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Review Question - QID 218222

QID 218222 (Type "218222" in App Search)
A 32-year-old male sustains a terrible triad injury to the right elbow five years ago. He presents to the clinic with minimal pain complaints but states he has limited range of motion of the affected elbow. He is right-hand dominant and is not able to use his hand for basic daily living functions. His elbow range of motion is 60 degrees to 95 degrees without pain. What is the most appropriate treatment option to address this patient's condition?
  • A

Bone scan to assess activity of heterotopic bone

9%

63/735

Arthroscopic elbow debridement

2%

16/735

Open elbow capsular release and heterotopic bone excision through lateral column approach

84%

616/735

Downsize radial head implant

1%

10/735

Ulnohumeral joint debridement and interpositional arthroplasty

2%

16/735

  • A

Select Answer to see Preferred Response

The patient is presenting with an elbow flexion contracture with extensive heterotopic bone formation. An open capsular release with heterotopic bone excision through a lateral column approach can effectively robust access to the anterior joint capsule and enable an improved range of motion.

Post-traumatic elbow stiffness can be a difficult entity to treat. Often, there are capsular contractures, arthritis, and heterotopic ossification that all act as constraints to physiologic motion. Treatment is directed at enabling a functional 90-degree flexion-extension arc to allow for normal activities of daily living. A lateral column approach allows for robust access to the anterior joint space to enable capsular release and heterotopic bone formation. This interval is developed by elevating the brachioradialis and extensor carpi radialis longus off the anterior supracondylar ridge.

Husband and Hastings reported on seven patients that underwent a lateral approach for elbow contracture release. They stated the average flexion contracture decreased from 45 degrees to 12 degrees and the average extension contracture decreased from 116 degrees to 129 degrees postoperatively. They denied any wound healing or heterotopic bone complications.

Mansat and Morrey reported on 38 elbows treated with a lateral column approach for elbow contractures. They stated the average flexion arc increased from 49 degrees preoperatively to 94 degrees postoperatively with 31 elbows achieving a satisfactory result. They concluded the lateral column approach provides a safe and effective method for addressing elbow flexion contractures.

Figure A is a lateral radiograph of the right elbow with a radial head replacement and extensive heterotopic bone formation.

Incorrect answers
Answer 1: The patient is presenting five years following the traumatic event. Typically, heterotopic ossification matures after 12 to 18 months. A bone scan at this phase is not necessary given the duration of time since the injury.
Answer 2: The extent of contracture and heterotopic bone formation favors an open approach in this patient.
Answer 4: The radial head implant is unlikely to be the culprit in this scenario given the extent of heterotopic bone formation and lack of pain.
Answer 5: Underlying ulnohumeral arthritis is not likely to be the cause of this patient's joint stiffness.

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