Figure 3. Change of Hand Placement Grading Following Surgery

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Surgical Treatment of Spastic Elbow Flexion Contracture. The Leeds Experience

Mr K G Chan1, Mr J Wiper2, Mr W Saeed2, Mrs J Burdon2, Miss M Dolan2

1 RIPAS Hospital, BSB, Brunei2St James’s University Hospital, Leeds, United Kingdom

SummaryThe Leeds Cerebral Palsy Clinic provides surgical treatment through specialist multidisciplinary team approach to patients afflicted by elbow flexion contractures from a variety of causes, as part of a treatment plan for the affected upper extremity. We present our results of surgical release of elbow flexion contractures. All patients gained cosmetic and majority functional improvement of elbow movement. The majority of patients had at least one grade improvement in Pinzur’s Classification1 on follow up. Our results show that this procedure is safe and produces predictable functional and aesthetic improvement with additional benefits (not predicted before surgery). We believe that good clinical judgment and comprehensive functional assessment using simple measurements is adequate in deciding whether surgery is beneficial to these groups of patients.

IntroductionSpastic conditions affecting the upper extremity typically cause flexion contracture at the elbow joint due to spasm of the biceps, brachialis and brachioradialis (Fig. 1 A&B). The first component of this is a fixed joint contracture. The second component is a dynamic contracture, which can be overcome passively to the level of the fixed contracture in the right conditions. It is this latter problem that severely restricts function and lends itself to surgery with a predictably good result (Fig.1 C).

References1. Pinzur MS. Surgery to achieve dynamic motor balance in adult acquired spastic hemiplegia. Journal of Hand Surgery 1985; 10A: 4: 547–553.

Conclusion1.There is a need to look at assessment of elbow using some modern assessments

(e.g. Pinzur’s) as they don't reflect what the patients gain.2.Patient satisfaction 98%

Fig. 2. Elbow release. (A, B) The biceps tendon is exposed and step-lengthened via a transverse approach. (C) Musculoaponeurotic lengthening of the brachioradialis (BR) and brachialis (B) muscles is achieved by excision of a strip of the investing fascia and division of intramuscular tendinous fibres at this level (Bi = biceps).

Fig. 1 (A&B) Pre-operative elbow flexion contracture. (C) Improvement after surgery

Results

1.A total of 31 patients (32 elbows) were treated by surgical release.

2.15 elbows (14 patients) had complete data for analysis.

3.Median age at time of surgery was 17.5 (range 1.8 to 56.8) years. The median duration of follow up was 2.8 (range 0.4 to 4.3) years.

4.There was no deterioration in Pinzur’s classification of upper limb placement (Fig 3). 67% had at least one grade improvement on follow up; the remainder did not change because patients had no voluntary control or are already in the highest grading groups and one patient had no voluntary control and the procedure was carried out purely for cosmetic reasons.

5.The median increase in extension for resting elbow position was 30° (Fig 4).

6.The median gain in active extension was 15 and active ROM was 15° (Fig 5).

7.There was one post op complication (lymphoedema).

Age 41, non CP

Age 18, non CP

Age 40, non CP

Age 41, non CP

Figure 5. Improvement of Active Extension and Active ROM Following Surgery

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Inclusion Criteria

1.If the patient has any use of the limb, cosmesis is required or a better position of the limb would aid personal hygiene then surgery was offered. Age, mental state, decreased sensation or position of the limb distal to the elbow had no impact on the decision for surgery.

2.Only those patients who have both complete sets of pre operative and post operative assessment data are included in the following analysis.

Exclusion Criteria

1.Patients who has contractures as a result of cerebrovascular stroke are excluded

Method and MaterialWe prospectively reviewed all procedures carried out by the senior author for the treatment of elbow flexion contractures. All patients underwent pre and post-operative assessment independent of the surgeon’s assessment. Post operative regimen of four weeks immobilisation of elbow in mid flexion is applied to all patients. Surgery consists of a lengthening of the elbow Flexors (Figs. 2 A-C).

Discussion1.Our results show that the elbow release that we perform is a predictable and

functional procedure with an element of cosmesis.2.Patients report increased balance when walking after having this surgery (although

this is not the primary goal).3.Other benefits of surgery that we also noted from patient’s and carer’s feedback

include ease of personal care and rather unexpectedly reduced pain and discomfort experienced at the elbow as a result of reduced intensity of spasm.

Figure 4 Comparison of Pre and Post Operative Elbow Resting Position

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