Anterior elbow release for post-traumatic flexion contractures in patients 21 years or younger

Clinical Outcomes Following Surgical Management of Post-Traumatic Elbow Contractures in the Pediatric Age Group: A Meta-Analysis and Systematic Review

PURPOSE

Post-traumatic elbow stiffness is a common occurrence resulting in potentially substantial functional limitations in both daily activities and recreational endeavors. In children, this can be particularly difficult given the early stages of childhood and development and the challenges of rehabilitation. Several studies have reported favorable results of elbow contracture releases in children, resulting in improvements in outcomes. This meta-analysis aimed to determine the efficacy and safety of elbow contracture releases in the pediatric population (<18 years), along with subgroup analyses comparing age groups, operative approach, and post-traumatic versus nontraumatic etiologies.

METHODS

Meta-analysis was performed with a multidatabase search (PubMed, OVID, EMBASE, and Medline) according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines on September 25, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed.

RESULTS

Seven studies were included, comprising 114 post-traumatic elbow contractures. Mean age was 13.7 years. Contracture releases of the elbow led to improvements in flexion-extension arc of motion by 48º, and pronosupination arc of motion by 22º. Subgroup analysis comparing age groups of <10, 10-14 and 15-18 years showed greater improvements in flexion-extension arc in the older age group, whereas subgroup analysis comparing injury patterns revealed a larger improvement in pronosupination motion for radial head fractures. Comparing open and arthroscopic procedures, open releases had greater improvement in both flexion-extension and pronosupination motion by 18º and 21º, respectively, although there were limited patients in the arthroscopy group.

CONCLUSION

Operative management of pediatric elbow contractures is effective. Older children, children with radial head fractures, and those receiving open contracture releases may be more likely to have greater improvements.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outcomes of Therapy and Ulnar Nerve Transposition for Elbow Stiffness After Pediatric Medial Epicondyle Fractures

Purpose

Following medial epicondyle fractures, a subset of pediatric patients has persistent limitations in elbow motion. This study soughted to understand the patient characteristics of this group and to assess the effectiveness of intensive therapy and ulnar nerve transposition in improving elbow range of motion and patient-reported outcomes.

Methods

A cohort of 31 pediatric patients with stiffness after elbow trauma was narrowed to 8 pediatric patients (7 female) ranging in age from 9 to 14 years, who were diagnosed with medial epicondyle fractures and underwent intensive therapy and ulnar nerve transposition with or without elbow joint release. We collected demographic and objective data as well as subjective data including Patient-Reported Outcome Measurement Information System (PROMIS) scores before and after ulnar nerve transposition.

Results

Following initial intensive therapy, elbow range of motion improved by an average of 56°, and 7 of the 8 patients reached a functional motion arc of 100°. Subsequently, following ulnar nerve surgery with or without elbow release, motion improved by an average of 22°, and 5 of the 8 patients demonstrated improvement from this intervention. Surgery led to improvements in subjective outcomes with an improvement in PROMIS mobility scores by an average of 9 points, pain interference by 6 points, and upper extremity scores by 3 points. Based on a previously determined minimally important difference of three points, these indicate significant clinical improvements.

Conclusions

A subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release. However, not all patients were improved after ulnar nerve surgery, and the identification and treatment of ulnar nerve irritability may not fully resolve preoperative symptoms in all patients.

Type of study/level of evidence

Therapeutic IV.

Supine-Position Ultrasound-Assisted Arthroscopic Surgery for Elbow Joint Contracture: A Case Report

A 16-year-old male had a right elbow contracture after dislocation. The patient underwent supine-position ultrasound-assisted arthroscopic surgery, combining open removal of the posterior oblique ligament with the medial collateral ligament. The elbow joint flexion angle improved from 120 degrees to 145 degrees, and the extension angle improved from -50 degrees to 0 degrees. The patient returned to sports without recurrence of elbow joint contracture three months after surgery. Supine-positioned ultrasound-assisted arthroscopic surgery for elbow joint contracture is a safe and effective technique that eliminates the need for intraoperative position changes and big skin incisions.