Treatment of post-traumatic contracture of the elbow in children

SUMMARYThe elbow is the most important joint in the upper extremity, because it places the hand in space. Normally, the arc of flexion-extension ranges from 0 to 145°. This range far exceeds what is normally required for activities of daily living. The stiff elbow is defined as elbow with a reduction in extension greater than 30° and/or a flexion less than 130°.The elbow joint is so prone to stiffness than any other joint even after minimal trauma. Post-traumatic elbow stiffness rarely occurs in children and adolescents, but, this is not to imply that they do not occur.It is important to identify the causes of the restricted motion in post-traumatic stiff elbow. Detailed history and physical examination should be done. Routine AP and lateral radiographs are the most helpful together with lateral tomograms in patients sustaining intra-articular fracture to assess joint congruity. A rational treatment can be constructed only after such a detailed preoperative assessment.Immobilization of the elbow should not exceed 4 weeks to avoid stiffness. In the first two months following injury, active range of motion is used primarily with the child left to move and play. Most often this resolves the problem. In the rare situations of chronic unresponsive stiffness conservative therapy in the form of physiotherapy and splinting, static or dynamic splinting, or serial casting if instituted soon after the contracture develops, often results in improvement of range of motion of the elbow. Aggressive manipulation of the pediatric elbow should be avoided.If nonoperative treatment fails to regain functional range of motion, operative treatment is then indicated. Operative treatment is either open or arthroscopic.Arthroscopic treatment has gained popularity since 1992 with excellent results if performed by expert orthopedic surgeon, but care should be taken to avoid injury of the neurovascular structures which are exposed to more injury by decrease in the capsular volume by contracture. So, arthroscopic release is limited to minimal contractures with flexion contracture less than 45 degrees.The increasing body of knowledge and experience regarding open surgical treatment of elbow stiffness in adults suggests that good results can be expected in most patients, but little information is available regarding the surgical treatment of elbow stiffness in the pediatric population. Some authers reported good results after surgical release in children and adolescents. However, others reported less favorable and less predictable results in pediatric patients. Poor results are anticipated in patients with intrinsic contractures.Patients with extensive intraarticular pathology limiting motion, but who have at least 50 percent of the articular cartilage intact, may benefit from distraction arthroplasty. Patients with intrinsic contractures and less than 50 percent of articular cartilage remaining may be considered for fascial interposition arthroplasty. It is less common to require these modalities in the pediatric population.Rehabilitation is as important as treatment, and the use of CPM and splinting is recommended after surgical treatment.