Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents. Surgical technique

[External fixator of the elbow]

AIM OF SURGERY

The placement of an external elbow fixator can be statically carried out as temporary stabilization or as a hinged movement fixator. As a hinged movement fixator a functional follow-up treatment is possible due to control of the joint guidance and reduction of the compromising forces on the osteoligamentous structures.

INDICATIONS

As a temporary stabilization of the elbow, the external fixator is used as a damage control method. As a movement fixator it is used as an additional protection and movement control after complex osteoligamentous interventions and persisting tendency to dislocation of the joint and also as a standalone procedure. In some cases, the procedure is also used in distraction arthrolysis of stiff elbows and as a salvage procedure in patients with relevant comorbidities as part of fracture treatment.

CONTRAINDICATIONS

Inexperience in relation to the procedure as well as a local acute infection at the level of the intended pin locations should specifically be mentioned as contraindications. In addition, compliance and patient understanding of the procedure are essential for the success of treatment.

SURGICAL TECHNIQUE

Soft tissue preparation for pin placement should be preferred over percutaneous incisions to enable a safe bone exposure. Knowledge of the course of neurovascular structures (particularly the radial nerve) is essential. When placing a hinge, knowledge of the position and detection of the idealized center of rotation is of fundamental importance.

POSTOPERATIVE MANAGEMENT

The type of postoperative management required essentially depends on the underlying injury. When placing a hinged fixator, the aim is to enable movement as early as possible. Nevertheless, blocking of the hinged fixator may be useful for a short period of time. Adequate pin care over the duration of the treatment is essential in order to prevent complications.

RESULTS

Good functional results have been reported for the treatment of unstable elbows after primary and secondary placement of a hinged external fixator. Good functional scores and improvement in the range of motion were also recorded in the context of an arthrolysis (additive for open arthrolysis or distraction arthrolysis); however, in contrast a significant number of complications associated with this surgery are likely to emerge. As a definitive salvage procedure, satisfactory results were obtained in a small case series of a selected older patient group with relevant comorbidities.

Spanning External Fixation for the Treatment of Open Joint Injuries in Pediatric Burn Patients

In this article, we report a case series on spanning external fixation for the treatment of open joint burn injuries in a pediatric population. We reviewed the case logs of all orthopedic surgeons from 2000 to 2010 at a burn hospital to identify pediatric patients with open joints secondary to burn injuries.

Nine patients who sustained open joint injuries after a burn and treated with a spanning external fixator (SEF) were identified. Characteristics of the burns included: five elbow, four knee; seven flame, two electrical; average total body surface area affected 49.4% (range 25%–79%); substantial third-degree burn in all patients. Average age at the time of the burn was 8.6 years (range: 2 months–17.9 years). Average time from the burn to SEF placement was 7.1 weeks (range: 3–10.5 weeks). Before SEF placement, an average of 3.8 skin grafting procedures (range: 1–7) were performed to treat the open joint injuries. SEFs remained in place for an average of 6.4 weeks (range: 3–9 weeks). After SEF application, skin graft procedures were performed on average 0.6 times (range: 0–3). There were two complications (22%) considered to be directly associated with the SEF procedure due to the failure of fixation.

Placement of an SEF for an open joint burn injury in children is an effective means to treat these uncommon and difficult injuries. We recommend early SEF to help assist with soft tissue healing and decrease the number of skin grafting procedures in this population.

Outcomes of Paediatric Elbow Dislocations

Introduction: Elbow dislocations are uncommon in children. The treatment and outcomes remains controversial. Materials and methods: We report retrospectively the clinical and functional results of elbow dislocations in children treated in Sahloul University Hospital. Both isolated or pure dislocations and those associated with other injuries were evaluated separately.

Results: Forty-eight children were selected based on inclusion criteria. All were unilateral injuries. Pure dislocations were observed in 19 cases, out of which according to the Robert’s criteria, 13 children (68%) had excellent, three (15%) good, two (10%) fair, and one (7%)poor outcome. Out of the 29 elbow dislocations associated with other injuries, 3 (10%) had excellent, 4 (13%) good, 8 (27%) fair and 14 (50%) poor result. Reviewing the functional results, better range of motion was found in elbows with pure dislocation compared to those with associated injuries.

Conclusion: Prolonged follow-up and effective rehabilitation programs are required for good outcomes.

The "floating forearm" injury in a child: a case report

The case of a eleven-year-old girl who had a fracture dislocation of the left elbow with entrapment of the ulnar nerve into the dislocated ulnar epicondyle anlage and unstable forearm fracture of the ipslateral upper extremity is described. This severe injury to the elbow and the ipsilateral forearm is termed "floating forearm" injury. The forearm was stabilized percutaneously and the elbow fracture dislocation, remaining unstable after internal fixation was treated with a pediatric elbow fixator with motion capacity.

[Fixator with motion capacity and distraction arthrodiatasis in post-traumatic elbow stiffness]

Elbow stiffness may result from trauma, burns and head injuries. It is defined as a total range of motion of <100° with no relevant loss of forearm rotation. Of particular relevance is the flexion deficit. A detailed analysis regarding the development of the elbow stiffness is required together with an exact diagnosis in order to plan the surgical intervention. Closed distraction of the elbow joint as arthrodiatasis with an external fixator is described and evaluated. Adequate long-term results can be achieved with this technique, which reflects proper selection of patients as well as coordination between surgeon, aftercare and physiotherapist. Contraindications are poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection and acute articular infection.

[Distraction arthrodiatasis in elbow stiffness]

OBJECTIVE

Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation are of utmost importance for planning any surgical intervention for elbow stiffness. Most activities of daily living are possible, if the elbow has a range of motion of 100 degrees (30-130 degrees of flexion, Morrey's arc of motion).

INDICATIONS

Stiff elbow, usually defined as less than 30 degrees extension or less than 130 degrees flexion.

CONTRAINDICATIONS

Poor compliance, poorly controlled diabetes mellitus, active hepatitis B and C infection, HIV infection, acute articular infection.

SURGICAL TECHNIQUE

Current operative techniques, such as closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure.

POSTOPERATIVE MANAGEMENT

If indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved.

RESULTS

In 14 children and adolescents the results after 5 years showed an increase of preoperative range of motion from 37 degrees to 108 degrees (flexion/extension; 75-130 degrees ) postoperatively.

Treatment of chronically unreduced complex dislocations of the elbow

Chronic dislocation of the elbow is an exceedingly disabling condition associated with severe instability, limitation of elbow function and significant pain. Due to the potentially conflicting goals of restoring elbow stability and regaining a satisfactory arc of motion, successful treatment is a challenge for the experienced trauma surgeon. We report our treatment strategy in three patients suffering from chronically unreduced fracture-dislocations of the elbow. The treatment protocol consists of in situ neurolysis of the ulnar nerve, distraction and reduction of the joint using unilateral hinged external fixation and repair of the osseous stabilizers. A stable elbow was achieved in all patients, without the need of reconstruction of the collateral ligaments. At final follow-up, the average extension/flexion arc of motion was 107 degrees (range, from 100 degrees to 110 degrees ). The average MEPI score at follow-up was 93, and the average DASH score was 19. This is a promising treatment protocol for the treatment of chronically unreduced complex elbow dislocations to restore elbow stability and regain an excellent functional outcome.

Static progressive splinting for restoration of rotational motion of the forearm

This study examined the use of a bidirectional, patient-directed orthosis that used the principles of static progressive stress to improve forearm rotation. Thirty-eight patients who had limited pronation and supination motions after injuries and who failed other physical therapy techniques underwent a 30- to 60-minute stretching protocol with the orthosis one to three times per day. The mean arc of rotation increased by 42 degrees (range, 0-122) after a mean treatment duration of 12 weeks (range, 3-57). The mean patient satisfaction score was 8.1 points on a scale of 0-10 points. All of the patients completed the treatment and no short-term complications were reported. The gains in motion were comparable to the published results of other orthoses as well as surgical procedures such as external fixators and closed manipulation, but fewer complications occurred with the static progressive stress technique. This orthosis is a useful treatment for patients who have limitations of forearm rotation.