Sir,Postoperative elbow ankylosis occurs owing to prolonged duration of plaster cast and inadequate physiotherapy. llkeKupeli et al. demonstrated that peripheral nerve catheter provides postoperative pain-free physiotherapy.[1] It also accelerates rehabilitation and healing, providing a good maintenance, especially in orthopaedics and traumapatients. We report the use of continuous infraclavicular peripheral nerve catheter for pain management as an aid to physiotherapy in postoperative elbow ankylosis.We encountered 2 patients, one 15-year-old male, ASA I, operated for open reduction and internal fixation of proximal end of right radius fracture before 1 month, and another 30- year-old male, ASA I, operated for open reduction and internal fixation of left olecranon fracture before 1 month.Both patients presented in orthopaedic outpatient department with flexion deformity of 90° at elbow joint and inability to extend the elbow due to elbow ankylosis [Figure 1]. Both patients had pain during movement of elbow joint and were unable to do adequate physiotherapy. So they were referred to us for pain management during physiotherapy. After obtaining written informed consent for ultrasound guided infraclavicular catheter insertion, patients were positioned supine with corresponding arm externally rotated. Pre-procedure VAS score in both patients was 7/10. Ultrasound high frequency linear probe (6–12 MHz) was placed longitudinally below the clavicle. Axillary artery with lateral, posterior and medial cords of brachial plexus was visualised below pectoralis muscles [Figure 2]. Using 18G Contiplex™ set, 50 mm echogenic needle was inserted from cephalad to caudal direction in an in plane technique. When the needle reached posterior cord, bolus dose of 20 cc 0.125% bupivacaine was given. U-shape spread of drug around axillary artery was confirmed [Figure 2]. Continuous catheter with black tip was threaded and fixed at 9 cm at skin surface. After 30 min, VAS score improved to 2/10, and active physiotherapy was done. Continuous infusion of 0.125% bupivacaine with 1 mcg/ml of fentanyl was started at 5ml/h for 5 days.[2],[3],[4] Patients were monitored for VAS score and range of motion at elbow joint every 6 h. Monitoring for any signs of catheter obstruction, migration, infection at site of insertion, local anaesthesia toxicity and any sensorimotor deficit was done. Passive physiotherapy was performed with Kinetec CPM machine in wards, and active physiotherapy sessions were given every 12 h for 30 min. On 5thday, range of motion at elbow increased to about 170–180°in both the patients without any pain [Figure 1]. Catheter was removed with black tip intact.
Figure 1
Elbow ankylosis pretreatment and after continuous catheter technique
Figure 2
Sonoanatomy and infraclavicular catheter insertion and U shape spread of the drug
Elbow ankylosis pretreatment and after continuous catheter techniqueSonoanatomy and infraclavicular catheter insertion and U shape spread of the drugInfraclavicular block can be given by anatomical landmark guided technique, using peripheral nerve locator or under ultrasound guidance. The ultrasound guided technique is real time, non-invasive, without any radiation exposure, with increased success rates and decreased complications such as pneumothorax and intravascular injection. In addition, the local anaesthetic requirement is decreased as drug is given in direct vicinity of nerves under vision. Continuous peripheral nerve blocks increase the flexibility of both duration and density of local anesthetic and help to accelerate resumption of passive range of motion of joint after surgery.[3],[4] Moreover, continuous peripheral nerve block can help us to provide pain relief for patients at home in an ambulatory setting, with proper instructions given to patient about the care of catheter.[3],[4] Infraclavicular catheter insertion is more stable as the catheter is held between pectoralis muscles, and there are less chances of dislodgement or migration of catheter.[4],[5]Thus, our report highlights that low dose continuous infusion of local anaesthetic through ultrasound guided infraclavicular catheter provides adequate analgesia while simultaneously preserving motor function for physiotherapy in patients of elbow ankylosis. In addition, it can be used for prevention of elbow ankylosis in patients operated for surgeries around elbow joint by achieving pain control during physiotherapy.
Figure 1
Figure 2