PREVENTION OF CONTRACTURES IN TREATMENT OF INJURIES TO ELBOW JOINT
Yaroslavl State Medical Academy,
Solovyev Clinical Emergency Hospital,
Yaroslavl, Russia
At the present time ulnar joint (UJ) injuries are identified in one-third of the patients with polytrauma. They take the first place according to the number of posttraumatic complications and result in persistent disability in 29.9 % [1]. 30-60 % of the patients need for different functional restorative operations [2, 3, 4].
One should note that the literature does not include findings with proper attention to preventing contractures in UJ injuries. Commonly the manuals and textbooks for traumatology include insufficiently concise or even superficial recommendations [3, 5, 6].
Posttraumatic ulnar contracture is not simple for treatment. Therefore, prevention with consideration of etiopathogenetic mechanisms of development presents great significance. Full anatomic reposition of bones forming the ulnar joint, proper fixation and early mobilization are the keys to restoring joint function [6, 7, 8].
All above-mentioned facts indicate the necessity for multidisciplinary treatment for UJ injuries by means of development the uniform protocol of presurgical preparation, clear rational indications to conservative and surgical treatment with designation of concise types of osteosynthesis with modern techniques.
MATERIALS AND METHODS
Within 13 years (2000-2012) we observed 395 adult patients with pre- and intraarticular injuries to the ulnar joint; among them 142 patients with injuries to the distal metaepiphysis of the humerus, 124 – with fractures of the proximal ulnar bone, 129 – with fractures of caput radii. There were 190 men (47.17 %) and 207 women (52.8 %). The mean age was 44 ± 2.
AO and Masson classifications were used for description of injuries to the bones forming the ulnar joint. The results of treatment were estimated with Mayo clinic scale [9] for the ulnar joint. The wrist joint functioning was estimated according to Green and O’Brien [10]. Additionally, for more objective estimation we also considered radiologic and clinical signs of fracture consolidation, development of heterotopic ossificates and deforming arthrosis, neurologic symptoms and possibility of further professional activity (ability to previous working activity).
For prevention of posttraumatic contractures in UJ all patients adhered to our protocol of conservative and surgical treatment and our rehabilitation program.
Conservative treatment was realized for 99 (22.05 %) patients, surgical – for 296 (74.9 %).
The protocol of conservative treatment
1. Full diagnostics of bone fractures in the ulnar region. In doubtful cases we used more informative techniques (special radiologic plains, CT and 3D CT).
2. Refusal from attempts of closed reposition of fracture, because in case of success 4-6 weeks (or more) of external immobilization are required, but it results in contractures.
3. Ulnar joint immobilization is realized by means of a separable brace bandage with hinged restrainers of motion range. The hinged brace realizes protective, discharging, statistic and dynamic functions. It allows rotation moment in flexion or extension. In case of fracture of the lateral epicondyle (type A1.1) the ulnar joint was fixed in the flexion position with 30° angle, the forearm – in maximal supination and the hand – in extension for relaxation of the extensor muscles. In fracture of the medial condyle (type A1.2) the ulnar joint was fixed in the flexion position at the angle of 60°, the forearm – in maximal pronation and the hand – in flexion at the angle of 30° for relaxation of the general flexors and the pronator. In isolate factures of the radial head the ulnar joint was immobilized in the scarf bandage at the angle of 90°.
4. Motions in the shoulder joint are allowed from the first day.
5. The joint is located in elevated position during 5 days (higher that heart level).
6. Within 48 hours local cooling for the ulnar region is realized for reducing edema and prevention of compression of soft tissues.
7. From the first day after trauma indomethacin (25 mg, 3 times per day) is prescribed for preventing sclerostenosis. The administration of the drug is 4-6 weeks.
8. Drug therapy with vein tonics (detralex) is an additional prescription in case of increasing edema and subcutaneous bleeding in the ulnar region.
9. Radiologic control is made in 10 days. If secondary displacement is absent, immobilization continues during 2 weeks. Recurrent radiologic control is performed in 3 weeks after trauma. If displacement is absent, then extension-flexion and rotation motions in UJ are allowed. Brace immobilization lasts for 6-8 weeks.
10. On the weeks 6, 12 and 24 the control X-ray imaging is realized. During each clinical examination one should estimate and document results of treatment (the table according to Mayo scale).
The protocol for surgical management
The protocol for surgical management is constructed with adherence to the main techniques of osteosynthesis with AO/ASIF – full reposition for intraarticular fractures, proper fixation (for possibility of early motions) with plates, screws, rods and wire in simple (non-comminuted) fractures of the olecranon. The features of osteosynthesis in different types of fractures are reviewed in the specified parts of the article. Postsurgical immobilization is made with the plaster bar in position of extension of the ulnar joint for 3 days (The extremity in elevated position), followed by the scarf bandage.
The program for rehabilitation in conservative and surgical treatment
The rehabilitation program was developed with consideration of the set of the rules and the principles of physical training.
1. Early initiation of active motions.
2. Refusal from redressing passive exercises causing pain and microinjuries in UJ and accelerating maturation of mesenchymal tissue by means of the scientific discovery by G.A. Ilizarov – stimulation of regeneration through tensile stress [11].
3. In immobilization and postimmobilization periods the forbidden procedures included physical procedures with use of heat, mudtherapy and massage for the injured ulnar region. The prohibition is related to possibilities of increasing bleeding, edema and stimulating reactive changes in tissues that provoke development of contractures and heteroscopic ossification of the joint. Massage is only allowed in very careful manner and only over and lower UJ, with stroking and frolement and avoiding the injured region. Massage for the ulnar joint is contraindicated!
4. After surgery the ulnar joint is immobilized in the position of full extension with the hand elevated for 3-7 days. The extremity is lowered for several minutes every hour for making motions in the adjacent joints and reducing discomfort and preventing perfusion disorders.
5. Active motions in UJ are initiated beginning from 5-7 days after trauma (in conservative treatment of non-displaced fractures and insignificant displacement). In case of less favorable position of fragments in intraarticular fractures, when surgery is impossible according to medical indications, active motions in UJ are initiated on 14th-21st day after trauma (depending on characteristics of fracture and its stability). In case of surgical treatment active motions are initiated on 3rd day after removal of the plaster bar.
6. During the second period after completion of UJ immobilization the special exercises for an injured joint are initiated. If treatment is realized with the hinged brace, active motions are initiated in 2 weeks: at first, rotation motions, after 1 week – flexion-extension motions (Fig. 1).
Figure 1
Development of active simplified motions in the ulnar joint with use of the industrial roller carriage moving along sliding surface.
The rehabilitation program for the patients with fractures of the bones in the ulnar joint was realized in the room of remedial exercises under medical control. Active procedures for the joint (Fig. 1) are recommended in home conditions (3-4 times per day with sessions of 1.5-2 hours). At each stage we documented the functional outcomes according to Mironov-Burmakova. The analysis of short term and long term results of rehabilitation measures can be realized with the same pattern.
The long term results of conservative treatment of fractures of distal metaepiphysis of the shoulder were examined in 35 and 49 patients (table 1).
Table 1
The long term results of conservative treatment of fractures of distal humerus metaphysis
These tables accent the doubtless efficiency of the protocol for conservative treatment of periarticular fractures of distal metaepiphysis of the shoulder without displacement of fragments. The fine and good results took place in 47.36 %, i.e. in all patients with fractures of type A, good results – only in 8.57 % and 33.17 % with fractures of type B. The satisfactory and unsatisfactory results were identified in 44.85 % of the patients with intraarticular fractures of distal metaepiphysis of the shoulder (type B and C). The secondary displacements were in 10 days in two patients with fractures of type B, but they refused from surgery. One patient demonstrated the satisfactory result, the second patient – the unsatisfactory one.
The long term results of surgical treatment of fractures of distal metaepiphysis of the shoulder were examined in 73 among 93 patients (table 2). The excellent results were observed in all patients (17.8 %) with extraarticular fractures (type A), in 21.9 % of 46.5 % with incomplete intraarticular fractures (type B), in 15 % of 35.6 % with complete intraarticular fractures (type C). The good results were observed in 21.9 % of 46.5 % with fractures of type B and in 15 % of 35.6 % with type C. The satisfactory results were in 2.73 % of 46.5 % with fractures of type B and in 6.8 % of 35.6 % with fractures of type C. They had intense pain in the ulnar joint with good range of motion (more than 125°). No patient had unsatisfactory results.
| Table 2 | ||||||||
| Long term results of surgical treatment for patients with fractures of distal humerus metaphysis | ||||||||
The described clinical case gives an example.
The patient A., age of 26, was admitted 3.5 hours after injury as result of falling from the stepladder (June, 16, 2012). The diagnosis: “Opened comminuted complete intraarticular fracture of distal metaepiphysis of the left humeral bone and the proximal part of the ulnar bone (Fig. 2)”.
Figure 2
The tear-contused wound in the ulnar region – a; two-section X-ray images of the ulnar joint – b, c.
a b c
The surgery was made (V.A. Kalantyrskaya). Surgical preparation of the wound was performed under conduction anesthesia: fixing the block of the humeral bone with screws (subchondral), fixation with two plates according to the standard technique (the plate was located along the internal border, 1/3 tube with 6 screws, along the posterior external border – reconstruction plate with 6 screws); reposition of the proximal department of the ulnar bone, fixation with 8 screw reconstructive plate (with 1 additional screw); ulnar joint draining, sutures, scarf bandage (Fig. 3).
Figure 3
Reposition of the block and capitated prominence of the humerus with use of screws – a; two-section X-ray images after osteosynthesis – b, c.
a b c
The wound healed without complications. The range of motion in the ulnar joint 12 weeks after surgery: flexion – 110°; extension – 0-145°; supination – 15°; pronation – 49° (Fig. 4).
Figure 4
The functional outcome after 12 weeks: a, b – flexion-extension; c, d – pronation-supination.
a b
c d
Treatment of fractures of the head of the radial bone
Within 12 years (2000-2012) 32 patients with fractures of caput radii were observed in the injury care center. They were treated with the protocol and the rehabilitation program of conservative treatment. 18 patients had the fractures without displacement: 11 – type I, 7 – type II. 14 patients had insignificant displacement (type II), but without block of passive rotation movements.
The long term results of conservative treatment (3 years) were investigated in all 32 patients.
The use of our protocol for conservative treatment and the rehabilitation program for fractures of caput radii (types I and II) resulted in compensated function of the ulnar joint in all 32 patients in the long term period.
Osteosynthesis of the head of the radial bone was made for 97 patients. According to Mason’s classification 21 cases (21.6 %) were related to the fracture of type II, 37 (38.3 %) – III, and 39 (41.8 %) – IV.
In complete fractures of the radial head, if the fragments were related to the main fragment, intracorporeal release from clots, fibrin and small fragments was made. At first we carried out reposition of fragments of the head against each other, then reposition of the head against the diaphysis of the radial bone. The miniplate (designed by us) was chosen according to the appropriate size. If the size of the plate exceeded the non-contact region of the head, then the excessive holes were cut off.
In the cases when realization of intracorporeal reposition and fixation was technically impossible or the fragments were unrelated to the diaphysis and positioned in the tissues (i.e. it required necessary taking out) we realized reposition and osteosynthesis after extracting the fragments out of the wound. We called such osteosynthesis as extracorporeal.
We identified a contactless region on the head of the radial bone and estimated a possibility for fixation of all fragments with use of the plate in the region of the head. In impossible cases we made preliminary fixation of fragments with use of screws and pins. Then the plate was fixed to the fastened head in the contactless region (Fig. 5).
Figure 5
Fixation for fragments of the head of radial bone: a – pins; b, c – plate installation.
a b c
The plate with the fixed radial head was placed into the surgical wound. Reposition of the head was made against the diaphysis of the radial bone. The necessary control was made for the position of Lister’s tubercle according to the plate position. It was made for preventing the conflict between the plate and the sigmoid notch during shoulder rotation (Fig. 6). Afterwards the plate was fixed to the diaphysis of the radial bone, and radiologic control was made.
Figure 6
Projection of the axis of radial bone through Lister’s tubercule.
Endoprosthetics for the head of the radial bone was made for all patients: one patient with the ununited comminuted fracture in the proximal end of the right ulnar bone and the comminuted fracture of caput radii, and 7 patients with old fractures of caput radii.
The long term results were estimated in 58 of 97 patients at average 18 (11-40) months after surgery. Among them 26 patients (45 %) had fractures of type IV, 21 (36 %) – III and 11 (19 %) – II. The motions in the ulnar joint were measured as absolute values (degrees) and relative ones on the uninjured extremity. The mean range of extension-flexion for the operated ulnar joint was 130°± 12° (0-12-142), for the healthy arm – 149° ± 2° (0-0-149), i.e. 87 % of the healthy extremity. The range of rotation movements in the operated hand was 131° ± 5° (73-0-58), in the contralateral hand – 157° ± 4° (90-0-67), i.e. 83 %. The strength of hand grip in the injured hand was 83 % of the uninjured one.
There is a clinical example.
The patient I., age of 46, visited the planned consultation. He had complaints about limiting the motions and pain in the left ulnar region. The examination found edema in the region of the left ulnar joint, the range of motions: flexion-extension 75/35/0, supination-pronation 25/10/15.
CT showed the consolidated comminuted fracture (in the incorrect position) of the head of the radial bone (Fig. 7).
Figure 7
Old fracture of the head of radial bone, a – top view; b – lateral view.
a b
The endoprosthetics for the left head of radius (V.A. Kalantyrskaya) was made. The postsurgical motions in the ulnar joint: flexion-extension 115/10/0, supination-pronation 45/50. The ulnar joint is stable (Fig. 8).
Figure 8
X-ray images after endoprosthetics for the head of radial bone.
8 months after surgery the patient had complaints of moderate pain during loading. The joint is stable. The range of motion: extension-flexion 110/10/0, pronation-supination 55/50. The place of employment is the same. Among his activities is skiing.
Treatment of fractures of proximal ulnar bone
18 (14.5 %) of 124 patients received conservative treatment for the fractures of the proximal ulnar bone.
The anatomic and biomechanical properties of the forearm require ideal aligning of the length of the ulnar bone; in most cases it is possible only with surgical treatment.
Surgical treatment was performed for 106 (85.4 %) patients, Weber osteosynthesis with pins and tension loop – for 38 (35.8 %). Weber osteosynthesis and screw fixation for the coronoid process were made for 6 (5.6 %) cases. The comminuted fractures of the proximal ulnar bone was made with plate – 43 (40.5 %), in 21 cases the additional screw fixation for the coronoid process was made. Therefore, we restored the length of the ulnar bone and the anatomic shape of the articular surface.
The long term results were examined in 73 patients. All patients showed union of their fractures. The mean amplitude of the motions was 118 ± 12°.
There is a clinical example.
The patient S., age of 39, was admitted on May, 27, 2001. He suffered from the road traffic accident resulting in the closed comminuted fracture-dislocation of the proximal ulnar bone and the fracture of the radial head. On the second day open reposition, plate osteosynthesis for the proximal ulnar bone and screw osteosynthesis for the radial head were made (V.A. Kalantyrskaya). The functional results were estimated in 20 weeks after surgery (Fig. 9).
Figure 9
Ulnar X-ray images: a – frontal view; b – lateral view; c – after surgery; d, e, f, g – functional outcomes after 20 weeks.
a b c
f g
The observation illustrates the possibility of restoration of good functioning in the ulnar joint after severe intraarticular fracture of the ulnar and radial bones with adherence to our protocol for surgical treatment and rehabilitation.
CONCLUSION
Fractures of the bones forming the ulnar joint present one-fifth of all skeletal injuries. Joint contracture is the common complication after conservative treatment, incorrect internal osteosynthesis and long term immobilization.
We agree with the opinion by the authors who state that active early motions play significant role in restoration of the function in the operated UJ. Moreover, if quality of osteosynthesis requires external immobilization, then the sense and advantage of surgery disappear.
Yaroslavl region has the single trauma center (on the basis of Solovyev Clinical Hospital) including 432 beds and 10 specialized departments. Treatment of injuries to the ulnar joint is concentrated in the department of hand surgery and plastic surgery. It allowed universalizing the technique for conservative and surgical treatment for such patients, developing pathogenetic approach to prevention of contractures and developing the protocol treatment of peri- and intraarticular injuries to the ulnar joint.
Among 99 patients receiving conservative treatment the long term results were examined in 53 patients. They were good and excellent in 49 (92.4 %) patients. Among 296 operated patients the results were investigated in 204 patients: good and excellent results in 178 (87.2 %) patients. There were no cases resulting in disability in the patients with ulnar joint injuries who received timely specialized aid.
SUMMARY
1. Presurgical preparation for patients with bone fractures in the ulnar region is an important element in successful treatment. It includes proper immobilization for the ulnar joint at the angle of 30-60° with the extremity in the elevated position, soft tissue preparation with use of drug therapy for prevention of edema, hematoma and possible risk of heterotopic ossificates. One should not perform closed reposition of peri- and intraarticular fractures of the distal humerus in adult patients. It is associated with burdening soft tissue injuries and need for long term external immobilization.
2. Conservative treatment is indicated for patients with periarticular fractures and without displaced fragments (type A) and for patients with intraarticular fractures (type B and C), when surgery is impossible. Four week immobilization is realized with the hinged orthesis, but not with plaster split. For positive results it is necessary to use our protocol for conservative treatment and our rehabilitation program.
3. In displaced fractures of the ulnar bones full reposition and congruence of the joint should be restored by means of open reposition within the first days after trauma or 4-6 days after disappearance of edema. Osteosynthesis with AO techniques provides proper fixation for non-plaster management and early restorative treatment after surgery. Surgical treatment should include our protocol and rehabilitation program.
4. Presence of osteoporosis in patients with fractures in the ulnar region is the indication to administration of implants with angle stability. Other osteosynthesis techniques do not preclude secondary displacement of fragments and require additional external mobilization.
5. The analysis of long term results of treatment for ulnar joint injuries confirmed high efficiency of our protocols for conservative and surgical treatment and our rehabilitation program. Among 99 patients who received conservative treatment the long term results were investigated in 53. The results were good or excellent in 49 (92.4 %) patients. Among 296 operated patients the results were examined in 178 (87.2 %) patients. There were no unsatisfactory results after surgical treatment.
6. In concordance with AO classification, systemization of bone fractures in the ulnar region allows selecting treatment options with consideration of injury severity and degree of displacement of fragments.
The scale from Mayo clinic allows objective investigation of efficiency at any stage and giving correct assessment of our protocols and rehabilitation program for management of patients.