Elbow surgery

Elbow surgery is frequently required in arthrogryposis. A lack of flexion impairs the ability to place the hand in close proximity to the mouth for feeding. Prior to surgery, an intensive period of physiotherapy and splintage may permit an improved passive range of motion. Surgery typically has to address two problems.

The first problem is that of a tight triceps tendon and joint capsule. This necessitates a release of the triceps tendon via a posterior approach. It is divided in a V shape which permits subsequent lengthening when it is closed as a Y. Division of triceps allows access to the posterior elbow joint capsule which must be released. The elbow is flexed to at least 90 degrees but with caution not to harm the humeral growth plate or the ulnar nerve behind the medial epicondyle. An ulnar nerve transposition may be required if it is stretched at the new extreme of flexion.

The second problem is that of a motor for elbow flexion. Most frequently, this is achieved through a tendon or muscle transfer. Donor muscles must be expendable in their function and have adequate strength and dynamic range. Possible transfers include:

• triceps to biceps transfer
• pectoralis major muscle; may be one or both parts of the muscle
• latissimus dorsi
• free gracilis muscle with coaptation of the obturator nerve to local recipients
• relocation of the flexor-pronator mass

Such transfers must not impair function eg, triceps should not be sacrificed if the child ambulates with crutches or similar walking aids.