Stiff elbow and fffd elbow managememt
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Transcript of Stiff elbow and fffd elbow managememt
STIFF ELBOW
FUNTIONAL ARC OF ELBOW
MOVEMENT NEEDED FOR ACTIVITIES OF DAILY LIFE:
30 TO 130 DEGREES OF FLEXION50 DEGREE EACH OF PRONATION &
SUPINATION
LOSS OF EXTENSION IS COMMON.LOSS OF FLEXION IS LESS TOLERATED.
FFD 45*
ROM 45-115*
KEY TO TREATMENTBASE TREATMENT ON FUNCTIONAL &
OCCUPATIONAL IMPAIRMENT.
NOT ON ABSOLUTE LOSS OF MOVEMENT.
COMPENSATORY BIOMECHANICAL FUNCTION IS ABSENT IN ELBOW.(unlike in shoulder)
ANATOMY & STIFF ELBOWTHREE JOINTS WITHIN SINGLE CAVITY.CRUCIATE ORIENTATION OF FIBRES OF
ANTERIOR CAPSULE.(contracture easy)CLOSE PROXIMITY OF CAPSULE TO
MUSCLES & LIGAMENTS.
80* FLEXION – ALLOWS 25 ml CAPACITY, & DROPS TO 6ml IN STIFF ELBOW.(contracture of capsule)
PATHOGENESIS of STIFF ELBOW
MULTIFACTORIAL & OBSCURE.
MYOFIBROBLASTS IN ANTERIOR CAPSULE.
MATRIX METALLO PROTEINASES INCREASED IN CONTRACTED CAPSULE.
COMPLEX CHAIN OF EVENTS IN HEAD TRAUMA.
EVENTS IN CAPSULEANTERIOR CAPSULE THICKENS (2 mm
normal)
COLLAGEN CROSS LINKING INCREASE.WATER CONTENT DECREASE.PROTEOGLYCAN CONTENT DECREASE.
COLLAGEN HYPERTROPHY.
STIFF ELBOW-CLASSIFICATION
INTRINSICEXTRINSICPERIPHERAL - MORREYSTATICDYNAMIC
INTRINSIC CAUSES OF STIFF ELBOWARTICULAR INCONGRUITY.
DEGENERATIVE CHANGES.INTRA ARTICULAR ADHESIONS.
LOOSEBODIES.SYNOVITIS.INFECTIONS.
EXTRINSIC CAUSES OF STIFF ELBOWSOFT TISSUE&CAPSULAR CONTRACTURE.MUSCLE FIBROSIS.
COLLATERAL LIGAMENT TIGHTNESS.
HETEROTOPIC OSSIFICATION.
SKIN CONTRACTURE.
PERIPHERAL CAUSES OF STIFF ELBOW FACTORS ANATOMICALLY SEPARATE
FROM ELBOW:
NEUROLOGICAL PROBLEMS
HEAD INJURY, STROKE, PERIPHERAL NERVE DISORDERS, CEREBRAL PALSY etc.
STATIC & DYNAMIC causesSTATIC: PATHOLOGY OF TISSUES IN &
AROUND ELBOW JOINT.
DYNAMIC: DEFECTIVE FUNCTION OF
MUSCLES AROUND THE JOINT
CLINICAL ASSESSMENT
DEGREE OF FUNCTIONAL IMPAIRMENT-ROM, ulnohumeral- affects flexion&extension,
superior radio ulnar- affects rotations, radio capitullar – both flexion-extension
&rotation
PRIOR TREATMENT-SURGICAL SCARS,
INFECTION,SOFT TISSUE COMPROMISE
PHYSICAL EXAMINATION:
ELBOW STABILITYELBOW RANGE OF MOVEMENTULNAR NERVE INTEGRITY
FUNCTION OF SHOULDERFUNCTION OF CERVICAL SPINEFUNCTION OF CONTRALATERAL LIMB
PHYSICAL EXAM- ROM
INVESTIGATIONSPLAIN RADIOGRAPHS VISUALISE THE BONE, JOINT CONGRUITY, HETEROTOPIC OSSIFICATION (status) OSTEOPHYTES, STATUS OF FRACTURE, etc
CT SCAN WITH IMAGE REFORMATION IN SAGITAL & CORONAL PLANES
ANTERIOR BLOCK TO MOVEMENT
WRIST X RAY - NEEDED
DIFFERENTIAL DIAGNOSIS
DYSPLASTIC RADIAL HEAD (congenital)ELBOW FRACTURE DISLOCATIONHETEROTOPIC OSSIFICATION
HEAD INJURYBURNSMUSCULAR HYPOTONIASTROKE
DYSPLASTIC ELBOW
NON OPERATIVE MANAGEMENTUPTO 6 MONTHS AFTER ONSET OF
CONTRACTURE
END POINT IF SOFT & SPONGY
ACTIVE ASSISTED ROM EXERCISESSTATIC / DYNAMIC SPLINTS (progressive)10-50 DEGREES OF MOVEMENT GAIN
ELBOW RELEASE (timing)AFTER 6 MONTHS OF INJURY:
SOFT TISSUE INFLAMMATION SETTLE DOWN
(ESR,CRP,S.ALKALINE PHOSPHATASE)
SUFFICIENT REHABILITATION PROGRAMME IS DONE
PRE OP-PLANNINGIDENTIFY THE ANATOMICAL
IMPEDIMENTS TO MOVEMENT
RECOGNISE ASSOCIATED PATHOLOGY WHICH CAN BE ADDRESSED AT THE TIME OF SURGERY
DECIDE ON THE TYPE OF OPERATION & APPROACH
IDENTIFY BARRIER TO MOTION
TIGHT STRUCTURE ON ONE SIDE contracted capsule
IMPINGEMENT ON THE OTHER bony spur, heterotopic
ossification,hardwares etc
CONTRA INDICATIONS OF ARTHROLYSIS
GROSS DISTORTION OF ARTICULAR COUNTOUR
> 50% LOSS OF ARTICULAR CARTILAGE
IF COLLATERAL LIGAMENT SACRIFICE IS REQUIRED
MOTOR DEFICIENCY/SPASTICITY
AIM OF ELBOW RELEASEREMOVE OFFENDING STRUCTURES
MAINTAIN STABILITY OF ELBOW
MAINTAIN INTEGRITY OF NEUROVASCULAR STRUCTURES
APPROACH (incision)MEDIAL/ LATERAL/ ANTERIOR/
POSTERIOR
DEPENDS ON EVALUATION OF EACH CASELOCATION & ANATOMY OF OFFENDING
STRUCTURES & CONCOMITANT PROBLEMS eg-ULNAR NERVE INVOLVEMENT,
NON UNION, HETEROTOPIC OSSIFICATION etc
GOAL OF TECHNIQUEWIDE EXPOSURE OF CAPSULE & OFFENDING
STRUCTURES.
MAINTAIN ELBOW STABILITY- retain lateral ulno- humeral ligament &
anterior band of MCL
PROTECT NEUROVASCULAR STRUCTURES ULNAR NERVE- EXPOSE & PROTECT RADIAL NERVE,MEDIAN NERVE & VESSELS- BY KEEPING SOFT TISSUE BARRIER
STEPS OF ARTHROLYSISULNAR NEUROLYSIS
RELEASE OF CONTRACTED SOFT TISSUES-remove contracted capsule both anterior& posterior ,+
subperiosteal elevation of muscles.
REMOVAL OF BONY IMPINGEMENT –DEBRIDEMENT ARTHROPLASTY(OUTERBRIGE-KASHIWAGI PROCEDURE)
DEEP LATERAL TECHNIQUELATERAL INCISION-bony land mark- lateral
supracondylar ridge
PRESERVE LCLBR & ECRL,ECRB elevated anteriorlyLATERAL TRICEPS & ANCONEUS elevated
posteriorly
VISUALISE anterior & posterior capsules,olecranon & coronoid fossae & processes
LATERAL INCISION
LATERAL COLUMNBONY LANDMARK INCISION
ANTERIOR CAPSULE
ANTERIOR CAPSULECTOMY
DEEP MEDIAL TECHNIQUEMEDIAL INCISION
ISOLATE ULNAR NERVEPRESERVE MCLELEVATE FLEXOR PRONATORS anteriorly
& TRICEPS posteriorly
VISUALISE anterior & posterior capsules & fossae & bony land marks.
POSTERIOR APROACHINCISION – LONGITUDINAL & MIDLINE
POSTERIORFLAPS RAISED BOTH MEDIALY & LATERALY to
point anterior to the epicondyles
CUTANEOUS NERVES ARE LEAST DAMAGEDALLOWS EXPOSURE OF CAPSULE BOTH
ANTERIORLY & POSTERIORLY ULNAR NEUROLYSIS EASIERESPECIALLY USEFUL IN FRACTURE NON UNION
INTRA OPERATIVE ASSESSMENT
GAINED RANGE OF MOTION – SOFT TISSUE CONTRACTURES GENTLY
STRETCHED OUT
STABILITY - ULNO HUMERAL SUBLUXATION WITH GRAVITY FORCE EXTENSION OF ELBOW
GENTLE STRETCHING
INTRA OP - ROMextension flexion
WOUND CLOSUREMUSCLES RE ATTACHED – DRILL HOLES,
SUTURE ANCHORS
METICULOUS HAEMOSTASIS – RELEASE TOURNIQUET
STRONG SKIN CLOSURE TO ALLOW EARLY EXERCISE
SKIN CLIPS TO ALLOW EXERCISE
POST OP MANAGEMENTBULKY DRESSING & SPLINT IN EXTENSION
SECOND DAY - REMOVE DRAIN, START ACTIVE ROM EXERCISE
NIGHT SPLINT IN EXTENSIONCPM IF AVAILABLE
VISITS – AFTER 2 WKS & THEN EVERY 4 WKS
POST OP - EXERCISEEXTENSION FLEXION
POST OP - EXERCISESUPINATION PRONATION
ELBOW ARTHROLYSIS- FUTURE ??