Review Question - QID 219835

The patient has evidence of heterotopic ossification (HO) and suspected synostosis after a terrible triad injury treated non-operatively. Prior to planned excision, the HO should be allowed to mature (typically at least 6 months) and should then be characterized by a CT scan with 3D reconstructions.

Heterotopic ossification (HO) and formation of a radioulnar synostosis are known complications of proximal radial head fracture-dislocations and terrible triad injuries. A CT scan with 3D reconstructions represents the best study to obtain to characterize the extent of the HO and/or synostosis, to determine whether operative intervention is necessary, and to determine what surgical approach to use. Though the exact timing of resection is controversial, it is recommended to allow the HO to mature for at least 6 months prior to considering resection in the setting of general trauma.

Jupiter et al. reviewed the operative treatment of post-traumatic proximal radioulnar synostosis. The authors retrospectively reviewed the results of operative resection of a post-traumatic proximal radioulnar synostosis performed by one surgeon in eighteen elbows over eight years. The resection was performed an average of nineteen months after the injury, with the authors finding that those without recurrence regained an average of 139 degrees of rotation of the forearm. They concluded that operative resection of a post-traumatic proximal radioulnar synostosis led to good results despite a lack of adjuvant radiation therapy or anti-inflammatory medication.

Osterman et al. reviewed the optimal management of post-traumatic radioulnar synostosis. The authors note that surgical intervention for synostosis is the standard of care and is determined based on the location of the bony bridge, with optimal surgical timing occurring after a 6- to 12-month period of bony maturation but early enough to prevent further stiffness and contractures. They concluded that adjuvant therapy, such as anti-inflammatories and radiation, is not considered necessary for all cases but can be beneficial in patients with high-risk factors such as recurrence or traumatic brain injury.

Figures A and B represent oblique and lateral elbow radiographs demonstrating evidence of post-traumatic heterotopic ossification.

Incorrect Answers:
Answer 2: Radial head excision alone without replacement in this patient would likely result in long-term longitudinal forearm instability.
Answers 3 and 4: Indomethacin and radiation can be considered immediately post-operatively, but are not indicated at 3 months post-injury and would not decrease the already accumulated HO.
Answer 5: Elbow arthroscopy can be used to approach HO excision such as this, but the HO should be allowed to mature and a CT scan should be obtained pre-operatively to characterize the ossification and determine whether or not arthroscopic excision can be performed safely.