Reversed dynamic slings

Injury,

35

8, 35-38

Reversed

dynamic

slings

A new concept in the treatment elbow flexion contractures

of post-traumatic

Robert A. Dickson Nuffield Department

of Orthopaedic Surgery, University of Oxford

Summary

Following the successful treatment of knee-flexion contractures in haemophiliacs using an external corrective system with reversed dynamic slings, these have been adapted to treat post-traumatic elbow contractures. A case is described in which 90” of fixed flexion was corrected in 1 week without discomfort. Clearly there is no need to resort to an internally applied hinge-distractor apparatus or capsulectomy if a simple external sling system is successful without complications.

INTRODUCTION THE

ELBOW does not tolerate injury well and frequently becomes stiff. The duration of immobilization of this joint should, therefore, be kept to a minimum and early active motion encouraged. There is no place for passive motion following elbow trauma, as this results in reduction of the range of movement by causing oedema and further fibrosis, and may lead to myositis ossificans or even ankylosis. The range of movement following injury to the elbow is, therefore, frequently disappointing. Capsulectomy has been recommended for the relief of post-traumatic elbow-flexioncontractures (Wilson, 1944) but involves extensive dissection with its own dangers and complications. Recently, a successful method of restoring movement in fixed-flexion contracture of the knee in haemophiliacs has been described (Stein and Dickson, 1975). This form of treatment involves the use of reversed dynamic slings. It is rapidly effective and without complications. Furthermore, being an external system, there are no problems with anaesthesia, pain, infection or the pulling out of

skeletal pins, all of which hamper hinge-distractor devices (Volkov and Oganesian, 1975). This paper describes a modification of the reversed dynamic sling system to suit the upper limb, and demonstrates its efficacy in relieving post-traumatic flexion contracture of the elbow. A description of the first case treated illustrates the method.

CLINICAL

DETAILS

AND

METHODS

S.B., a 35year-old female, sustained a lateral dislocation of the left elbow joint. Reduction was achieved within 6 hours of injury, and after 3 weeks rest in a sling, active motion was encouraged with daily physiotherapy. Despite intensive treatment, the range of motion obtained was a fixed-flexion contracture of 90” with full flexion to 100”. This was the state when the case was taken over for treatment at 1 year from injury. In addition to the obvious cosmetic deformity, there was a significant functional loss in that she had difficulty in performing persona1 functionse.g. hair styling, washing, dressing, carrying a shopping bag. Treatment began with the left arm resting on a well-padded Thomas’s splint, suspended at a comfortable height. A longitudinal pull of 4 lb was exerted on the forearm by means of a cord fastened to a plastazote splint (Fig. 1). Three days later, the flexion contracture was reduced to 40” and at this point the reversed sling was added (Fig. 2). A Pearson knee-flexion piece was attached to the Thomas’s splint, the angle between them being 10” less than the angle of the elbow-flexion contracture. The reversed sling was

36

Injury:

the British

Journal of Accident Surgery Vol. B/No. 1

Fig.

1. initial

longitudinal

Fig. 2. The reversed fashioned from a 6 in inelastic bandage, the sling passing under one rod of the knee-flexion piece, over the forearm and under the other rod of the knee-flexion piece. A cord was attached to the sling and a 4 lb upward pull achieved by cord and pulley. Theupwardpull on the sling, therefore, applied a downward force to the forearm. As the elbow continued to straighten, so the knee-flexion

traction

of 4 lb.

sling is now added.

piece was approximated to the Thomas’s splint until the elbow was within 10” of full extension, which occurred 7 days after the start of treatment (Fig. 3). Throughout this period active flexion was encouraged but no additional weights were required to achieve full correction. At this point, the arm was removed from the slings and the

Dickson

: Reversed

37

Dynamic Slings

patient discharged home with a plastazote extension splint to be worn at night only (Fig. 4). Active flexion and extension exercises were performed by the patient at home during the day, and 3 weeks later the night splint was discarded. At follow-up 9 months after treatment, she had a painless range of active motion from 10-120” (Fig. 5).

3. The elbow is within 10” of full extension after 1 week’s therapy.

Fig.

Fig. 4. Plastazote

extension

DISCUSSION As yet there is no satisfactory method of treating the elbow stiffness which so commonly follows trauma to this joint. Reversed dynamic slings have already proved their value in knee-flexion contractures in haemophiliac patients in whom operation is dangerous. There were two further benefits in their use in the elbow; the time taken for correction to be achieved was independent of

night splint.

b

a

Fig. 5. Final range of motion.

a, lo”; b, 120”.

38

Injury: the British Journal of Accident

the degree and duration of contracture, and the resistance to joint movement that the sling system overcame was load-independent (not more than 8 lb weight being needed for full correction). This system has been modified for the upper limb while retaining simplicity of design and ease of operation. The correction of a 90” fixed-flexion contracture in 1 week without complications, and maintenance of this correction at 9 months, testifies to its value. Two further cases have been successfully treated but follow-up is too short to be absolutely conclusive. The advantages over existing methods are that it not only appears to be rapidly effective but avoids the dangers of operation on a complex joint that is easily damaged. Volkov and Oganesian (1975) used their hinge-distractor apparatus on 11 elbows with flexion contractures and 17 similarly affected knees. Superficial and deep-pin sepsis occurred in 8 of 28 cases and pain was also a complication. Their knee-contracture correction

Reyue~rs

for rqw;m

should br aLldressed to: Robert

A. Dickson,

Surgery Vol. ~/NO.

1

rate was not as good as the reversed sling series and duration of treatment was considerably longer. The small amount of weight required to correct the elbow contracture in the case described (4 lb axial traction and 4 lb reversed sling traction), suggests that the stretching of contracted soft tissues is load-independent. Local discomfort is not a problem when such small forces are applied.

REFERENCES Stein H. and Dickson R. A. (1975) Reversed dynamic slings for knee-flexion contractures in the haemophiliac. J. Bone Joint Surg. 57A, 282. Volkov M. V. and Oganesian 0. V. (1975) Restoration of function in the knee and elbow with a hinge-distractor apparatus. J. Bone Joint Surg. 57A,

591. Wilson P. D. (1944) Capsulectomy for the relief of Hexion contractures of the elbow following fracture. J. Bone Joint Surg. 26, 71.

ChM,

FRCS,

Nut&Id

Orthopaedic

Cmtre.

Headington,

Oxford