Mechanical Distraction for the Treatment of Post Traumatic Stiffness of the Elbow in Children and Adolescents

Author(s): Gausepohl T, Mader K, Pennig D

Source: Journal Bone Joint Surg 88A: 1011-1021, 2006.

Summary:

This study is a case series review of 14 children and adolescents that were treated for posttraumatic stiffness of the elbow with a mechanical distraction hinged external fixator.  The indication for surgery was defined as a persistent loss of elbow motion that caused limitation in the activities of daily living for at least 6 months despite intensive therapy.  Eleven patients had undergone a mean of 3.2 previous operative procedures (range, 2 to 11 procedures).  The distraction procedure was performed at a mean of 21 months (range, 3 to 120 months) after the initial injury.  The procedure initially involved the placement of a distraction fixator across the elbow joint via 2 half pins on the radial side of the humerus and 2 in the olecranon.  The ulnohumeral joint was distracted up to 12 mm and two half pins were then placed in the more distal ulna.  A standard hinged unilateral Orthofix external fixator was constructed with and distraction was maintained at twice the normal joint space (that is, up to 5 mm).  Concomitant soft-tissue releases were not performed; however, in 4 patients heterotopic ossification that was limiting motion were removed via a limited arthrotomy.  In situ ulnar nerve neurolysis was performed in 7 patients.  The operative procedure was followed by a relaxation phase of 6 days with the elbow fixator generally in a locked flexed position.  Indomethacin was administered twice a day for 6 weeks postoperatively.  On the 6th postoperative day, physical therapy was started 2 times per day with the fixator locked overnight alternating between maximum extension and maximum flexion.  The external fixator remained in place for a mean of 7 weeks (range, 6 to 8 weeks).

Preoperative extension improved from an average of 44? (range, 20 to 75?) to 15? (range, 0 to 45?) at an average last follow up of a mean of 44 months (range, 25 to 70 months).  Preoperative flexion averaged 81? (range, 40 to 110?) which improved to 123? (range, 110? to 140?).  The total arc of motion preoperatively averaged 37? (range, 0 to 80?) improved to 108? (range, 75 to 130?).  No patients exhibited instability postoperatively and the mean Morrey elbow score was 93 (range, 78 to 97) which represented 5 excellent, 8 good and 1 fair result. Two patients had palpable crepitus and 3 patients had further progression of degenerative changes at final follow-up.  No patient exhibited progression of soft-tissue calcification.  There were no cases of pin tract infection or nerve injury but one patient sustained a humeral fixator pin breakage.

Previous studies have documented variable results for open contracture release in the pediatric and adolescent population.  This study is the first to use a distracting hinged external fixator without open contracture release in the pediatric population with remarkably good results.  The authors report that at final follow-up, the total arc of motion approximated that measured intraoperatively indicating the ability to maintain intraoperative results which is often not found following open procedures. This technique is very untraditional in that no formal joint release was performed, and the ulnohumeral space was distracted intraoperatively to up to 12mm. Further prospective randomized studies may be beneficial to compare the results of the use of a distraction hinged external fixator to those of traditional open procedures.

 

Elbow, Contracture, Pediatric, Hinged, Fixator, Adolescents


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J Bone & Joint Surg