Characteristics of mechanical bony block at the elbow region following noncompliant treatment in rural settings: A retrospective study from a teaching hospital

Ganesh Singh Dharmshaktu

doi:10.4103/jssrp.jssrp_8_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 2 | Issue : 1 | Page : 10-13

Characteristics of mechanical bony block at the elbow region following noncompliant treatment in rural settings: A retrospective study from a teaching hospital

Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission	25-Dec-2020
Date of Acceptance	23-Jan-2021
Date of Web Publication	28-May-2021

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jssrp.jssrp_8_20

Abstract

Background: Elbow function is important for activities of daily living and restriction of its full range of motion affects the quality of life. Various localized reasons such as trauma, congenital deformities, and diseases may alter bony anatomy resulting in suboptimal joint movement and require appropriate diagnosis and subsequent management. It is therefore important to know the common causes of mechanical elbow block and their pattern. Materials and Methods: A retrospective account of serial cases of mechanical flexion block with the radiological presence of bony hindrance to elbow motion were included with relevant characteristics like patient demographics, laterality, reason, anatomical involvement, previous and further treatment were noted for each of them. Result: A total of 21 cases (18 males and 3 females) with mechanical flexion block were part of the study with a mean age of 20.19 years. Malunited supracondylar and malunited radial head fractures were commonly identified the reason for the bony block, followed by other singular causes. Operative intervention was done in most of the cases, while one case was managed conservatively. Lack of availability of specialist doctors, lack of regular transport to higher center, and financial issues were reasons behind noncompliance to the treatment. Conclusion: Mechanical motion block is disabling condition and dedicated preventive and therapeutic intervention is required to deal with it. The pediatric cases can be observed for remodeling failing which operative intervention can be done. The surgery in selective adult cases leads to good outcome.

Keywords: Elbow, flexion block, mechanical block, range of motion, stiffness, trauma

How to cite this article:
Dharmshaktu GS. Characteristics of mechanical bony block at the elbow region following noncompliant treatment in rural settings: A retrospective study from a teaching hospital. J Surg Spec Rural Pract 2021;2:10-3

How to cite this URL:
Dharmshaktu GS. Characteristics of mechanical bony block at the elbow region following noncompliant treatment in rural settings: A retrospective study from a teaching hospital. J Surg Spec Rural Pract [serial online] 2021 [cited 2023 Mar 31];2:10-3. Available from: http://www.jssrp.org/text.asp?2021/2/1/10/317015

Introduction

The functional range of elbow motion is described as 30° to 130° of flexion-extension and 50° supination to similar degree of pronation for most activities of daily living.^[1] Less than 120° of flexion and extension block more than 30° can be labeled as elbow stiffness.^[2] Although the true incidence is difficult to ascertain, traumatic causes are major reasons for elbow stiffness. The stiffness may result from abnormalities in soft tissue, muscle-tendon units, fibrous tissues, joint incongruencies, etc., Mechanical causes of stiffness may result from malunion or nonunion of fractures of the bones around the elbow joint, congenital deformity, neoplastic, infective, or inflammatory etiologies. Flexion limitation is more common feature of most elbow stiffness.^[3] Failure of nonsurgical management, severe contracture, or bony blocks may require surgical in intervention. The decision to select treatment options also needs consideration of occupation, functional demands, location of pathology, future prognosis, and surgeon's experience.^[4] The details of prevalent causes of mechanical blocks thus help in anticipation, preparation, and appropriate intervention of these challenging cases.

Materials and Methods

A retrospective data of all consecutive cases of elbow stiffness cases secondary to traumatic events coming to the outpatient department were noted within a period of August 2014 to December 2018. The relevant patient demographics such as age, sex, type of injury, mechanism of injury, laterality, affected anatomical part, type of mechanical block, history of previous treatment, and management done by us were noted for each case. Cases with a history of incomplete treatment or noncompliance to treatment once received were included in the study. The first contact of consultation and reason for the discontinuation of treatment was noted by leading questions. The functional limitation was measured by a handheld goniometer in a standard manner and compared to the opposite limb. On clinical movement testing, the status of endpoint, whether soft or hard, was also noted. The other associated injuries such as head injury, burn, electric shock, presence of open injury, and presence of current or previous infection were also noted. The cases with postsurgery mechanical blocks done at our center or elsewhere were also included in the study, but cases of old unreduced dislocations were excluded as these invariably cause elbow restriction. The radiographs were evaluated for the presence of mechanical reasons such as bony block, bony malunion, nonunion, bony bar or callus along with notification of proximal radius and ulna, distal humerus, and olecranon for any injury or its sequelae. The condition of coronoid or olecranon fossa was also noted for any abnormality. Cases with congenital or acquired complete ankylosis of elbow cases were also excluded. Cases with extrinsic causes showing no mechanical or bony reasons for motion restriction were excluded from the study like those with only involvement of soft tissue, heterotrophic ossification, myositis ossificans, infective disease, inflammatory condition, or neoplastic lesions. The relevant details of management, both conservative and surgical, were noted and the outcome was evaluated by the quick disability of arm, shoulder, and hand (DASH) scoring system. The data were managed with Microsoft Excel and Word program [Figure 1] [Figure 2] [Figure 3] [Figure 4].

Figure 1: The elbow radiograph in the orthogonal plane (a and b) showing abnormal proximal radius anatomy by malunited radial head fracture producing a mechanical bony block to movement. The radiograph following excision of the radial head (c and d)

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Figure 2: Another case with malunited radial head fracture (a) also managed by excision of the radial head part (b)

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Figure 3: Loose body and radial head malunited fracture in the elbow (a) managed by removal of excision of loose body and fashioning of part of proximal radius (b)

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Figure 4: Radiograph showing malunited supracondylar fracture with anterior spike blocking motion (a and b). Remodeling of the deformity to some extent to a better range of motion (c) in follow-up

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Results

A total of 21 were included in the study all with elbow flexion block due to associated bony abnormality. 18 cases were male and 3 were female. The mean age of the cases was 20.19 years (range 6–66 years). The left side was more commonly involved. The conditions in decreasing order of prevalence were malunited supracondylar humerus fracture (9 cases), malunited radial head fractures (6 cases). The other cases with singular number of case were – malunited radial head with nonunion olecranon, cubitus varus deformity with radial head subluxation, malunited capitellum, ulnohumeral arthritis with radial head malunion, elbow arthritis with lateral condyle nonunion, and radiohumeral bony bridge. The radiographs clearly showed a bony obstruction in all our cases and further tests such as computerized tomography (CT) or magnetic resonance imaging (MRI) were refused by the patient due to financial constraints. The five cases of malunited radial head fracture were managed by excision of the radial head, while one case refused the surgery. Most of our cases belonged to extrinsic causes and only one with intrinsic cause as malunited capitellum fracture. One mixed case of the loose body with articular arthritis was also noted. The extension in all our cases was not restricted and flexion in the range of 40°–110° short of full flexion was noted. On clinical movement testing, the firm endpoint of blocked movement was also noted that signifies bony obstruction. All our cases had intact distal neurological status except in two cases of old supracondylar fractures with initial history of ulnar neuropraxia which was resolved by now. All cases were managed by surgical intervention except one child in which conservative care was opted by parents and the radiographs showed remodeling to result in improvement in range of motion. The postoperative posterior interosseous nerve neuropraxia was noted in two cases with radial head excision which resolved spontaneously in the follow-up. The quick DASH scoring was used to document the outcome of the treatment with the average score of 60 in the preoperative phase showed a mean improvement of 20 points. Only one pediatric case had poor outcomes and was referred to dedicated centers for further treatment. Regarding the reasons for discontinuation of treatment that led to current status, the reasons cited were nonavailability of specialist doctor at the primary care center, lack of regular and easy availability to nearest higher center, and financial issues by 9, 7, and 5 patients, respectively. These social issues even in the present era were found to be crucial in the proper management of these cases.

Discussion

Elbow stiffness is a problematic complication resulting from both traumatic and atraumatic causes. Elbow may directly or by secondary processes undergo changes that promote stiffness following traumatic events.^[5] Morrey has devised simple classifications of elbow stiffness into extrinsic, intrinsic, and mixed.^[6] Extrinsic causes mainly include extraarticular malunion, while the intrinsic causes include loose body, osteophyte formation, intraarticular adhesions, and malaligned articular surface. Preoperative nerve functions are required to note along with postoperative comparison for any nerve injury.

Supracondylar humerus fracture malunion is common complication of conservative or even operatively managed fractures that lose reduction in the early postoperative period. Early identification and remedial management is critical for good outcome.^[7] Corrective osteotomies are effective methods to manage supracondylar fracture malunion and the complications can be lowered by choosing lateral approach or pinning methods.^[8] Radial head malunion poses challenges for not only pronosupination but if associated with severe deformity may affect flexion-extension arc as well. There are operative fixation methods for acute fracture, but old malunited fractures are surgically corrected with osteotomies in very few studies. The authors, however, noted good outcomes within 6 months of injury before arthritic changes develop and concluded it worth an attempt.^[9] Cadaver studies reveal that radial head fracture that leaves deformity like more than 2 mm depression and 30° angulation may severely affect concavity-compression stability of radiocapitellar joint.^[10] All our cases were managed by radial head excision as they refused osteotomies or radial head arthroplasty. An excision is also a good option with long-term favorable outcomes recorded.^[11] The capitellum malunion case with malunited fragment has been reported to be managed by osteotomy and internal fixation with headless screws.^[12] Only one case of the loose body was noted in our series but refused surgery and continued physiotherapy. The cases of loose bodies or at times pathologies like synovial chondromatosis may be the main cause of mechanical elbow movement block requiring open or arthroscopic removal.^[13] Shortcomings of the study were failure to use advanced imaging modalities such as CT or MRI to the comprehensive status of elbow anatomy and alterations apart from the bony hindrance that may have bearing on the outcome. The small case pool is also there as the strict criteria of inclusion of only cases with a bony mechanical block were responsible for it. Early rehabilitation and minimal immobilization is important to avoid elbow stiffness. Prevention is the best option to manage this disabling complication.^[14] In developing countries, many a times various elbow injuries are missed due to various factors like lack of knowledge to properly appreciate the radiological anatomy of the elbow particularly that of the immature skeleton.^[15] As our understanding of posttraumatic elbow stiffness has increased over the years with better knowledge about pathogenesis and treatment options with pros and cons of each, so is our responsibility to be part of preventive and ameliorative efforts.^[16] Sometimes, the causes of elbow stiffness are both extrinsic and intrinsic and injuries with complications including bony block or connection restricting elbow movement respond well to the surgical excision of the culprit lesion.^[17] The poorly managed radial head fracture in our study was an important cause of decreased elbow movement and underlines the importance of appropriate management of these fractures. The radial head is critical to elbow stability and range of motion and warrants optimal treatment to limit complications.^[18] Newer design or techniques in braces or splints that provide dynamic corrections are additional options in the conservative care of elbow stiffness.^[19] Conservative treatment in cases of the stiffness of <6 months can be done and may include the use of serial casts, static or dynamic splints, continuous passive motion, physical therapy, manipulations, or functional re-education on case-by-case basis.^[20] Elbow arthroplasty is the treatment limited to recalcitrant cases of elbow stiffness, especially following surgeries or not improving despite physiotherapy.^[21] Many of the cases belonged to rural areas with limited availability of expert care and practical problems in frequent follow-up visits. The improvement of primary care facility, availability of specialist doctor or trained allied personnel along with better patient education shall be instrumental to cut down the burden and disability to a large extent. The current study aims to highlight important causes leading to limitation of elbow motion in patient hailing from the particular rural region and advocate studies directing similar data-based observations from other rural areas also to have a comprehensive overview of common injury patterns. The takeaways from these studies shall be helpful in the prevention and management of such causative factors. The other lessons from this work can be educative for health-care personnel at the rural level or rural population at large that cases pertaining to visible bony obstruction to elbow motion on radiographs need not live with their disability and their condition can be improved by meticulous excision of the offending structure in most cases. Many of such cases, though, would require referral to the orthopedic facility in absence of the specialist, but in centers with an attending specialist, few simple cases can even be done in primary care level without requiring specialized gadgets. The results of the studies shall also enable health-care personnel to get state-supported additional training or activities related to continuous professional development in the management of common causative injuries to limit the incidence of misdiagnosis, inappropriate treatment, and promote due referral when required. Basic skills in splinting and primary management of such injuries can be strengthened by self-directed learning or other means.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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