Between September 1996 and September 2001, we managed fourteen children and
adolescents who had posttraumatic stiffness of the elbow with use of a
prospective standardized protocol. The mean age of the patients was fourteen
years (range, five to eighteen years). The cause of the elbow contracture was
a lateral humeral condylar fracture in three patients, a supracondylar humeral
fracture in four, and a fracture-dislocation in seven. The original fracture
treatment had consisted of closed reduction in four patients, open reduction
and internal fixation with Kirschner wires in nine, and open reduction and
internal fixation with screws and plating in one. Casting was used in all
patients for a mean of five weeks. In all patients, more than fifty sessions
of physical or occupational therapy had been carried out prior to referral.
Eleven patients had undergone a mean of 3.2 previous operative procedures
(range, two to eleven procedures). Five of these operations had been performed
with the primary goal of improving range of motion. The patients included five
girls and nine boys. The dominant limb was affected in eight patients. The
distraction procedure was performed at a mean of 20.5 months (range, three to
120 months) after the initial injury.
The indication for surgery was defined as a persistent loss of elbow motion
that had caused a limitation in the activities of daily living for at least
six months despite intensive physical or occupational therapy. Specific
details on the patients can be found in the Appendix. The study was approved
by the hospital review board.
A standardized protocol was used to evaluate all
patients12.
Preoperative assessment included physical examination, a detailed history of
the injury and previous treatment, and a review of hospital charts and all
available previous radiographs. The radiographic evaluation included
conventional anteroposterior and lateral radiographs as well as
high-resolution computed tomography scans with a 1-mm slice thickness. Nerve
conduction velocity testing of the radial, median, and ulnar nerves was
performed for all patients. At the time of follow-up, pain was rated according
to severity and the frequency of occurrence, with visual analog scales being
used to assess peak and general levels of elbow pain during the day and at
night. The function of the affected elbow with respect to activities of daily
living, hobbies, and sports was recorded, and patient satisfaction was
assessed. Elbow function was determined with use of the questionnaire
developed at the Mayo Clinic on the basis of the ability to carry out twelve
common tasks13. The
elbow score as described by
Morrey11 was
calculated for each patient.
The physical findings at the time of follow-up consisted of the measured
range of motion of the elbow, an assessment of pain during movement, elbow
stability, and motor and sensory examination with determination of two-point
discrimination and grip strength with use of a Jamar hydraulic hand
dynamometer. Patient satisfaction was evaluated with use of a visual analog
scale ranging from 0 to 10 points. Stability was tested manually, and the
elbow was classified as stable (0 points), mildly unstable (1 point; defined
as <5° of varus-valgus laxity in either direction without symptoms),
moderately unstable (2 points; defined as 5° to 10° of laxity with
mild symptoms), or severely unstable (3 points; defined as gross varus-valgus
laxity of >10° with serious problems during daily
activities)14.
Anteroposterior and lateral elbow radiographs were evaluated for alignment,
joint-space quality, the presence of joint degeneration, loose bodies, and
heterotopic bone.
We performed a statistical analysis with use of the Student t test for
evaluation of the numerical data and the Wilcoxon rank-sum test for evaluation
of the visual analog scales. The level of significance was set at p < 0.05.
The two-tailed test was used in all cases.
Devices
For intraoperative distraction of the humeroulnar joint, a temporary,
strong fixator with distraction capacity was used to achieve sufficient joint
separation to lengthen the periarticular soft tissues. A standard dynamic
axial fixator (DAF; Orthofix Srl, Verona, Italy) with a standard clamp for the
humeral pins and a T-clamp for two proximal ulnar pins was used in patients
older than fourteen years, whereas a monolateral wrist fixator (Pennig
II-Dynamic Wrist Fixator; Orthofix Srl) with a built-in distractor and a
T-clamp was employed for younger patients. For mobilization of the elbow under
moderate distraction of the joint space and correction of axial malalignment,
a monolateral external fixator with motion capacity (Orthofix Srl) was used.
In children younger than thirteen years of age, smaller pediatric hinges were
used. The fixator consists of two separate slotted bars, which can be
connected on one side to a fixator clamp. The bars overlap each other and a
central screw passes through the slots of both bars, thus allowing free
movement of one against the other until the central connecting unit is
tightened by the surgeon. The central connecting unit consists of a central
locking screw and two additional link-locking screws that allow the surgeon to
fix the position of the central unit at the elbow center of rotation in each
fixator bar independently. Locking of both link-locking screws results in a
hinged movement between both fixator bars corresponding with elbow flexion and
extension, whereas further locking of the central screw serves to immobilize
the humeroulnar joint.
Operative Technique
All operations were performed with the patient under general anesthesia and
without the use of a tourniquet. The patient was placed in the supine
position, with the upper extremity lying on a hand table. Image
intensification was used. Application of the external fixator began with the
fluoroscopic identification of the center of rotation of the humeroulnar
joint. The upper extremity was positioned on the table to obtain a true
lateral view of the elbow (Fig.
1-A), which is the desired view for showing the circular shape of
the radial and ulnar epicondyles symmetrically overlapping each
other15,16.
The tip of the Kirschner wire was placed at the proximal border of the rings
of the humeral condyles as seen on the image-intensifier screen. A pilot wire
was then advanced into the lateral condyle without penetrating the trochlear
area.
After marking of the axis of rotation of the humeroulnar joint, the
cannulated central unit of the elbow fixator was placed over the end of the
Kirschner wire. With use of the fixator as the template for pin insertion, the
humeral pins were inserted from the lateral side at the level of the insertion
of the deltoid muscle, with care being taken to avoid injury to the radial
nerve15. The ulna
was approached from the same direction as the humerus, with alignment of the
ulnar fixation pins with the humeral pins
(Fig. 1-A). Half-threaded
fixator pins with a conical thread of 3.5/4.5 mm and a shaft of 6 mm
(Orthofix, McKinney, Texas) were used in both the humerus and the ulna after
predrilling with a 3.2-mm drill.
For distraction, two additional pins of the same dimension were inserted in
the posteroradial aspect of the olecranon after removal of the elbow fixator
(Fig. 1-A). Intraoperative
distraction of the elbow was then performed with use of a standard dynamic
axial fixator in patients fourteen years of age and older and with use of a
wrist fixator in younger patients (Fig.
1-B). The temporary intraoperative use of the distraction fixator
ensured a symmetric, controlled opening of the humeroulnar joint space. The
humeroulnar joint was distracted twice for up to 12 mm with release of the
tension after each distraction period for fifteen minutes
(Fig. 1-C). The distraction
fixator was then removed, and the elbow motion fixator with small distractors
was applied (Fig. 1-D).
After removal of the pilot Kirschner wire, distraction along the humeral
link of the fixator with use of the small distractor to effect a distraction
of the humeroulnar joint of up to twice the normal joint space (that is, up to
5 mm) was performed. Intraoperative motion was recorded with use of a sterile
goniometer. In cases in which there was a lack of flexion, the locking
position was set between 100° and 120° of flexion. Soft-tissue release
was not performed. Areas of heterotopic ossification were removed through a
limited arthrotomy when indicated. Posterior or rotational elbow subluxation
was reduced intraoperatively with use of the ball-joint capacity of the
fixator. Decompression and neurolysis of the ulnar nerve in the cubital tunnel
without transposition was performed in seven cases in which motor and sensory
compromise had been demonstrated on the preoperative evaluation. In the case
of one patient with incomplete motor palsy of the radial nerve, the deep
branch of the radial nerve was explored and decompressed in the arcade of
Frohse. Additional procedures included hardware removal in the cases of eight
patients. In one patient, skin coverage at the elbow was performed with use of
a full-thickness skin graft after scar tissue removal. In one patient, plating
of a concomitant nonunion of the ulna was necessary. In two patients,
corrective osteotomy and shortening of the radius with plating was performed.
In one patient, distraction of the proximal radioulnar joint with an
additional fixator screw was used to improve rotation of the forearm. In one
patient, a reconstruction of the ulnar collateral ligament complex was
performed with a fascia lata graft. No patient had musculotendinous
lengthening.
Postoperatively, neurologic function was assessed in the recovery room and,
in four cases, the amount of elbow flexion was reduced because of ulnar nerve
dysesthesias. An indwelling axillary catheter was not used, and only mild
analgesic medication was administered orally. The procedure was followed by a
relaxation phase of six days, with the elbow fixator in a locked position.
Indomethacin (25 mg) was administered twice a day for six weeks
postoperatively to reduce the formation of heterotopic bone, and no adverse
effects were observed.
On the sixth postoperative day, mobilization of the elbow was begun. The
central unit of the fixator was unlocked and physiotherapy was started two
times per day, with cryotherapy prior to each session. The fixator was locked
overnight, alternating between maximum extension and maximum flexion. To
increase flexion and/or extension, a standard compression-distraction unit was
sometimes inserted into the cams of the fixator to allow an increase in the
arc of motion. Continuous passive motion was not used. Radiographs were made
at one, seven, fourteen, and twenty-eight days postoperatively and before
removal of the fixator. In order to gain an unobstructed lateral radiographic
view, a 10 × 7-cm radiographic film was placed between the fixator and
the skin with the x-ray machine placed on the ulnar side of the elbow.
Pin-site care with a mild disinfectant and a gauze dressing was performed two
or three times in the first weeks and then was performed with decreasing
frequency. The fixator remained in situ for six to eight weeks. All fixator
pins were removed in the outpatient department without local anesthesia.
Details on all patients are given in the Appendix. None of the patients
were lost to follow-up. The last follow-up was performed at a mean of
forty-four months (range, twenty-five to seventy months) postoperatively. The
external fixator was in place for a mean of seven weeks (range, six to eight
weeks).
Movement
Preoperatively, extension was limited to an average of 44° (range,
20° to 75°), and flexion averaged 81° (range, 40° to
110°). The total arc of motion averaged 37° (range, 0° to
80°). Pronation averaged 46° (range, 0° to 90°), and
supination averaged 56° (range, 10° to 90°). The intraoperative
arc of motion averaged 100° (range, 90° to 130°) and was
significantly greater than the preoperative arc of motion (p < 0.05); the
amount of improvement was only slightly less by the time of the final
follow-up examination. At the time of follow-up, the total range of elbow
motion had improved in all patients. All patients but two gained a functional
arc of motion that measured at least 100°. Extension was limited by an
average of 15° (range, 0° to 45°), and flexion averaged 123°
(range, 110° to 140°). The total arc of motion averaged 108°
(range, 75° to 130°). Pronation averaged 73° (range, 20° to
90°), and supination averaged 75° (range, 10° to 90°).
Stability
No patient had instability at the time of removal of the fixator or at the
time of the most recent follow-up examination. There was no clinical evidence
of varus, valgus, or posterolateral instability, and there was no medial
laxity with stress-testing.
Function
The mean Morrey elbow score was 93 (range, 78 to 97), representing five
excellent, eight good, and one fair result. Preoperative measurements of grip
strength were available for all patients; grip strength improved from a mean
of 12.3 kg preoperatively to a mean of 20.1 kg at the time of the final
followup (p < 0.05). This value was slightly less than the mean grip
strength of 23.5 kg in the unaffected arm. Patients who had sustained an
intra-articular fracture or a fracture-dislocation seemed to have slightly
poorer grip strength than those who had sustained an extra-articular fracture.
Because of the limited number of patients, no significant conclusions could be
drawn. Two patients had palpable crepitus during active flexion and extension
(one patient) or during rotation of the forearm (one patient).
Radiographic Evaluation
Radiographic analysis revealed a preserved joint space in all patients but
one. No patient had reformed excised osteophytes. Three patients had further
progression of degenerative changes of the elbow at a mean of forty-four
months postoperatively. No patient had anterior or posterior soft-tissue
calcifications, except for those that had been present before the index
operation (Figs. 2-A through
2-J).
Complications
Postoperatively, no patient had severe pain requiring additional analgesia.
There was one case of breakage of a humeral fixator pin. There were no cases
of pin-track infection, deep infection, or nerve injury. There were two
additional operations in two patients. In the first patient, who had a full
range of motion of the elbow joint, persistent loss of forearm motion was
treated with removal of scar tissue in the proximal radioulnar joint. In the
other patient, removal of hardware from the radius was combined with tenolysis
of the brachioradialis tendon.
Posttraumatic elbow contracture in children may be caused by simple elbow
dislocations, physeal fractures, complex fracture-dislocations, or
extra-articular
fractures17-22.
Although the increasing knowledge and experience regarding the surgical
treatment of elbow contractures in adults have suggested that good results can
be achieved in most
patients11,23,
Stans et al. reported a more pessimistic prognosis for patients with an age of
twenty-one years or younger who were managed with various surgical
techniques1. Their
retrospective review of a large but heterogeneous group of thirty-seven
patients who had been managed with different open surgical procedures revealed
less successful and predictable results as compared with those in studies of
adults11,12,23,24.
In their subset of twenty-eight patients who had a posttraumatic contracture,
they found that patients with intra-articular abnormalities had less
improvement after surgical release than did those who had extra-articular
abnormalities and that a nearly complete recovery of motion intraoperatively
was followed by a gradual but substantial loss of motion despite intensive
continuous passive motion, extension and flexion splinting, and active
range-of-motion exercises over the subsequent weeks and
months1. Two smaller
series have also been
described4,5.
Mih and Wolf 4 used
an open surgical approach combined with extensive muscle or tendon-lengthening
procedures in nine patients with a mean age of twelve years at the time of
surgery, and Bae and
Waters5 used an
extensile medial approach in twelve adolescents with a mean age of 16.5 years.
The results of the present study will be discussed in comparison with the
results of those three
studies1,4,5.
All three groups of investigators used indwelling axillary catheters for
brachial plexus blockade in most of their patients for three to seven days
postoperatively, coupled with continuous passive motion. This was followed by
periods of splinting overnight in flexion or extension as splinting previously
had been shown to result in improved range of motion in
adults25. This
treatment concept of extensile open surgery, postoperative analgesia with
continuous passive motion, and splinting differs substantially from our
protocol. Intraoperative joint distraction with an external fixation device
slowly separates the joint space and gradually stretches the contracted
ligaments and joint capsule. We believe that continuous joint distraction
might be the crucial factor that is responsible for our improved long-term
results. In agreement with the results reported by Stans et
al.1, we also
observed a slight difference in outcome when we compared elbows with
intra-articular and extra-articular pathology. It should be noted, however,
that the resection of heterotopic bone in four of our patients did add
considerably to the intraoperative range of motion achieved. In contrast with
the other investigators, we did find a continuous gain in motion in the
subsequent mobilization phase and during the period of six months after
removal of the elbow fixator. The amount of motion at the time of the most
recent follow-up nearly reached the amount of motion that had been achieved
intraoperatively. Furthermore, preservation of slight widening of the joint
space was noted to persist for as long as twenty-four months after
distraction.
This technique has been used to treat severe contracture of the elbow in
adults, with remarkable
success11,24.
However, previous cadaveric
studies26 have
shown that gradual distraction by means of the hinged monolateral articulated
frame causes asymmetric opening of the joint, creating varus alignment of the
axis of the upper extremity and stress on the ulnar pin group. We have found
that our technique involving the temporary intraoperative use of a distraction
fixator allows a symmetric controlled opening of the humeroulnar joint
space.
Encouraged by our favorable results in adults, we adapted this technique
for use in children (thirteen years of age and younger) and adolescents
(fourteen years of age and older). Despite concern about the fact that
distraction in the immature skeleton could theoretically affect the physes or
cause osteonecrosis of the trochlea and capitulum by severance of the nutrient
vessels of the ossification
centers27, slow
intraoperative distraction under image intensification did not show any
widening of the physes or dislocation of the epiphyseal ossification centers.
Interestingly, the distraction forces that were needed were lower in children
than in adolescents or adults. Therefore, a low-profile wrist external fixator
with an incorporated distraction unit was found to be sufficient in children
whereas a more substantial device was necessary in adolescents. Postoperative
follow-up did not show growth arrest in any patient in whom the physes had
been healthy before distraction. All children but one were skeletally mature
at the time of the latest follow-up, and they all demonstrated a normal growth
pattern in the affected upper extremity. The youngest child (five years of age
at the time of the index operation) had a follow-up of five years with no
signs of malalignment of the elbow. There were no signs of osteonecrosis in
any patient. Therefore, although the number of patients is low, we believe
that closed distraction of the immature elbow joint over this limited period
of treatment probably does not affect the physes. Moreover, open surgical
procedures with subsequent scarring of the periarticular soft tissues can be
avoided. The unilateral hinged elbow fixator maintains a slight separation of
the joint space throughout the postoperative mobilization phase, thereby
ensuring an unloaded environment under physiologic motion with optimum
conditions to promote cartilage
recovery28. After
careful distraction of the joint space, the soft tissues around the elbow are
allowed to rest for six days postoperatively. This relaxation period is needed
to allow the soft-tissue swelling to subside, to facilitate wound-healing, and
to reduce pain. With the elbow joint immobilized in full flexion, the
distraction effect is maintained.
Whenever possible, mobilization is carried out without additional analgesia
or brachial plexus blockade. The best results are seen when the patient plays
an active role during this
phase29,30.
Physical and occupational therapy therefore is carried out within the limits
of pain. In our experience, this active process involves all tissues,
including muscles and tendons and their proprioceptive units, and is superior
to a merely passive motion protocol.
In summary, controlled distraction of the stiff pediatric elbow joint
following fracture produced favorable results compared with those described in
previous reports.
A table showing the clinical details for all patients is available with the
electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?