Replies to elbow flexion contracture question

Replies to elbow flexion contracture question

T Jarrott

5/4/2005

Dear Colleagues,

Thanks for the replies to my elbow flexion contracture questions, here are the replies I received.

Original question:
I have recently seen a 30 year old female who had a cererbral aneurysm around 2 years ago. As a result she has very high increased tone especially in her upper body. In particular her right elbow is maximally flexed, shoulder adducted and internally rotated. She can be passively stretched out to about 100 degrees off full extension with much force. This severe flexion position obviosuly creates some issues with personal care and skin integrity in the cubital fossa. She has sought surgical opinion but is not keen to proceed with this for now. Past Botox and serial casting have made some improvements but only temporarily. Some orthotic options have been tried by other orthotists with various problems in the past and currently the physio. uses 'second skin' garments with an elbow wedge (however these aren't very satisfactory). She is now due to have another round of Botox and serial casting and then we hope to put her in a definitive elbow brace to maintain / imrove the position acheived. Any suggestions as to the most likely successful option? I am, thinking that a custom elbow orthosis with either ratchet hinge or a turnbuckle system might be best. Thanks for your replies.


Have you thought about trying an ultraflex system??
Instead of the turnbuckle or ratchet type system, this provides a constant
tension assist with a joint that will allow for increase in tension as
patient improves. I have found their work to be very good and have good success with elbow
flexion contractures. It would be very nice to capture the benefits of the botox with this device.

I have had success with a custom molded elbow orthosis with the Monodos
joint which is distributed by Becker. Use the heaviest hinge, since
over time I have found that the lighter model will sometimes slip.

In cases much like the one you described, I have used Ultraflex (www.ultraflexsystems.com) and have been Very Happy with the results.I have been using them for about 10 years. There are so many advantages to a coil system over a spring or a turnbuckle. I don't want to sound like an advertisement for them, but when something works well, it works well. The Ultraflex joint applies a long, low, sustained stretch, below the level that would engage the spastic response, but enough to stretch the muscle. Much like the physio. does during a session but this is sustained all nigtht. Because this system is used in rest and/or at night the muscles actually remodel rather than stretch and tear - they grow longer and stronger. I have had excellent results and feel that the cost is certainly worth it in results, and I would certainly recommend the custom as opposed to the off-the-shelf. We generally use the system in conjunction with Botox and most of the patients vastly prefer it to wraps and wedges, or other custom items. Ultraflex can be set to allow some flexion, a flexion stop, or any range inbetween.

You will probably get a few hits recommending the Ultraflex joint, a
progressive load extension hinge. Principle is lower levels of active force
(extension)over a longer period of time. Have used a couple on elbows with
good results. You need to know if the elbow has a boney or anatomical end
block. Has the surgeon done manipulation under anaesthetic to ascertain the
potential of extension that is possible.


It sounds like a perfect case for the StepLock knee joint.

I have a series of one where I made bilateral, lined, elbow orthoses
with posterior cuffs, using the step lock hinges on the lateral side and
free motion hinges on the medial side. She has used them for over ten
years at night time and has maintained enough RoM for normal hygeine.
The other option would be to use the Ultraflex joints.


Hello you may not have heard of Ultraflex. We make dynamic braces
that are therapeutic and work synergistically with Botox and vs. serial
casting can save money. Our braces work on the LLPS (Low Load Prolong
Stretch) method. The one caution I'd have is that there is no physical source blocking the extension in the joint. If it is purely musculature then Ultraflex
technology can help.

If you can get the joints I would recommend a custom EO with Ultraflex
joints. This joint is dynamic, and can be incrementally increased in
force applied to the contracture lessening your chance of skin
breakdown.

Please check out www.rcai.com and look at the ROM Elbow or the Flex cuff
ECO. These have flex/ext joints (aluminum) that have been used successfully
on pts with tone.

I regularly treat the pediatric population, most with CP. After serial
botox and serial casting I fit them with custom EWHFO's, co-poly or poly
eth, aliplast lined and use either a ratchet or ROM joint ath the elbow.
Occasionally I use a joint at the wrist. All are available from PEL. Most
fo the kids get BOTOX regularly and serial casting fairly regularly. We've
had good results with this treatment.

Have you thought about trying an ultraflex system??
Instead of the turnbuckle or ratchet type system, this provides a constant
tension assist with a joint that will allow for increase in tension as
patient improves. I have found their work to be very good and have good success with elbow flexion contractures. It would be very nice to capture the benefits of the botox with this device.


Your case is not that unusual when you consider how many stroke patients go
without any orthoses. The situation you are facing can be interesting, I've
found that by using a ratchet joint with a custom elbow orthosis I have some
good success with re educating the muscles and reducing tone. It may help if
you can locate the pressure points that release the tone in her upper
extremity. An important consideration is orientation of the limb in the
orthosis to help promote the most relaxed sustainable position without pain.
This alone will take trial and error but once keys are found they can unlock
many doors. In the past if someone was spastic or very high tone I would use
an OTS ratchet knee joint attached to a custom EWHO. By including the hand I
have been able to get better control of tone and motion.


Ultraflex or similar will give much better compliance of a spastic patient.


I have had some success with the turnbuckle approach for similar patients, and I anticipate the likely success of the ratchet hinges. However, in my thirty years experience with increased tone cases, NONE of these are the whole answer. The orthotic approach is ALWAYS only part of the answer. Botox is a place to start and the serial effect is achieved through the turnbuckle or ratchet BUT passive twice daily manual stretching and range-of-motion regime is an essential adjunct. Physios often do not like the monotony of this regime but it is really the only thing that shows consistent incremental results.I find that once weekly physio sessions with the twice daily regime carried out by family, partner or friend is the most reliable answer. The orthotic compliance without the adjunctive hands-on is more often than not compromised. I would expect that the passive range that she is now getting, as you describe, is a realistic first goal and will give her some ease of hygiene and skin integrity issues.

we've done a couple of these with some success I think. Definitely custom, we tried variuos joints.The Monodos was functionally good but it is bulky which created it's own problems. An UL ratchet joint Otto Bock are planning to release looks nice and low profile, but had quite large 'steps'.

We have used both the ratchet and the turnbuckle setup for the problem you have. But for a dynamic style of extension assist, we have used the Hosmer 53889 elbow flexion assist joints (clock spring type) and just put them on in reverse. You may need to extend the uprights on them and also change the position of the tension pin for the spring to increase the force. If using turnbuckles, buy masthounds from marine hardware to attach to the plastic shells.

i have used exactly the same device----custom molded --lined--elbow extension orthosis with rachet joint on outside of elbow and a free motion joint on the medial side---need to use a well padded elbow pad to prevent tissue breakdown----if she is a sound sleeper it would be nice if permissible to extend clinically her elbow to see if she demonstrates lees of a contracture---so you have a good starting position----have fun

DeRoyal manufactures both dynamic and static/progressive splints for the
elbow. The hinges or mechanisms for the static/progressive splints (our
Static-Pro) can be purchased without softgoods. This way the Orthotist
can custom fabricate the softgoods or cuffs if desired.

I have had the same exact case at my clinic. I tried the dyna-splint and
the proglide but these torsion type hinges seem to cause tendonitis and also
tends to rotate off mid line. I tried the Mayo Clinic Brace from Aircast.
I tried it more to appease the rep. With all my doubts it actually worked.
Here is the link. <URL Redacted>
863-9CA4959D57AE&rnd=167341423 I borrowed the sales rep sample for a few days. I then bought one as a definitive after we noticed that the patients tolerance and progression
increased.


Wow, good luck. Sorry I don't have any suggestions.
At her young age, I understand that she doesn't want
surgery, but a z-plasty might loosen up the joint
without actually cutting muscle or tendon. Do you
know if any of the local docs do z plastys? That's
where the tendon is nipped in a few spots along the
length to allow the tendon to unwind a bit for
lengthening.


I do a lot of this in my practice. One of the best orthoses to use in conjunction with a botox regimen and maintain the range afterwards is the Ultra Flex orthosis. the joint was designed specifically for use with neuro patients and UMN patients with tone issues. Give them a call. They do great work and your results will make you the envy of the team.

Try looking at our website www.orthoinnovations.com We have a line of
static progressive orthoses that may benefit your patient.

Cheers,

Tim Jarrott, Orthotist / Prosthetist

Melbourne, Australia