29: Release of a Spastic Elbow Flexion Contracture

Published on 19/04/2015 by admin

Filed under Surgery

Last modified 22/04/2025

Print this page

This article have been viewed 3300 times

Procedure 29 Release of a Spastic Elbow Flexion Contracture

Sandeep J. Sebastin, Kevin C. Chung

See Video 22: Biceps and Brachialis Lengthening

Indications

Fixed elbow flexion contracture as a result of long-standing muscle spasticity as seen in cerebral palsy, stroke, or traumatic brain injury

• More than 40 degrees in patients with volitional control of the elbow and hand

• More than 100 degrees in patients without volitional control (for hygiene)

Examination/Imaging

Clinical Examination

The three major causes of an elbow flexion contracture resulting from spasticity are cerebral palsy, stroke, and traumatic brain injury. There are some differences in the approach to treatment among these three causes.

• Cerebral palsy: The functional use of the hand and upper limb should be evaluated before surgery is considered. This is usually possible only in late childhood (6 to 12 years) and requires multiple visits. The patient should be asked to perform activities with both hands, and videotaping the child is helpful. Reconstruction in older patients should be undertaken carefully because they may have learned to compensate for their disabilities. The aim is to differentiate between spastic muscle, muscle contracture, and joint contracture. This requires the patient to relax and can be difficult. Patients with muscle spasticity demonstrate full range of motion of an affected joint, whereas those with muscle contracture and joint contracture do not. Children do not usually present with joint contractures. It is also important to determine voluntary use of the hand, sensibility, intelligence quotient, and the presence of athetosis because these factors affect the functional result that may be achieved with surgery. Wheelchair-bound patients (with lower limb involvement) are less troubled by elbow spasticity than ambulatory patients because most of their upper limb use is limited to height of the wheelchair.

• Stroke: Surgery for correcting spastic contractures in stroke patients should be considered after they are neurologically stable. Spontaneous neurologic recovery occurs in the first 6 months, and stroke patients are considered to be neurologically stable at 12 months. Hemiplegia with a nonfunctional upper extremity and a less involved lower extremity is the most common presentation in stroke. The degree of spasticity seen in stroke is less because the patients are usually older with weaker muscles and the period of spontaneous recovery is shorter. For the same reasons, the recovery of motor function in stroke is also poor. Therefore, surgical procedures in stroke patients help more in correction of the contracture than in improving function.

• Traumatic brain injury: Spontaneous neurologic recovery can occur for up to 18 months after injury, and surgery should be deferred until this period. In contrast to patients with stroke, patients with traumatic brain injury are likely to be younger with quadriplegic involvement and may have concomitant peripheral nerve injuries, deformities from fractures, and heterotopic ossification. The degree of spasticity is much greater, and the recovery of motor function is also better. However, the degree of cognition and patient cooperation may be lower.

Extent of release: The spastic muscles that contribute to an elbow flexion contracture are the biceps brachii, the brachialis, and the brachioradialis. Depending on the degree of contracture and amount of volitional control, they can be either lengthened or divided sequentially. The lacertus fibrosis is always divided, and an anterior capsulectomy of elbow joint or a Z-lengthening of the antecubital skin may be rarely required.

Imaging

X-ray of the elbow joint: Radiography can help differentiate muscle contracture from joint contracture. It is especially useful in traumatic brain injury, in which heterotopic ossification around the elbow is common and can be associated with compression of the ulnar nerve.

Nerve block: A local anesthetic nerve block can be used to differentiate between muscle spasticity and muscle contracture.

Dynamic electromyography: This helps in identifying spastic and flaccid muscles and can help with the surgical decision-making process. It can show the muscles under volitional control and determine phasic activity.

Surgical Anatomy

The cubital fossa, bounded medially by the pronator teres and laterally by the brachioradialis, contains the lateral cutaneous nerve of the forearm, the tendon of the biceps brachii, the brachial artery, and median nerve. The brachial artery and median nerve are located medial to the biceps brachii, and the lateral cutaneous nerve of the forearm is lateral to the biceps brachii. The lacertus fibrosus, also known as the bicipital aponeurosis, continues distally as deep fascia of the forearm (Fig. 29-1).

FIGURE 29-1

Positioning

The patient is placed in the supine position.

A pneumatic tourniquet is placed as high as possible toward the axilla so that it does not interfere with the operative field (Fig. 29-2).

FIGURE 29-2

Exposures

A 15-cm long “lazy S”–shaped incision is made over the antecubital fossa. The incision begins on the lateral aspect of the arm over the origin of the brachioradialis muscle and gently curves over the antecubital crease distally toward the anteromedial aspect of the forearm (see Fig. 29-2).

The subcutaneous dissection is continued from medial to lateral, to expose the cubital fossa. The lacertus fibrosus and the biceps brachii tendon are identified (Fig. 29-3A and B). The median nerve and brachial artery are identified medial to the biceps tendon, and the lateral antebrachial cutaneous nerve is identified lateral to the biceps tendon emerging from the interval between the biceps and brachialis.

FIGURE 29-3

Pearls

A longitudinal incision on the lateral aspect of the elbow should be considered in patients who have more than 100 degrees of flexion contracture. This will allow design of multiple Z-plasties during wound closure.

Procedure

Step 1

The bicipital aponeurosis, located medial to the biceps brachii tendon, is elevated and should be resected completely (Fig. 29-4).

FIGURE 29-4

Step 2

The contracted biceps brachii is exposed and dissected distal to its insertion. The decision regarding the degree of biceps lengthening should be made at this time. A fractional lengthening is performed for mild contractures, and a Z-lengthening is performed for more severe contractures.

A fractional lengthening is performed by making two transverse and slightly oblique cuts, 1 to 2 cm apart, halfway through the tendinous portion of the musculotendinous junction, with care taken to leave the muscle fibers intact. One cut is made on the lateral side of the tendon, and the other cut is made on the medial side. Passive extension of the elbow allows separation of these tenotomy sites, keeping the muscle in continuity.

A Z-lengthening (step-cut) is performed over as much length of the tendon as possible because this gives more tendon substance to do a strong repair (see Fig. 29-4).

Step 3

The release of the biceps brings the brachialis into view. Depending on the degree of contracture and the volitional control of the patient, a partial or complete release of the brachialis can be done.

A partial release can be done using one or two incisions (Fig. 29-5A). A double incision gives more release. A transverse incision is made over the aponeurotic portion on the anterior aspect of the muscle, leaving the muscle intact. If two incisions are used, they are spaced about 1 to 2 cm apart (Fig. 29-5B).

In patients who have severe contractures without volitional control, the brachialis can be completely transected using electrocautery.

FIGURE 29-5

Step 3 Pearls

If a double-incision release of the brachialis is planned, the proximal incision should be made first. If the distal incision is made first, the proximal migration of the brachialis will make it difficult to make the second incision (Fig. 29-6).

FIGURE 29-6

Step 4

At this point, assessment of the brachioradialis is done. A partial or complete release of the brachioradialis can be performed, depending on the degree of spasticity and the volitional control of the patient. Dissection is carried out between the brachialis and the brachioradialis.

• A partial release is done by detaching the origin of the brachioradialis by a combination of blunt dissection and electrocautery. This allows the origin of the brachioradialis to slide distally.

• A complete release is done by dividing the brachioradialis through its muscle belly using electrocautery (Fig. 29-7).

FIGURE 29-7

Step 4 Pearls

If the brachioradialis has volitional control and the elbow contracture is not very severe, a partial release can be done through a separate 3-cm longitudinal incision made on the dorsoradial aspect of the mid-forearm. The tendinous portion of the brachioradialis is on its deeper surface; the muscle needs to be reflected to visualize this portion. A transverse incision is used to divide only the tendon, keeping the muscle in continuity.

Step 4 Pitfalls

The radial nerve needs to be identified and protected during any procedure on the brachioradialis.

Step 5

An anterior capsulectomy of the elbow joint or a Z-plasty of the antecubital skin is required only in the rare very severe contracture.

Step 6

The biceps tendon is sutured with a Pulvertaft type weave using 3-0 Ethibond sutures with the elbow in 30 degrees of flexion (Fig. 29-8).

FIGURE 29-8

Step 7

The tourniquet is released, hemostasis is secured, and all incisions are closed.

Tension over the wound closure is relieved by advancing the lateral skin by the S-shaped incision.

Postoperative Care and Expected Outcomes

A long-arm plaster of Paris splint that keeps the elbow at 30 degrees of flexion is applied.

Ten days after surgery, the wound is inspected, and sutures are removed. If a Z-lengthening of the biceps was done, the elbow is splinted for an additional 4 weeks in 30 degrees of flexion. Active and passive range of motion is initiated thereafter. Night splints are used for an additional 3 weeks to protect the biceps tendon repair. If only a fractional lengthening of the biceps was done and there was no repair of the biceps tendon, the patient can be started on mobilization immediately.

Patients who undergo fractional lengthening of the biceps can expect a 10- to 30-degree improvement in the flexion contracture without appreciable loss of flexion power. Patients who undergo Z-lengthening can expect up to a 45- to 60-degree improvement in flexion contracture, but they do lose elbow flexion power. It is important to avoid full extension of the elbow in patients with volitional control because difficulty with elbow flexion after a full release may become a greater problem for the patient (Fig. 29-9).

FIGURE 29-9

Mital MA. Lengthening of the elbow flexors in the cerebral palsy. J Bone Joint Surg [Am]. 1979;61:515-522.

This report describes the correction of elbow flexion contracture in 32 elbows of 26 children with cerebral palsy using Z-plasty of the biceps brachii and transverse tenotomy of the brachialis. The average extension gain after surgery is 40 degrees. (Level IV evidence)

Related

Operative Techniques Hand and Wrist Surgery