Radioulnar Synostosis Using a Vascularized Pedicled Radial Periosteal Flap for Supination Deformity in Residual...

Supination posture is a common secondary deformity in brachial plexus birth injury (BPBI) that results in functional upper limb impairment. Radioulnar synostosis using a vascularized ulnar periosteal flap has recently been reported, with dorsal forearm scarring as the main reported disadvantage. This report evaluates outcomes in a series of children with forearm supination deformity and complete pronation palsy secondary to severe BPBI undergoing radioulnar synostosis in slight pronation using a novel proximal pedicled vascularized radial periosteal flap (VRPF).

We completed a retrospective analysis of patients with residual BPBI who underwent radioulnar synostosis with an antegrade proximally pedicled VRPF transfer to the volar ulna. The interosseous membrane was released when necessary, and the forearm was fixed in 10°-20° of pronation for 4 weeks, using a Kirschner wire. Inclusion criteria included complete pronation paralysis, presence of active wrist extension, and a minimum of 6 months follow-up. Demographic information, preoperative passive pronation, postoperative forearm rotational position, radiographic union, and parental satisfaction using a 4-point Likert-type ordinal scale were evaluated.

Twenty-one children with a mean age of 59 months (range 24-132 months) were included in this report. Mean preoperative passive forearm pronation was -9° (range -60° to 45°) and mean follow-up was 17.1 months (range 9-32 months). A partially ossified radioulnar synostosis was radiographically observed at 4 weeks in all cases. Mean postoperative rotational position measured 20° of pronation (range 0°-30°). All parents expressed satisfaction with both functional and cosmetic outcomes.

Forearm fusion achieved by radioulnar synostosis using a proximally pedicled VRPF appears promising as an effective and rapid technique for correction of BPBI-associated supination deformity and should be further explored in the management of residual supination deformity.