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Scientific Articles   |    
Mechanical Distraction for the Treatment of Posttraumatic Stiffness of the Elbow in Children and Adolescents
Thomas Gausepohl, MD1; Konrad Mader, MD1; Dietmar Pennig, MD1
1 Department of Trauma Surgery, Hand and Reconstructive Surgery, St.Vinzenz-Hospital, Merheimer Strasse 221-223, D-50733 Cologne, Germany. E-mail address for K. Mader: k.mader@ndh.net
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. One or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Orthofix Inc., McKinney, Texas). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Trauma Surgery, Hand and Reconstructive Surgery, St.Vinzenz-Hospital, Cologne, Germany

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 May 01;88(5):1011-1021. doi: 10.2106/JBJS.D.02090
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Abstract

Background: Elbow contracture is a recognized sequela of elbow injuries in children and adolescents, but previous studies of operative treatment with formal capsular release have demonstrated unpredictable outcomes and unfavorable results.

Methods: Over a period of five years, fourteen children and adolescents with a mean age of fourteen years who had posttraumatic stiffness of the elbow were managed according to a prospective protocol. Eleven patients had undergone a mean of three previous operative procedures before the index operation. After intraoperative distraction with an external fixator, there was a relaxation phase for six days followed by mobilization of the elbow joint under distraction in the fixator for a mean of seven weeks. Intraoperative range of motion under distraction reached a mean of 100°. Open arthrolysis was not performed, but in four children impinging heterotopic bone was removed through a limited approach. Decompression of the ulnar nerve was performed in seven patients.

Results: The mean preoperative arc of total elbow motion was 37°. The mean pronation was 46°, and the mean supination was 56°. After a mean duration of follow-up of thirty-four months, all patients but two had achieved a functional arc of motion of 100°. The mean arc of flexion-extension was 108° (range, 75° to 130°). The mean range of pronation was 73° (range, 20° to 90°), and the mean range of supination was 75° (range, 10° to 90°). There were no pin-track infections or deep infections, and all elbows were stable. At the time of follow-up, three patients had radiographic evidence of humeroulnar degeneration.

Conclusions: Closed distraction of the elbow joint with use of a monolateral external fixation frame with motion capacity yields more favorable results than other previously reported options for the treatment of posttraumatic elbow contractures in children and adolescents.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Shawn W. O'Driscoll, Ph.D., M.D.
    Posted on September 26, 2006
    Functional Arc of Motion
    Mayo Clinic, Rochester, MN 55905

    To The Editor:

    I congratulate the authors on an innovative and informative study. The results are also encouraging. However, I would like to offer a correction on their use of certain terminology.

    The authors state, “all patients but two had achieved a functional arc of motion of 100˚.” The concept of the “functional arc of motion” is well understood and accepted in the field of elbow surgery since its original definition by Morrey, Askew, An, and Chao (1). Morrey, et al., defined the functional arc of motion as a 100˚ arc from 30 to 130˚. Note that it is not simply a 100˚ arc. A patient who has motion from 0 to 100˚ does not have a functional arc of motion, not does a patient who moves from 50 to 150˚.

    In the supplementary material published in the online version of the article, the data for the individual patients reveal that only 3 of the 14 patients achieved a true functional arc of motion; in other words, 11 did not. In all 11 patients, this was due to a lack of sufficent flexion and in two of the patients, there was also inadequate extension.

    While the contribution of their work is important, it is equally important to ensure that such misunderstanding or miscommunication not occur.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    References:

    1) Morrey BF; Askew LJ; An K-N; and Chao EY. A biomechanical study of normal elbow motion. J Bone Joint Surg. 1981;63-A872-877.

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