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Reversed dynamic slings: results of use in the treatment of post-traumatic flexion contractures of the elbow
400
Injury (1991) 22, (5), 40@402
Pri’ntedin Great Britain
Reversed dynamic slings: results of use in the treatment of post-traumatic flexion contractures of the elbow D. J. Shewring, M. Beaudet and J. E. Carve11 Department
of Orthopaedics,
Salisbury General Infirmary, Salisbury, Wiltshire, UK
We report our experience wifh reversed dynamic slings used in the treatment of post-fraumatic flexion contractures of the elbow. There were 21 patients treated for deformities rangingfrom 35” to 70” (average 55’). Thflexion d&r@ afkr treatment variedfrom 25” to 45” (average 34.8”),giving an average increase in range of movement of 39.1 per cent.
Introduction The elbow joint is particularly intolerant of trauma. Flexion contractures are common. They may cause unacceptable functional and cosmetic impairment (Urbaniank et al., 1985). To avoid them active movement should start as soon as possible after the injury. Passive movement is not recommended as this may further damage the joint leading to increased deformity and occasionally myositis ossificans. Various methods of treating post-traumatic elbow stiffness have been described. Capsulectomy (Wilson, 1944) entails extensive surgery around a previously damaged joint, risking a multitude of complications. Hinge distractor devices (Volkov and Organesian, 1975) may be complicated by pain, pin site infection and cut-out. Reversed dynamic slings are an external corrective system based on the Thomas splint. They have been used since 1975 in the treatment of haemophiliac deformities of the knee (Stein and Dickson, 1975; Goguin and Houghton, 1983). One case has been described in which a reversed dynamic sling was used successfully to treat a posttraumatic flexion contracture of the elbow (Dickson, 1976). Figure 1. The canvas sling applies an extension
Method The affected arm is supported in a Thomas splint, suspended at a comfortable height. A Pearson knee flexion loop is attached to the Thomas splint at elbow level and angled at 10"less than the flexion contracture. A canvas sling is passed over the forearm and under both rods of the Pearson loop (Fipre I). Weight is suspended via a cord from the sling and over a pulley, so that an extension force is applied to the forearm (Figure 2). A weight of 1.8 to 3.6 kg (4-8 lb) is added, depending on size and comfort of the patient. Progressive 0 1991 Butterworth-Heinemann 0020-1383/91/05040&03
force to the
forearm.
Ltd
approximation of the Pearson loop to the Thomas splint allows gradual reduction of the deformity. Treatment is given on an outpatient basis. Initially patients are admitted daily and placed in the sling intermittently through the day, the time in traction being gradually lengthened up to 5 h as patient tolerance increases. After 10 days the patient attends three times a week for 5 h of traction, until nor further extension is obtained. During
401
Shewring et al.: Reversed dynamic slings
Fracture/dislocation
Dislocation
Ooen
reduction
Figure 4. Types of injury. Figure 2. Patient in reversed dynamic sling.
Results
I O-10
IO-20
20-30
30-40
40-50
SO-60
60-70
70-80
Age
Figure 3. Age distribution of patients.
traction the patient is encouraged to flex the elbow within the limits of the splint. A Plastazote extension splint to be worn at night is provided until 3 weeks after treatment finishes. During the day, active elbow movement is encouraged.
Patients Between 1984 and method at Odstock contractures of the tically unacceptable
1990,2l patients were treated with this hospital. All had post-traumatic flexion elbow that were functionally or cosmeto them.
Age The age range was 13 to 73 years (average 33.5 years). The distribution is illustrated in Figure 3. Sex Seven male and 14 female patients were treated. Injuries
The deformity had been present from between 2 and 41 months (average 12.5 months). The deformity was on the dominant side in 10 patients. Six of the patients had an uncomplicated posterior dislocation of the elbow treated with manipulation under anaesthetic. Four of the patients had a dislocation associated with a fracture, one of which was treated by open reduction and fixed internally. Eleven of the patients had fractures around the elbow joint, seven of which were fixed internally (Figure 4).
Before treatment the mean flexion contracture was 55” f 12.2” (range 40’-70”). After treatment, the mean reduction was 21.3 f 11.5” (range 15”--27”), a significant correction (PC 0.001). The range of movement also increased significantly, from 66.2 f 37.0 before treatment to 92.1” f 48.9” after treatment (0.01 > P> 0.001). The amount of correction achieved was found to bear no relationship to the duration of the flexion contracture. There were no complications encountered by any of the patients during treatment. Two patients had a short period of inpatient treatment due to the severity of the contractures and the length of time required in traction. Both reverted to outpatient treatment within 4 days. Review at discharge, 6 months after treatment, revealed further reduction of the residual flexion contracture by an average 5”. One patient was lost to follow-up.
Discussion The natural history of elbow stiffness after injury was found to be gradual improvement reaching a plateau after a few weeks. We therefore used this method only in patients who had reached such a plateau for at least 2 or 3 weeks, despite a programme of supervised exercise. This method avoids complex and dangerous surgery around the joint and the pin site problems and pain that may complicate hinge distracters. Further advantages include ease of application and suitability for children with open epiphyses. Treatment can be carried out on an outpatient basis and the patient may do active exercises during treatment. Reversed dynamic slings are an effective treatment in the correction of flexion contractures of the elbow, following a wide range of injury. The treatment is well tolerated by all age groups and generally pain free, so that supplementary analgesics are not required during treatment. Maximum correction is usually achieved within 2 weeks.
References Dickson R. A. (1976) Reversed dynamic slings. A new concept in the treatment of flexion contractures of the elbow. Injury 8,~.
402
Injury: the BritishJournalof Accident Surgery (1991) Vol. 22/No. 5
Goguin J. P. and Houghton G. R. (1983) Reversed dynamic slings for fixed flexion contractures in haemophilia. Acta O&q. Belg. 49, 365. Stein H. and Dickson R. A. (1975) Brief notes: Reversed dynamic slings for knee flexion contractures in the haemophiliac. 1. Bone ]oint Surg. 5 7A, 282. Urbaniank J. R., Handsen P. E., Beissinger S. F. et al. (1985) Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. 1. BoneJointSurg.67A, 1160. Volkov M. V. and Organesian 0. V. (1975) Restoration of function in the knee and elbow with a hinge distractor apparatus. 1. Bone]oinf Surg. 57A, 591.
Wilson P. D. (1944) Capsulectomy for the relief of flexion contractures of the elbow following fracture. 1. BoneJoint Swg. 26, 71.
Paper accepted 4 February 1991.
Requests for reprints should be addressed lo: Mr D. J. Shewring FRCS, Orthopaedic Registrar, Department of Orthopaedic and Trauma Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2
2QQ, UK.
Injury (1991) 22, (5), 40@402
Pri’ntedin Great Britain
Reversed dynamic slings: results of use in the treatment of post-traumatic flexion contractures of the elbow D. J. Shewring, M. Beaudet and J. E. Carve11 Department
of Orthopaedics,
Salisbury General Infirmary, Salisbury, Wiltshire, UK
We report our experience wifh reversed dynamic slings used in the treatment of post-fraumatic flexion contractures of the elbow. There were 21 patients treated for deformities rangingfrom 35” to 70” (average 55’). Thflexion d&r@ afkr treatment variedfrom 25” to 45” (average 34.8”),giving an average increase in range of movement of 39.1 per cent.
Introduction The elbow joint is particularly intolerant of trauma. Flexion contractures are common. They may cause unacceptable functional and cosmetic impairment (Urbaniank et al., 1985). To avoid them active movement should start as soon as possible after the injury. Passive movement is not recommended as this may further damage the joint leading to increased deformity and occasionally myositis ossificans. Various methods of treating post-traumatic elbow stiffness have been described. Capsulectomy (Wilson, 1944) entails extensive surgery around a previously damaged joint, risking a multitude of complications. Hinge distractor devices (Volkov and Organesian, 1975) may be complicated by pain, pin site infection and cut-out. Reversed dynamic slings are an external corrective system based on the Thomas splint. They have been used since 1975 in the treatment of haemophiliac deformities of the knee (Stein and Dickson, 1975; Goguin and Houghton, 1983). One case has been described in which a reversed dynamic sling was used successfully to treat a posttraumatic flexion contracture of the elbow (Dickson, 1976). Figure 1. The canvas sling applies an extension
Method The affected arm is supported in a Thomas splint, suspended at a comfortable height. A Pearson knee flexion loop is attached to the Thomas splint at elbow level and angled at 10"less than the flexion contracture. A canvas sling is passed over the forearm and under both rods of the Pearson loop (Fipre I). Weight is suspended via a cord from the sling and over a pulley, so that an extension force is applied to the forearm (Figure 2). A weight of 1.8 to 3.6 kg (4-8 lb) is added, depending on size and comfort of the patient. Progressive 0 1991 Butterworth-Heinemann 0020-1383/91/05040&03
force to the
forearm.
Ltd
approximation of the Pearson loop to the Thomas splint allows gradual reduction of the deformity. Treatment is given on an outpatient basis. Initially patients are admitted daily and placed in the sling intermittently through the day, the time in traction being gradually lengthened up to 5 h as patient tolerance increases. After 10 days the patient attends three times a week for 5 h of traction, until nor further extension is obtained. During
401
Shewring et al.: Reversed dynamic slings
Fracture/dislocation
Dislocation
Ooen
reduction
Figure 4. Types of injury. Figure 2. Patient in reversed dynamic sling.
Results
I O-10
IO-20
20-30
30-40
40-50
SO-60
60-70
70-80
Age
Figure 3. Age distribution of patients.
traction the patient is encouraged to flex the elbow within the limits of the splint. A Plastazote extension splint to be worn at night is provided until 3 weeks after treatment finishes. During the day, active elbow movement is encouraged.
Patients Between 1984 and method at Odstock contractures of the tically unacceptable
1990,2l patients were treated with this hospital. All had post-traumatic flexion elbow that were functionally or cosmeto them.
Age The age range was 13 to 73 years (average 33.5 years). The distribution is illustrated in Figure 3. Sex Seven male and 14 female patients were treated. Injuries
The deformity had been present from between 2 and 41 months (average 12.5 months). The deformity was on the dominant side in 10 patients. Six of the patients had an uncomplicated posterior dislocation of the elbow treated with manipulation under anaesthetic. Four of the patients had a dislocation associated with a fracture, one of which was treated by open reduction and fixed internally. Eleven of the patients had fractures around the elbow joint, seven of which were fixed internally (Figure 4).
Before treatment the mean flexion contracture was 55” f 12.2” (range 40’-70”). After treatment, the mean reduction was 21.3 f 11.5” (range 15”--27”), a significant correction (PC 0.001). The range of movement also increased significantly, from 66.2 f 37.0 before treatment to 92.1” f 48.9” after treatment (0.01 > P> 0.001). The amount of correction achieved was found to bear no relationship to the duration of the flexion contracture. There were no complications encountered by any of the patients during treatment. Two patients had a short period of inpatient treatment due to the severity of the contractures and the length of time required in traction. Both reverted to outpatient treatment within 4 days. Review at discharge, 6 months after treatment, revealed further reduction of the residual flexion contracture by an average 5”. One patient was lost to follow-up.
Discussion The natural history of elbow stiffness after injury was found to be gradual improvement reaching a plateau after a few weeks. We therefore used this method only in patients who had reached such a plateau for at least 2 or 3 weeks, despite a programme of supervised exercise. This method avoids complex and dangerous surgery around the joint and the pin site problems and pain that may complicate hinge distracters. Further advantages include ease of application and suitability for children with open epiphyses. Treatment can be carried out on an outpatient basis and the patient may do active exercises during treatment. Reversed dynamic slings are an effective treatment in the correction of flexion contractures of the elbow, following a wide range of injury. The treatment is well tolerated by all age groups and generally pain free, so that supplementary analgesics are not required during treatment. Maximum correction is usually achieved within 2 weeks.
References Dickson R. A. (1976) Reversed dynamic slings. A new concept in the treatment of flexion contractures of the elbow. Injury 8,~.
402
Injury: the BritishJournalof Accident Surgery (1991) Vol. 22/No. 5
Goguin J. P. and Houghton G. R. (1983) Reversed dynamic slings for fixed flexion contractures in haemophilia. Acta O&q. Belg. 49, 365. Stein H. and Dickson R. A. (1975) Brief notes: Reversed dynamic slings for knee flexion contractures in the haemophiliac. 1. Bone ]oint Surg. 5 7A, 282. Urbaniank J. R., Handsen P. E., Beissinger S. F. et al. (1985) Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy. 1. BoneJointSurg.67A, 1160. Volkov M. V. and Organesian 0. V. (1975) Restoration of function in the knee and elbow with a hinge distractor apparatus. 1. Bone]oinf Surg. 57A, 591.
Wilson P. D. (1944) Capsulectomy for the relief of flexion contractures of the elbow following fracture. 1. BoneJoint Swg. 26, 71.
Paper accepted 4 February 1991.
Requests for reprints should be addressed lo: Mr D. J. Shewring FRCS, Orthopaedic Registrar, Department of Orthopaedic and Trauma Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2
2QQ, UK.