Publication At-A-Glance

Anterior Release of Elbow Flexion Contractures in Children with Obstetrical Brachial Plexus Lesions

For individuals with obstetrical brachial plexus injury (OBPI), it is common to have multiple types of issues pertaining to the muscles and bony structure. When a muscle is strong and it's opposing muscle is weaker, an out-of-balance condition will occur. The stronger muscle gets tight and shortened and this is what we call a "contracture". Contractures can occur in any joint (scapula, shoulder, elbow, wrist, fingers) but for the purpose of this study, we studied only the elbow.

If an individual cannot fully straighten their arm at the elbow then we say that they have a "flexion contracture of the elbow". So that you understand the degree of tightening: if 360 degrees is a full circle, 180 degrees is a half circle, 90 degrees is one quarter of a circle and 45 degrees is half of that, you can now visualize what 30 degrees is. If the elbow contracture is less than 30 degrees, the usual treatment is a conservative treatment that consists of therapeutic stretching, nighttime bracing or serial casting. If the elbow contracture is greater than 30 degrees, a different approach is taken that usually involves surgery.

We use a similar approach to Garcia-Lopez who studied 10 individuals with OBPI where C5 & C6 nerves were injured and they had an elbow flexion contracture of greater than 35 degrees. Using the British Medical Research Council Scale, the flexion strength of the elbow was graded at 4 or higher. Also, each patient had no bone abnormalities in the elbow region. The surgery included "anterior releases of the elbow" (release of the muscles in the front of the elbow joint) and lengthening of the distal tendons (farthest from the shoulder joint) of the biceps and anterior brachialis muscle.

They followed the individuals for an average of 3 years after the surgery. The average gain of flexion (the ability to straighten the arm) was 28 degrees. (28 degrees BETTER then it was to start). There was some slight re-tightening that we noted at follow-up which averaged out at 2 degrees since the measurement taken at surgery. All the patients maintained good flexion strength; they were happy with the results; and there were no major complications. This has been our experience as well. Additionally, we will perform scar removal ("neurolysis") of any nerves that are trapped in the elbow contracture. This canimprove function of the hand and wrist as well as the elbow. We sometimes are able to do partial elbow releases in appropriate patients, which has a shorter recovery period.

These anterior releases of the elbow are very successful for the treatment of the elbow flexion contracture greater than 30 degrees. The contracture itself was reduced without compromising elbow flexion strength.

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