Working Diagnosis:
Radioulnar Synostosis, with subsequent shortening of the left arm.

Treatment:
Conservative management. Patient has minimal disability with mild rotational abnormality. Simple observation of growth and development is appropriate. Patient will follow up yearly ath the Orthopaedice Upper Extremity Clinic at Shriner Hospital.

Outcome:
Good prognosis.

Author's Comments:
Surgical interventions for radioulnar synostosis have low success rates and are rarely attempted unless patient has significant functional loss (which this patient does not have). His limb length discrepancy is minimal on exam, as is the rotational deformity of 35 degrees pronation. If the deficit remains constant, compensation should be easily achieved.

A both-bone forearm rotational osteotomy can be performed to place the arm in a different position, closer to 90 degrees. However, with our technological society and use of computers this would most likely put him at a greater disadvantage. Currently patient is adapting well, training himself to function with the rotational loss.

Stopping growth of the "normal" arm is also sometimes considered. Therefore, despite rotational differences the limb lengths are symmetric. However, this is usually not done for the upper extremities. As a patient continues to grow, if the discrepancy enlarges, this procedure would become more relevant.

Overall, the surgical options for radioulnar synostosis can be fraught with potential complications. With adequate compensation and otherwise normal development, observation and yearly progress evaluations are ideal for our patient.

References:
1. Physicians at Shriner Hospital for Children, Orthopaedic Upper Extremity Clinic, Greenville, South Carolina.
2. Tachdjian, MO. The Neck and Upper Limb. In: Clinical Pediatric Orthopedics. Stamford, CT: Appleton and Lange; 1997. p.306-8.
3. Cleary JE, Over GE, Jr. Congenital proximal radio-ulnar synostosis. Natural history and functional assessment. Journal of Bone & Joint Surgery - American 1985; 67(4):539-45.

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