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Anterior Release of Elbow Flexion Contracture


- See: Hetertopic Ossification of the Elbow:

- Discussion:
    - most indicated for flexion contractures of the elbow (w/o extension contracture);
    - disadvantages:
           - some patients may gain extension but will loose flexion (especially if they are casted in extension);
           - possible wound dehiscence from tension on the anterior soft tissues;
           - inability to address the posterior structures;

- Incision:
    - oblique transverse incision is made extending across the antecubital fossa
           - insision is carried obliquely and proximally along the radial aspect of the arm, a distance of 5-6 cm;
           - incision is carried obliquely distally along the medial aspect of the arm, a distance of 5-6 cm;
    - incision is carried thru subQ tissues, with care to avoid injury to superficial veins, and the medial and lateral antebrachail cutaneous nerves;
    - it is necessary to develop full thickness subcutaneous flaps for adequate exposure;
    - lacertus fibrosis of the biceps is incised, which allows subsequent exposure of the the median and ulnar nerves;

- Deep Dissection:
    - identification of radial nerve;
            - radial nerve is identified between the brachioradialis and brachialis;
            - nerve is tagged with a rubber dam;
            - during the procedure the nerve is retracted laterally w/ a thyroid retractor;
    - identification of median nerve and brachial artery
            - both the median nerve and brachial artery are tagged w/ rubber dam;
            - the deep dissection procedes medial to the N/V bundle;
            - the nerve and artery will be gently retracted laterally during the case w/ an appropriately sized thyroid retractor;
    - identification of joint capsule:
            - use a kitner rolled up sponge (peanut) to gently sweep the remaining soft tissues off the joint capsule (which is white compared to the other tissues);
                    - begin at the most medial aspect of the capsule and proceed to sweep the overlying tissues off the capsule in a radial direction;
                    - flexion and extension of the joint will help keep the dissection over the most central portion of the dissection;
                    - the coronoid process process is another useful landmark;
            - once the dissection becomes difficult due to the overlying biceps and brachialis, then begin to sweep the soft tissues off the 
                    capsule (using a peanut) starting at the most radial aspect of the joint and then proceding medially;
                    - if there is any question of the level of the capsule, pass a right anlge retractor along the capsule from a
                           medial to radial direction and then locate the tip of the right angle thru the lateral windon;
    - transection of the capsule
            - prior to transection of the capsule, their should be a clear view of the capsule from both the medial and lateral directions;
            - flex and extend the elbow to identify the center of the capsule;
            - use a 15 blade scapel to transect a window of the capsule from the medial to the lateral edges of the capsule;
                    - it is essential that the dissection begn as far medially as possible w/o injuring the MCL;
                    - the medial tongue of capsule is grasped w/ a clamp and is passed into the lateral window;
                    - laterally the dissection needs to procede past the radial head;

- Manipulate Elbow:
    - gentle extension force is applied to the elbow;

- Post Op:
    - the elbow can be splinted in extenion for one week prior to ROM;

- Case Example by Dr James R. Urbaniak MD:






Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy.

Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study.

Anterior Release of the Elbow for Extension Loss.