Procedure 29 Release of a Spastic Elbow Flexion Contracture
See Video 22: Biceps and Brachialis Lengthening
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.
