Research Article| Volume 5, ISSUE 1, P30-41, February 2005

Heterotopic ossification in the forearm

      Heterotopic ossification (HO) resulting in radioulnar cross-union occurs in approximately 2% of all forearm injuries and causes significant functional impairment. Risk factors for cross-union are incompletely understood, however, injuries to the proximal forearm account for the majority of cases. Concomitant central nervous system injury greatly increases the risk for HO after forearm fracture. Although surgical excision of forearm cross-union has produced mixed results in the past, and recurrence of synostosis has been common, more recent treatment attempts have resulted in nearly full recovery of forearm rotation. Questions remain regarding the appropriate timing for excision and the advisability of adjuvant low-dose radiotherapy to prevent recurrence. It would seem that HO resulting from local trauma in the absence of other risk factors can be safely excised 6 to 12 months after injury. Adjuvant radiotherapy may be warranted in more aggressive cases of HO with a greater risk for recurrence, such as those cases involving the proximal forearm or associated with closed head injury.
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        • Viola R.W.
        • Hastings H.
        Treatment of ectopic ossification about the elbow.
        Clin Orthop. 2000; 370: 65-86
        • Hastings H.
        • Graham T.J.
        The classification and treatment of heterotopic ossification about the elbow and forearm.
        Hand Clin. 1994; 10: 417-437
        • Kaplan F.S.
        • Hahn G.V.
        • Zasloff M.A.
        Heterotopic ossification.
        J Am Acad Orthop Surg. 1994; 2: 288-296
        • Garland D.E.
        A clinical perspective on common forms of acquired heterotopic ossification.
        Clin Orthop. 1991; 263: 13-29
        • Angervall L.
        • Stener B.
        • Stener I.
        • Ahren C.
        Pseudomalignant osseous tumor of soft tissue.
        J Bone Joint Surg. 1969; 51B: 654-663
        • Spjut H.J.
        • Dorfman H.D.
        Florid reactive periostitis of the tubular bones of the hands and feet. A benign lesion which may simulate osteosarcoma.
        Am J Surg Pathol. 1981; 5: 423-433
        • Vince K.G.
        • Miller J.E.
        Cross-union complicating fracture of the forearm. Part I: Adults.
        J Bone Joint Surg. 1987; 69A: 640-653
        • Garland D.E.
        • Dowling V.
        Forearm fractures in the head-injured adult.
        Clin Orthop. 1983; 176: 190-196
        • Failla J.M.
        • Amadio P.C.
        • Morrey B.F.
        Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment.
        J Bone Joint Surg. 1989; 71A: 1208-1213
        • Jupiter J.B.
        • Ring D.
        Operative treatment of post-traumatic proximal radioulnar synostosis.
        J Bone Joint Surg. 1998; 80A: 248-257
        • Beingessner D.M.
        • Patterson S.D.
        • King G.J.
        Early excision of heterotopic bone in the forearm.
        J Hand Surg. 2000; 25A: 483-488
        • Abrams R.A.
        • Simmons B.P.
        • Brown R.A.
        • Botte M.J.
        Treatment of posttraumatic radioulnar synostosis with excision and low-dose radiation.
        J Hand Surg. 1993; 18A: 703-707
        • Cullen J.P.
        • Pellegrini V.D.
        • Miller R.J.
        • Jones J.A.
        Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation.
        J Hand Surg. 1994; 19A: 394-401
        • Morrey B.F.
        • Askew L.J.
        • Chao E.Y.
        A biomechanical study of normal functional elbow motion.
        J Bone Joint Surg. 1981; 63A: 872-877
        • Safaee-Rad R.
        • Shwedyk E.
        • Quanbury A.O.
        • Cooper J.E.
        Normal functional range of motion of upper limb joints during performance of three feeding activities.
        Arch Phys Med Rehabil. 1990; 71: 505-509
        • Cleary J.E.
        • Omer G.E.
        Congenital proximal radio-ulnar synostosis. Natural history and functional assessment.
        J Bone Joint Surg. 1985; 67A: 539-545
        • Kanaya F.
        • Ibaraki K.
        Mobilization of a congenital proximal radioulnar synostosis with use of a free vascularized fascio-fat graft.
        J Bone Joint Surg. 1998; 80A: 1186-1192
        • Breit R.
        Post-traumatic radioulnar synostosis.
        Clin Orthop. 1983; 174: 149-152
        • Chapman M.W.
        • Gordon J.E.
        • Zissimos A.G.
        Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna.
        J Bone Joint Surg. 1989; 71A: 159-169
        • Ring D.
        • Jupiter J.B.
        • Simpson N.S.
        Monteggia fractures in adults.
        J Bone Joint Surg. 1998; 80A: 1733-1744
        • Vince K.G.
        • Miller J.E.
        Cross-union complicating fracture of the forearm. Part II: Children.
        J Bone Joint Surg. 1987; 69A: 654-661
        • Stern P.J.
        • Drury W.J.
        Complications of plate fixation of forearm fractures.
        Clin Orthop. 1983; 175: 25-29
        • Mikic Z.D.
        • Vukadinovic S.M.
        Late results in fractures of the radial head treated by excision.
        Clin Orthop. 1983; 181: 220-228
        • Karunakar M.A.
        • Cha P.
        • Stern P.J.
        Distal biceps ruptures. A followup of Boyd and Anderson repair.
        Clin Orthop. 1999; 363: 100-107
        • Botting T.D.
        Posttraumatic radio-ulna cross union.
        J Trauma. 1970; 10: 16-24
        • Bauer G.
        • Arand M.
        • Mutschler W.
        Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis.
        Arch Orthop Trauma Surg. 1991; 110: 142-145
        • Garland D.E.
        • Blum C.E.
        • Waters R.L.
        Periarticular heterotopic ossification in head-injured adults. Incidence and location.
        J Bone Joint Surg. 1980; 62A: 1143-1146
        • Burd T.A.
        • Lowry K.J.
        • Anglen J.O.
        Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures.
        J Bone Joint Surg. 2001; 83A: 1783-1788
        • Seegenschmiedt M.H.
        • Makoski H.B.
        • Micke O.
        Radiation prophylaxis for heterotopic ossification about the hip joint—a multicenter study.
        Int J Radiat Oncol Biol Phys. 2001; 51: 756-765
        • McAuliffe J.A.
        • Wolfson A.H.
        Early excision of heterotopic ossification about the elbow followed by radiation therapy.
        J Bone Joint Surg. 1997; 79A: 749-755
        • Lichtman D.M.
        • Ganocy T.K.
        • Kim D.C.
        The indications for and techniques and outcomes of ablative procedures of the distal ulna.
        Hand Clin. 1998; 14: 265-277
        • Kamineni S.
        • Maritz N.G.
        • Morrey B.F.
        Proximal radial resection for posttraumatic radioulnar synostosis.
        J Bone Joint Surg. 2002; 84A: 745-751
        • Ring D.
        • Jupiter J.B.
        Operative release of ankylosis of the elbow due to heterotopic ossification. Surgical technique.
        J Bone Joint Surg. 2004; 86A: 2-10