius-ulna following a roller-skating accident (Fig. 1A). On the same day, the fracture was reduced and stabilized in a cast. Twenty days later, control radiographs showed a 30° angulation at the fracture site. Under general anes- thesia, the fracture was reduced and fixed by a Rush pin in the ulna and stabilized in a cast. Two months after this procedure, radiographs showed heterotopic ossification at the fracture site, and the Rush pin was removed. Thirty-three months after the fracture, the patient was seen again and complained mainly about the inability to rotate the forearm. On examination, supination was 10°, and there was no pronation. Flexion-extension of the elbow was full. Radiographs and computed tomography scans showed a radioulnar synostosis type II (Figs. 1B and 1C). The synostosis was surgically excised, and no interpositional material was introduced. Following this procedure, the patient received physical therapy for 5 weeks, using active and passive exercises of the forearm. At last follow-up, 13 months postoperatively, pronation was 45° and supination 70°. There was no clinical or radiologic evidence of recurrence (Fig. 1D). Patient 2 A 12-year-old boy with a fracture of his left midshaft radius and ulna with no other injuries was admitted to the emergency room following a fall from a tree (Fig. 2A). On admission, the fracture was fixed using flexible in- tramedullary nails (NANCY) and stabilized with a cast. One month following surgery, radiologic signs of union were seen, with moderate displacement of the ulna. The cast was removed and physiotherapy started. Six months after surgery, the patient was seen in the outpatient clinic complaining of inability to rotate the forearm. On exami- nation, the forearm was found to be in a fixed midposi- tion, with no pronation possible at all. There was full range of flexion-extension of the elbow and wrist. Ra- Address correspondence and reprint requests to Menachem Singer, M.D., Orthopaedic Department, Wolfson Medical Center, Holon, P.O.B. 5, Holon 58100, Israel (e-mail: m7671866@BEZEQINT.NET). From the *Pediatric Orthopaedic Unit, Orthopaedic Department, Wolfson Medical Center, Holon, Israel; and the †Orthopaedic Unit, Sneider Pediatric Hospital, Petah Tikva, Israel, and Sackler Faculty of Medicine, Tel Aviv University, Israel. None of the authors received financial support for this study. Journal of Pediatric Orthopaedics 22:598–600 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia 598 DOI: 10.1097/01.BPO.0000026119.34569.C8