surgery for elbow contractures

[BrookesMom]

Can someone explain to me the different type of secondary surgical procedures for elbow contracture.

Thanks.

[admin]

Here is an illustration of biceps tendon lengthening that I found at Dr. Nath's site
http://www.drnathmedical.com/injury/ima ... 6x_big.asp
It explains how he does it. But I don't know how others do it.

My daughter had it done and one and 1/2 years later, her arm is still straight. It seemed to be the easiest (for her) of all the procedures she had, too. The only problem she had was within two days after the surgery, she had some muscle spasms because the biceps wasn't used to being loose like that. But that passed in just a couple of days and has been fine since. (I think they gave her a tiny bit of muscle relaxer but I'm not really sure)

We do triceps e-stiming to strengthen her triceps to overcome the muscle imbalance. You must treat the reason for the contracture or the contracture can have the possibility of returning. The reason could like in the elbow or could be in the shoulder (malpositioning) or could be a muscle imbalance issue. Or it could even be caused by constant posturing (either for a reason or by habit). So I think you need to really figure out why the contracture exists before you do any surgery and then come up with the plan for what to do after the surgery if you decide that surgery is your best option.

[admin]

Can the elbow become dislocated like the shoulder? Does mod quad help with this? Does mod quad help with supination? Thank you for any info.

[katep]

Yes, the elbow can become dislocated similarily to what happens with the shoulder - ie., the joint can gradually become malformed ("dysplasic") if the muscular forces aren't balanced on it. Typically, only the head of the radius (which is the "thumb-side" wrist bone - the other is the ulna) gets out of position, but the ulnar head can dislocate, too. The corresponding parts of the humerus can also malform.

Dislocations are correlated to internal rotation contractures of the shoulder and also biceps contractures. Biceps contractures are also associated with internal rotation contractures, so it all might come down to internal rotation contracture and the abnormal positioning of the joint and muscles from this.

Tendon transfer and/or release of contracted muscles or the joint capsule could also help with elbow problems, by putting the shoulder in a more neutral position. (Note: "Mod Quad" is the name TCH gives to their particular set of releases, tendon transfers and neurolysis, but most of the MQ is performed by most orthopedic surgeons.)

I'm in the process of looking, but so far I haven't been able to find any studies linking secondary surgery to improved elbow outcomes. But it makes sense.

Secondary surgery can help with supination by putting the arm in a more neutral rotation, so that any active supination of the forarm doesn't have so much internal rotation to overcome. Supination refers specifically to the rotation of the wrist and forearm. From a neutral elbow position, supination of the forearm results in a "palm up" position. But supination of the forearm alone isn't able to turn the palm up if the upper arm is internally rotated.
Secondary surgery on the shoulder doesn't actually provide supination directly, but rather "enables" what supination is present to actually be able to put the hand in a functional position.

Kate

[admin]

Thank you so much Kate, that was really helpful in answering my question. I am the second guest that posted. I really appreciate it. Thank you.

[baby4us]

Can anyone address the risks associated with this surgery (Kate?). It was recommended for my daughter, her conctracture is slight (can get it to 2% passively, but she tends to hold it anywhere from 8-20%, actively. I'm still holding out hope that we can find other ways to improve the contracture (estim on triceps, splints), etc., but I know it is another option that I'd like to research. Her therapists are not thrilled with the idea of that surgery at all, since she is functional and at 2%, she looks like it's held more in neutral. (am I making sense??)

Anyway, can someone address the risks and tradeoffs for this surgery?

[admin]

We did the biceps lengthening surgery on Juliana. She was not able to passively be ranged to full extension or flexion. Essentially, she had a 2" arc of function. She had already had primary and modquad. I am glad we did it, as Juliana's arm is held in a straight, not "erbs" position. It helped her "look" tremendously. Plus, she was given the potential to use her arm more effectively.

However, I would not rush into this, especially if function is good (which Juliana's was not). The recovery is tough and we were left with a bicep that had "forgotten" how to fire. We went from a bent arm to an hyperextended arm. We then used botox (which is a great tool) to relax the triceps so we could work on the biceps.

Now, 2 1/2 years later, she has an arm that hangs straight, but can bend.

I would look into botox and splinting before I tried biceps lengthening surgery.

And, as for dislocated elbows, many times this happens when the arm is stretched beyond its limits. It is not exactly the same as when a typical arm is dislocated (which has happened to two of my kids).

I hope this helps,
claudia

[Julie Surber]

My son had the bicep lengthening as well. It didn't completely straighten out his arm but close to it. He still holds his arm in the air though. Any ideas out there?

What can be done about internal rotation on the arm?

[Allison]

This is an issue we have been struggling with for 2 1/2 years with Bradley. We have tried an ultraflex splint, NMES, and MFR. He outgrew his ultraflex splint. He was recently casted for a new one. The splint also comes with a supinator attachment. We are going to give it a little more time to see if this works. He will wear the splint only at night when the muscles are relaxed. Part of me feels that this is a hopeless case. If the biceps are firing stronger than the tri's, how will this ever be corrected? I am glad to hear of the sucess of the bicep tendon lengthening. If in the future we decide to go through with it, who's to say the contracture wont come back? Is it worth it? What are the ramifications of a long term elbow contracture. His shoulder is looking better than ever. Once again we are faced with difficult decisions:-( I'm skeptical about botox, I dont like the fact of paralyzing the biceps, when we hoped and prayed he would get them back. Please share your experiences with botox. I'm curious about the results anyone has had.

[katep]

I've been looking into biceps contractures, and still have a lot of papers I want to look at (have to make a trip to the medical library to get them, they are older and not online, since this problem has been around a long time).

The indications and prognosis for treatment depends on what the root cause for the shortened bicep is. If the cause was removed, such as correction of internal rotation contracture, but the bicep contracture remains, then it is possible that the contracture won't reoccur if the tendon is lengthened. This might be the case if the problem is due to an overly strong bicep and weakly recovered tricep, but this is not typical at all.

Usually the cause is, paradoxically, WEAK biceps, and with overly powerful internal rotation. These kids usually have really strong triceps, with excessive extension in the beginning, but then as they recover they switch over to the "erb's engram" posture - internally rotated with the elbow flexed. Why, if the biceps are weak, do they stay permanently flexed?

Biomechanically, the perpetually flexed elbow serves two functions:

First, it provides a limit to internal rotation in the presence of a contracture - the flexed elbow means the forearm provides a "stop" for the arm to prevent it from rotating even further internally. If there is excessive internal rotation, and the arm was held straight, the shoulder would continue to rotate until the forearm was behind the back - not a very functional position. So the "engram" helps maintain the arm in front of the body where it can be more useful.

Second, when the triceps are strong and the biceps weak, maintaining a permanent flexion in the bicep can help the weak biceps "overpower" the strong triceps. The biceps have a definite mechanical advantage over the triceps when the elbow is flexed, and the triceps are at their strongest when the elbow is fully extended. Since a flexed position provides more use than a fully extended one (the hand can function and do stuff, for instance) the elbow is maintained in a flexed position, since the biceps are not strong enough to flex the elbow in a fully extended arm.

Since the problem is typically due to internal rotation and a weak bicep trying to maintain a mechanical advantage over strong triceps, I have trouble seeing how deliberately reducing the effectiveness of the bicep itself - by lengthening its tendon - is going to solve the problem. The concern is that this would even further weaken and limit the range of the bicep. If the bicep is limited in both ends of the range - can't fully contract or extend - then lengthening the tendon is only going to "shift" that range lower. This would make the biceps even less able to provide functional use.

In fact, I've found a few papers that discuss tendon transfers, such as brachioradialis or pectoral muscle, to provide elbow function, and those procedures often include a deliberate "contracture" created surgically (the muscle is attached so that the elbow is not able to fully extend) for just this reason - the new muscle is not as strong and needs a mechanical advantage over the triceps.

Its so hard to be hoping for biceps one minute, only to worry about over flexion the next! Our son is 7 months old (today) and he is showing signs of bicep shortening and loss of range. We have added in bicep stretches, and I am also trying to work with him flexing his elbow from a fully extended position, in the hopes that I can get that end range of the bicep stronger so that he doesn't have to keep his elbow flexed all the time. We'll see if it does any good...

I hate the idea of this obvious indication of his injury, but I also am not going to jump into "correcting" something that may actually be helping him function the best he can with what recovery he has.

Kate