Congenital unilateral proximal radioulnar synostosis: A surgical case report

Abstract

Rationale: Congenital proximal radioulnar synostosis is a rare genetic malformation of the upper limb. This deformity, which is found mainly in preschool-aged children, has no recognized diagnosis and treatment. Current diagnostic methods cannot effectively assess both bone structure and soft tissue abnormalities, and most surgical treatments introduce complications and do not prevent recurrence. More work is needed; therefore, to address the diagnosis and treatment of this disease.

Patient concerns: An 8-year-old male patient was hospitalized in our department. He reported deformity and limited motion in his right elbow for the past 2 years. He denied a traumatic or family history of bony malformation. The chief complaint at the time of the hospitalization was the limitation in forearm rotation.

Diagnosis: Digital radiography of the right elbow joint showed proximal radioulnar synostosis and a valgus deformity. A 3-dimensional computed tomography scan further showed proximal ulna and radius dysplasia as well as anterior dislocation of the radius head. The patient was diagnosed with congenital right proximal radioulnar synostosis.

Interventions: Surgical procedures included arthrolysis of the right proximal radioulnar joint, osteotomy of the proximal radius, internal fixation with Kirschner wires, and reconstruction of the annular ligament. The right elbow was immobilized in plaster in a flexion and supination position for 2 weeks.

Outcomes: Recurrence of the right proximal radioulnar synostosis was observed during the 6-month follow-up, but the rotation function of the patient's forearm was significantly improved.

Lessons: The findings from this case suggest that we should carefully monitor all patients younger than 6 years old who report long-term issues with forearm rotation. This case also highlights the need to assess soft tissue and epiphysis abnormalities in addition to bone assessments via digital radiography and 3-dimensional computed tomography. We suggest that surgery should not be performed until the proximal radius epiphysis has closed. Not all cases require surgical treatment, but when surgery is needed, a suitable method should be selected according to the individual needs of the patient. Any surgery performed should treat both the bony malformations and soft tissue abnormalities to maximize the therapeutic effect and reduce complications during and after surgery.

Figure 1

(A) Carrying angle: 25°. (B) Elbow flexion: 120°. (C) Forearm supination: 60°. (D) Forearm supination: 80°.

Figure 2

(A) Preoperative X-ray of the anteroposterior elbow. (B) Preoperative X-ray of the lateral elbow.

Figure 3

(A) Preoperative 3-dimensional computed tomography (3D CT) scan of the anteroposterior elbow. (B) Preoperative 3D CT scan of the oblique elbow. (C) Preoperative 3D CT scan of the lateral elbow.

Figure 4

(A) Congenital proximal radioulnar synostosis and anterior dislocation of the radial head was confirmed during surgery, and the epiphysis of the radius was closed. (B) The proximal radius and ulna were separated, reduction of the radial head was performed by osteotomy, and a lateral fascia patch with blood supply was prepared to repair the annular ligament. (C) The radial head was fixed on the radial shaft through the humeral head. The elbow joint was fixed in 90° flexion, and then the annular ligament was reconstructed using the fascia patch.

Figure 5

(A) Immediate postoperative X-ray of the anteroposterior elbow. (B) Immediate postoperative X-ray of the lateral elbow.

Figure 6

(A) X-ray of the anteroposterior elbow at the 4-wk postoperative follow-up. (B) X-ray of the lateral elbow at the 4-wk postoperative follow-up.

Figure 7

(A) X-ray of the anteroposterior elbow at the 2-mo postoperative follow-up. (B) X-ray of the lateral elbow at the 2-mo postoperative follow-up.

Figure 8

(A) X-ray of the anteroposterior elbow at the 4-mo postoperative follow-up. (B) X-ray of the lateral elbow at the 4-mo postoperative follow-up.

Figure 9

(A) Carrying angle (15°) at the 6-mo postoperative follow-up. (B) The range of flexion (130°) at the 6-mo postoperative follow-up. (C) Pronation (15°) at the 6-mo postoperative follow-up. (D) Supination (90°) at the 6-mo postoperative follow-up.

Figure 10

(A) X-ray of the anteroposterior elbow at the 6-mo postoperative follow-up. (B) X-ray of the lateral elbow at the 6-mo postoperative follow-up.