A 4-Year-Old Child Who Could Not Supinate Her Forearm

Sanjeev Tuli, MD; Maria Kelly, MD; Kathleen Ryan, MD; Sonal Tuli, MD; Beverly P. Giordano, MS, RN, CPNP, PMHS


J Pediatr Health Care. 2014;28(4):357-360. 

In This Article


Surgical treatment of RUS is controversial and is based more on functional deficits than absolute forearm position (James & Bednar, 2010). No surgical techniques are available to restore complete palm-up/palm-down motion (Wurapa, 2012). Surgical repair usually involves a derotational osteotomy either directly through or distal to the area of synostosis. Derotational osteotomy changes the synostosis position but not forearm motion (James & Bednar, 2010). For unilateral deformities, neutral rotation is the postoperative goal. For persons with bilateral deformities, one extremity is fixed with 20- to 30-degree pronation, and the other arm is placed in either a neutral position or 20 to 30 degrees of supination ( Hung, 2008). Takedown of the synostoses usually results in recurrence, and contracted soft tissues prevent meaningful return of motion (Wurapa, 2012). Surgical complications include ulnar nerve palsy and compartment syndrome. Excision of the radial head may be indicated if the patient has progressive loss of elbow function as a result of impingement of the anteriorly dislocated radial head in patients with type 4 synostosis (VanHeest, Lin, & Bohn, 2013).

Affected persons commonly have hypermobile midcarpal and radiocarpal joints and use scapular and glenohumeral motion to compensate for the lack of motion at the radioulnar joint. Given the dismal outcomes of surgical intervention and the ability to use compensatory mechanisms, most persons with congenital RUS decline surgery. The child in this case study had adapted well to the deformity and had nearly full function of the affected arm. After learning about the various surgical options available, her mother declined surgical intervention. The mother was informed that this child would be able to participate in activities that do not require supination of the right forearm. She was also reassured that RUS does not place this child at increased risk for fractures.

Patients who have Cleary and Omer type 4 synostosis may experience a progressive decrease in elbow flexion. This flexion difficulty develops over time, mandating that patients with this type of synostosis be followed up in orthopedic clinics until they achieve skeletal maturation (VanHeest et al., 2013). The child is this case study had bony synostosis (Cleary and Omer type 2), which is not a risk factor for potential elbow flexion problems.