Observation About “Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents”

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To the Editor:
Piper et al1 recently published the paper entitled “Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents,” exploring an important orthopaedic problem in young population. The authors retrospectively investigated the open surgical release of posttraumatic elbow contracture, in 26 patients, finalized to restore the elbow range of motion. The subjects were evaluated from a clinical point of view and by the use of radiography. The interventions to administer were decided on the basis of patients’ conditions and could provide for capsulotomies, osteoplasties, heterotopic ossification removal, ulnar nerve transposition, or decompression and ligament rebuilding. After the surgery, rehabilitation, consisting of static progressive bracing program or use of continuous passive motion machine, was administered. The authors found the elbow range of motion was ameliorated through the open contracture release.
The paper by Piper and colleagues is very interesting and instructive for different reasons. The bone fractures in children and adolescent are relatively frequent and their consequences could be very impacting in quality of life. As the authors showed, elbow contracture can occur and the restriction of elbow range of motion in young people is very limiting for the upper limb function. Hence, an appropriate treatment of this contracture should be mandatory.
Another important theme that can be derived from this paper is the occurrence of other possible complications related to these bone fracture. In particular, the sample evaluated by Piper et al1 revealed recurrent contractions in 2 patients and 2 cases of ulnar neuropathy. These data are extremely important, because they suggest the importance of an accurate diagnosis and follow-up. The causes of neuropathies due to elbow traumas may be different: direct damage, surgical maneuvers, bursitis, bone callus formation. In many cases, the neuropathy can be avoided, but if particular conditions exist, for example, anatomic variation, a nerve damage may arise. Nerve involvement should be always considered in this type of bone fractures and appropriate use of diagnostic tool, able to definitely depict or exclude it, should be considered. Furthermore, a possible late neuropathy can happen, for example in cases of bone callus formation. The nerve involvement can be extensively assessable by the use of high-frequency ultrasound (US).2 US is able to study the morphologic features, depict possible presence of compressing external structures, distinguish between axonotmesis and neurotmesis, reveal the possible anatomic variations, and support the surgeon with information obtained before intervention.3
The authors wrote that transposition of ulnar nerve was performed if the nerve subluxated during elbow flexion.1 The same information can be obtained by US, before the surgical exploration, providing the possibility to plan the intervention and eventually inform the patient (or the family) about the operation that has to be achieved.4 Finally, US is inexpensive, not invasive, and can provide information in fast way and without side effects. For these reasons, we would like to underline the importance in using US as completion of clinical examination and as a tool essential for a complete comprehension of patient’s condition in elbow trauma.
The authors would like to thank Dr Claudia Loreti for her support.

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