Elbow flexion contracture related to brachial plexus birth injury

What is an elbow flexion contracture?

An elbow flexion contracture can result from a brachial plexus injury.

The brachial plexus is a group of five nerves located at the top of the spinal cord that send signals to the muscles in the arm. If the nerves are injured, the muscles in the arm are weakened. At the elbow, if the nerves have been injured, the muscles that bend the elbow can become short and tight, while the muscles that straighten the elbow may become weak. This makes it hard to straighten the elbow all the way. This results in a bent and stiff elbow called an elbow flexion contracture.

Not everyone with a brachial plexus injury will get a stiff elbow

About half of children with a brachial plexus birth injury will develop an elbow flexion contracture. One in three of these children will have a stiff elbow that is bent more than 30 degrees. When a contracture is greater than 30 degrees, it is more visible and may cause limitations in daily activities. Most often, a stiff elbow does not stop most children from doing everyday activities, but they may need to adjust how they do it.

What your child wants to know

Most children and teens with a brachial plexus birth injury usually want to know why the nerves make one of their arms smaller than the other.

The nerve injury at birth affects how the muscles and bones in the arm and hand will grow. This is why their arm and hand on the injured side may be smaller in size.

How is an elbow flexion contracture treated?

There are three treatment options available for children with an elbow flexion contracture:

1. Watch and wait
2. Stretching program (cast and splint)
3. Elbow release surgery

Watch and wait

It is important to ask your child how they feel about the look and movement in their elbow. If they are happy with how it looks and feels for day-to-day activities, think about watching and waiting. If they are not happy, a stretching program might help.

It is important to keep an eye on how bent the elbow is. For some children who do not receive treatment, the bend can slowly get worse as they grow. If this happens, it is important to think about doing a stretching program (cast and splint).

Stretching program (cast and splint)

A regular stretching program, including exercises, casting or splinting, may help straighten the elbow. Your child’s therapist can teach them some exercises to do every day. The therapist will let you know how long and often your child should stretch their elbow. Heat packs and massage may help relax and warm-up the arm muscles before stretching.

Stretching is a commitment. About half of children who start a stretching program stay committed to the stretches, casting or splinting prescribed by their therapist. Before agreeing to a regular stretching program, it is important that you and your child talk with the therapist about strategies to help your child keep committed to a stretching program every day.

Casting can help to stretch the arm straighter. Serial casting is repeating the steps of stretching and wearing a cast. A therapist will typically use massage and heat packs before stretching your child’s elbow to help it become straighter. After the stretching exercises, your child’s therapist and an orthopaedic technologist will apply a cast to your child’s arm. This cast is typically made out of fibreglass and is not removable; your child will wear the cast for one week.

After the cast is removed, the process of stretching and casting is repeated to help the elbow to become straighter week by week. Your therapist will let you know how many weeks of casting you will have. Some studies show that casting can help decrease the elbow contracture to an average 15 degrees. Casting will not likely make the elbow completely straight.

After casting, a custom splint is made to help keep your elbow in its straighter position. This splint is removable and typically worn at nighttime, while your child sleeps. Your child’s therapist will talk to you about the different splinting options. On occasion, serial splinting can be used as an option to stretch your elbow straight when wearing a cast, which is not removable, is not suitable.

Starting a stretching routine when children are young improves the success of getting the best movement in the elbow. When comparing the options to stretch the elbow, casting has been shown to be more effective in making the elbow straighter. Splinting and stretching can help, but may be less effective on their own. Most importantly, wearing a splint is important to keep the elbow straighter after stretching. Your child’s elbow will bend back up if they stop stretching and splinting.

Risks of a stretching program (casting and splinting)

A stretching program, with or without splinting or casting, does not have a lot of risks.

Your child’s muscles may ache from stretching or they may have trouble sleeping because the splint is uncomfortable. Wearing a cast may cause weakness in the muscles that bend and straighten the arm, but this goes away once they use their arm again. Sometimes a cast may be put on too tight and your child can have pain or a sore on their skin. Sometimes stretching the elbow can cause changes to the elbow joint. Your child’s therapist will watch for this and stop treatment if this happens.

Elbow release surgery

Your child must try stretching, casting or splinting before considering surgery.

Surgery is done to make the tight and short muscles in the elbow longer, which helps straighten the arm. It is only offered by your child’s doctor if their elbow is making everyday activities more difficult. This is because surgery makes the muscles that bend the elbow weak and risks taking away some of the bending movement in the elbow.

After surgery there are exercises that need to be done every day for three months to help the elbow move easily again. Wearing the splint is important to keep the elbow contracture from coming back again. Your child’s surgeon will let you know how long your child needs to wear the splint.

What happens after elbow release surgery?

The results of surgery are hard to predict. Successful recovery will depend on how strong the elbow muscles are, how much bend there is in the elbow and if there are any changes to the shape of the bones. Some studies show that surgery can help decrease the elbow contracture to 10 to 25 degrees. Surgery will not make the elbow completely straight.

The biggest concern when choosing to have surgery is the risk of losing strength in the muscles that bend the elbow. Loss of muscle strength makes it difficult to bend the elbow to move your hand to your mouth or face. This ability is important for every day self-care including washing your face and eating.

Making a decision about treatment

Important: Your child needs to be involved in any decision making about their treatment. Stretching, casting and splinting are more likely to be successful if your child is engaged in the process and wants to participate in the treatment program.

You and your child should understand the benefits and risks of each option and feel confident about your decision. If your child needs help deciding what the best option is for them, have them fill out the "What matters most" questionnaire.

If there is any disagreement as to what the best treatment option is for your child, try to find things that you agree on. Have you, your child, and others involved in the decision fill out the Decision Support Tool below. Together, you and your child can speak to a neutral party or health-care professional to receive coaching on making a decision.