Post-traumatic Elbow Stiffness Research Articles

Is anterior transposition of the ulnar nerve necessary for post-traumatic elbow stiffness? A retrospective study

ObjectiveTo explore whether anterior transposition of the ulnar nerve is necessary in patients with post-traumatic elbow stiffness.MethodThis was a retrospective study of 177 patients with post-traumatic elbow stiffness treated at Shandong Provincial Hospital from 1 January 2012 to 31 October 2022. Sixty-one patients presented with ulnar nerve symptoms, and 116 patients had no nerve symptoms. Outcomes between patients with and without symptoms were compared using a range of clinical measures, namely range of motion (ROM), ulnar nerve symptoms, and various standardized scoring systems, namely, the Mayo Elbow Performance Score (MEPS), visual analog scale (VAS), improved Broberg and Morrey Score (BMS), Quick disabilities of the Arm, Shoulder, and Hand (DASH) score, Oxford Elbow Score (OES), and Amadio score.ResultsOpen elbow release surgery significantly improved elbow joint function in patients with post-traumatic elbow stiffness, regardless of the presence of ulnar nerve symptoms. Patients with ulnar nerve symptoms showed significant improvement after anterior transposition compared with in situ release. For patients without ulnar nerve symptoms, there was no significant difference in outcomes between the two types of ulnar nerve surgery.ConclusionAnterior transposition of the ulnar nerve is preferable for patients with ulnar nerve symptoms, while the choice between anterior transposition and in situ release can be individualized for patients without symptoms, based on intraoperative findings.

Three-Dimensional Printed Models For Surgery Planning Of Post-Traumatic Stiff Elbow

Three-Dimensional Printed Models For Surgery Planning Of Post-Traumatic Stiff Elbow

Management of post-traumatic elbow stiffness in paediatric and adult patients: an update

Posttraumatic elbow stiffness can have a large impact on the ability of a patient to perform activities of daily living. Following a stepwise approach to treatment helps clinicians in this otherwise difficult-to treat condition. Treatment in adults is based on dealing with the involvement of soft tissue contracture, osseous impingement or both. Unlike adults, posttraumatic elbow stiffness in children has distinctly different causes and the thrust of treatment is primarily non-surgical. In skeletally immature children, the skeletal growth potential should be properly assessed and closely followed, observing either progression or natural correction of the deformity. Early active motion aided by physiotherapy is the first step in treatment for both adults and children. Following physiotherapy, brace therapy is a proven cheap and effective therapy for treatment-resistant stiffness. If adequate conservative treatment is unsuccessful, the next step is surgical arthrolysis. This procedure can be performed either open or arthroscopically, with the decision dependent on multiple factors. Early active mobilization after surgery is equally important, with the addition of bracing or continuous passive motion (CPM) in pending contractures following surgery. This paper provides a review of the current literature and a state-of-the-art guidance on the management of posttraumatic elbow stiffness in adult and paediatric patients.

Soft-tissue origin joint contractures treated with the Ilizarov fixation method

Introduction Soft-tissue origin joint contractures are a common orthopedic problem. It could be due to various etiologies. Treatment options are available from conservative to surgical methods. These joint contractures slowly become irreversible causing impairment in activities of daily routine. The Ilizarov method is a well established and time-tested method used for management of bone pathologies, but its use in the management of soft-tissue origin contractures is also possible. It has an established role in neoosteogenesis and histogenesis. Fixator assisted soft-tissue stretching done at sustained slow pace leads to histoneogenesis that avoids stretching of neurovascular structures and reduces the possibility of recurrence.Aims To determine usefulness of the Ilizarov method in management of joint contractures of soft tissue origin; to meet functional requirements of patients; to study complications of Ilizarov method in management joint contractures due to soft tissue origin.Material and methods A total of 6 cases of soft-tissue origin joint contractures due to tuberculosis, post‑traumatic stiffness, post-burn contracture, deformity due to a snake bite in the age group from 3 to 55 years were treated with gradual distraction of joint with the Ilizarov method from January 22 to October 23. Two cases were of triple knee deformity, two were post-traumatic elbow stiffness, one was post-burn great toe contracture and one was post snake bite valgus foot contracture. All cases were operated with transarticular Ilizarov frame application and gradual distraction of joints and soft tissue with the help of hinge- and rod distractor assembly done. All cases completed follow up of 1 year. Aggressive physiotherapy was given postoperatively.Results All cases obtained a reasonable functional outcome, with no recurrence of deformity. All patients walk independently.Conclusion The Ilizarov method can be used for treating joint contractures due to traumatic and non‑traumatic pathologies.

Three-dimensional printed models for surgery planning of post-traumatic stiff elbow: Current concepts

The post-traumatic stiff elbow is a challenge for the surgeon, requiring expertise for the treatment choice and accurate planning. Stiffness can result from traumatic injury involving the periarticular soft tissues and the joint articular surfaces. In this article, we want to assess the impact of three-dimensional (3D) printed models in selecting the appropriate surgical strategy for this pathology.Six cases of increasing complexity regarding post-traumatic stiff elbow were submitted to four expert elbow surgeons who had the possibility to evaluate videos and reports of clinical examination, plain radiograms and CT with 3D reconstruction for each case.After a first treatment proposition given by the experts for each patient, a three-dimensional printed model of each elbow based on the CT was provided to the surgeons, asking them to evaluate again all the cases having the possibility to assess also the 3D models.In the four most complex cases all surgeons found more beneficial the use of three-dimensional representation for treatment planning and rate the risk of complications than the sole CT imaging with 3D reconstruction and many of them changed surgical strategy after analysing the model.3D printing technology is a useful tool in surgery planning for treating complex cases of post traumatic elbow stiffness, especially in the presence of joint deformity. Level of EvidenceIV

Hinged External Fixation Combined with Open Debridement for Post-traumatic Elbow Stiffness: A Systematic Review and Meta-analysis.

Open debridement remains the gold standard for the clinical treatment of post-traumatic elbow stiffness. However, postoperative complications, such as re-contraction and heterotopic ossification of the elbow joint, are highly prevalent. Hinged external fixation appears to offer the potential for greater improvement of joint function and reduction of complications. The purpose of this article is to provide the latest evidence on the effectiveness and safety of hinged external fixation combined with open debridement for the treatment of post-traumatic elbow stiffness. We searched for randomized controlled trials (RCTs) from the China National Knowledge Infrastructure, MEDLINE, PubMed, Web of Science, EMBASE, and Cochrane Library databases until December 31, 2022. STATA 15.1 software was used to analyze all the data for this article. The quality of the included articles was evaluated using the Cochrane Reviewer's Handbook 5.3. Finally, we selected 8 high-quality RCTs for our meta-analysis, which included 555 patients. The meta-analysis demonstrated that hinged external fixation combined with open debridement for post-traumatic elbow stiffness (treatment group) showed a significant increase in elbow flexion and extension mobility (WMD = 5.16, 95% CI 4.39-5.49, Z = 13.02, P = 0.000), Mayo elbow function scores (WMD = 5.25, 95% CI 4.33-6.17, Z = 11.15, P = 0.000), and Mayo excellent rate (RR = 1.25, 95% CI 1.14-1.37, Z = 4.87, P = 0.000). Additionally, there was a significant decrease in the complication rate (RR = 1.11, 95% CI 1.02-1.20, Z = 2.54, P = 0.011) compared to open debridement alone (control group). Furthermore, the results of the publication bias test showed no significant bias. With the assistance of hinged external fixation, open debridement for post-traumatic elbow stiffness can lead to increased elbow mobility and a reduced complication rate. However, due to the small sample size, a multicenter randomized controlled trial with a larger sample size is still necessary to further confirm the effectiveness and safety of hinged external fixation combined with open debridement for post-traumatic elbow stiffness. The online version contains supplementary material available at 10.1007/s43465-023-01087-y.

Treatment and rehabilitation of post-traumatic elbow stiffness with heterotopic ossification.

To investigate surgical treatment, postoperative rehabilitation and prevention of heterotopic ossification (HO) in patients with post-traumatic elbow stiffness. We performed a retrospective review of patients with post-traumatic elbow stiffness combined with HO between 2007 and 2021. This study was performed on a total of 15 patients (18 elbows) admitted to our hospital, consisting of 12 males and 3 females, with post-traumatic stiffness of the elbow combined with HO, where elbow function could not be recovered by rehabilitation and orthosis treatment. Fifteen patients were treated by surgical excision of heterotopic bones and release of elbow contracture combined with postoperative rehabilitation and orthosis-wearing. Comprehensive treatments, including radiation, oral ibuprofen medication, and manipulation techniques to improve range of motion, were used to prevent HO recurrence. The flexion-extension arc and functional score of the elbow were measured after treatment and compared with the preoperative measurements. Roentgenography was used to observe HO recurrence. After surgical treatment and postoperative rehabilitation, the patients' range of motion improved, and the functional score improved considerably. The postoperative flexion-extension arc and The Hospital for Special Surgery (HSS) functional score were statistically significantly higher than the preoperative values (p < 0.01). Roentgenographic examination showed no HO recurrence during the follow-up period. Surgical excision of heterotopic bones and elbow contracture release combined with postoperative rehabilitation and preventative HO measures can be an effective treatment for cases of post-traumatic elbow stiffness combined with HO, for which conservative treatment is ineffective.

Clinical Outcomes Following Surgical Management of Post-Traumatic Elbow Contractures in the Pediatric Age Group: A Meta-Analysis and Systematic Review

Post-traumatic elbow stiffness is a common occurrence resulting in potentially substantial functional limitations in both daily activities and recreational endeavors. In children, this can be particularly difficult given the early stages of childhood and development and the challenges of rehabilitation. Several studies have reported favorable results of elbow contracture releases in children, resulting in improvements in outcomes. This meta-analysis aimed to determine the efficacy and safety of elbow contracture releases in the pediatric population (<18 years), along with subgroup analyses comparing age groups, operative approach, and post-traumatic versus nontraumatic etiologies. Meta-analysis was performed with a multidatabase search (PubMed, OVID, EMBASE, and Medline) according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines on September 25, 2020. Data from all published literature meeting inclusion criteria were extracted and analyzed. Seven studies were included, comprising 114 post-traumatic elbow contractures. Mean age was 13.7 years. Contracture releases of the elbow led to improvements in flexion-extension arc of motion by 48º, and pronosupination arc of motion by 22º. Subgroup analysis comparing age groups of <10, 10-14 and 15-18 years showed greater improvements in flexion-extension arc in the older age group, whereas subgroup analysis comparing injury patterns revealed a larger improvement in pronosupination motion for radial head fractures. Comparing open and arthroscopic procedures, open releases had greater improvement in both flexion-extension and pronosupination motion by 18º and 21º, respectively, although there were limited patients in the arthroscopy group. Operative management of pediatric elbow contractures is effective. Older children, children with radial head fractures, and those receiving open contracture releases may be more likely to have greater improvements. Therapeutic IV.

Tranexamic acid in patients with post-traumatic elbow stiffness: protocol for a randomised, double-blind, placebo-controlled trial investigating the effectiveness of tranexamic acid at reducing the recurrence of heterotopic ossification after open elbow arthrolysis

IntroductionExaggerated inflammatory response is one of the main mechanisms underlying heterotopic ossification (HO). It has been suggested that the antifibrinolytic drug tranexamic acid (TXA) can exert a significant anti-inflammatory effect...

Effect of Physiotherapy Management of the Post-Traumatic Stiff Elbow: A Case Report

23 years old female who is a student by occupation had a history of a direct fall on her right elbow and injury takes place on her left elbow. After the injury, an orthopedic surgeon and the patient wastreated conservatively. The patient came to the physiotherapy department with a chief complaint of left elbow pain with difficulty in moving the left elbow. On examination, restriction in elbow flexion and extension assortment of motion and tightness of left biceps brachii were seen. The intervention was carried out for 6 sessions per week for 6 weeks. The patient was treated with electrotherapy and exercise therapy. After 6 weeks of intervention pain was reduced (VAS score from 7 to 3), elbow extension range of motion was improved and OES was 20 to 39. This case report results suggest that physiotherapy treatment is important in reducing pain and increasing range of motion and functional ability.

Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness.

Post-traumatic elbow stiffness (PTES) may substantially affect the patient's functional range of motion and quality of life. Open elbow release has been extensively studied, but arthroscopic techniques are limited, particularly in differentiating between post-traumatic and non-traumatic stiffness. The purpose of this study is to assess the clinical outcomes after arthroscopic release of PTES regarding the range of motion (ROM), pain, functional assessment, and complications. A prospective cohort was conducted on adult patients who underwent arthroscopic arthrolysis for PTES, with 32 patients included in the final analysis. The ROM was measured using the orthopedic goniometer. Grip strength was measured using the Camry digital hand dynamometer (Camry, CA, USA) and compared to their contralateral side. The functional status of the patients was evaluated using the American Shoulder and Elbow Surgeons Score (ASES)andthe Mayo Elbow Performance Index (MEPI). All measurements were done before surgery and at the last follow-up visit. Pre-operative and post-operative changes in MEPI, ASES, and visual analog (VAS) scores were compared with the paired t-test. After surgery, the ROM significantly improved from 74 ± 11 to 110 ± 15 degrees (p<0.001). Additionally, the ASES score and MEPI index both significantly improved from 69 ± 3.4 to 79 ± 6.3 and from 64 ± 5.7 to 82 ± 8, respectively (p<0.001). VAS scores also significantly improved from 1.1 ± 0.87 to 0.31 ± 0.53 at rest (p<0.001). The complication rate was 12%, including three transient ulnar nerve paresthesia and one superficial infection. Post-traumatic elbow release was more offered in distal humerus fractures (53%), followed by proximal ulna fracture/dislocations (25%). We believe that arthroscopic arthrolysis is a safe and reliable treatment of PTES, which improves joint visibility and reduces pain. Patients can be counseled regarding the risk of a secondary surgery following distal humerus or proximal ulna fractures, including the expected recovery and complication rate.

3D-printing of the elbow in complex posttraumatic elbow-stiffness for preoperative planning, surgery-simulation and postoperative control

BackgroundRestoration of mobility of the elbow after post-traumatic elbow stiffening due to osteophytes is often a problem.MethodsThe anatomical structures were segmented within the CT-scan. Afterwards, the Multi Jet Fusion 3D-printing was applied to create the model made of biocompatible and steam-sterilizable plastic. Preoperative simulation of osteophyte resection at the 3D-model was performed as well as the direct comparison with the patient anatomy intraoperatively.ResultsThe patient-specific was very helpful for the preoperative simulation of the resection of elbow osteophytes. The 3D anatomical representation improved the preoperative plan its implementation. A high degree of fidelity was found between the 3D Printed Anatomical representation and the actual joint pathology.ConclusionsArthrolysis of complex post-traumatic bony changes is an important indication for the use of 3D models for preoperative planning. Due to the use of 3D printing and software simulation, accurate resection planning is feasible and residual bony stiffening can be avoided. 3D printing models can lead to an improvement in surgical quality.

Elbow stiffness: Interview with professor Bernard Morrey

Stiff elbow is a complex condition whose diagnosis and management are sometimes quite a challenge. Compared to the other joints, the elbow is disproportionately affected by loss of motion following trauma or surgery. It is unclear why the elbow tends to develop stiffness; its anatomical complexity, namely the presence of three highly congruent joints in the same capsule and synovial space, the tautness of the lateral and medial collateral ligaments through the whole range of motion, and the very close relationship among tendons, muscles, and skin 2 may account for this characteristic. In a stiff elbow, it is critical to assess the possible involvement of articular and periarticular tissues, particularly the degree of preservation of the articular surfaces and joint congruency.Morrey et al have classified post-traumatic stiff elbow into three types: 1) extrinsic contracture, which involves the soft tissue around the joint (capsule, ligaments, muscles) and heterotopic ossification across the joint, 2) intrinsic contracture, secondary to intra-articular fractures that have altered the anatomy of the articular surface, and 3) mixed contracture, combining intrinsic and extrinsic contracture.In the preoperative clinical assessment, we assume capsule contracture to be present in all patients with a stiff elbow. Two main associated lesions can affect prognosis and surgical management: heterotopic ossification and an altered bone joint anatomy. According to Morrey et al, most activities of daily living can be accomplished within an arc of motion from 30° to 130° in extension and flexion and of 50° in pronation and supination. The elbow arc of motion is not compensated for by the wrist and shoulder, thus loss of extension impairs the use of the hand in the space around the body and loss of flexion limits its use for grooming and self-care. The elbow should carefully be tested for deformity of the axial bone alignment (varus and valgus deformity) and rotational stability. Several treatment options are available for stiff elbow, from conservative management with a dedicated rehabilitation program to surgical treatment and from arthroscopic capsulectomy to joint replacement.

The Shanghai Elbow Dysfunction Score: Psychometric Properties, Reliability and Validity Study of the Turkish Version.

The Shanghai Elbow Dysfunction Score (SHEDS) is a self-reported assessment of post-traumatic elbow stiffness that measures elbow-related symptoms and elbow motion capacities. This study aimed to (1) translate and cross-culturally adapt the SHEDS into Turkish and (2) investigate the psychometric properties of the Turkish version in patients with post-traumatic elbow stiffness. The psychometric properties of the Turkish version of the SHEDS (SHEDS-T) were tested in 108 patients (72 male; mean age, 43.2 ± 11.2years) with post-traumatic elbow stiffness. Cronbach's alpha was used to assess internal consistency. The intraclass correlation coefficients were used to estimate test-retest. Construct validity was analyzed with the Turkish version of the Disabilities Arm, Shoulder and Hand (DASH), the Mayo Elbow Performance Score (MEPS), and the Short Form-12 (PCS-12 and MCS-12). The SHEDS-T showed sufficient internal consistency (Cronbach's α coefficient = 0.83) and test-retest reliability (ICC = .96). The correlation coefficients between the SHEDS-T, the DASH, and the MEPS were .75 and .54, respectively (p < .001). There was a moderate correlation between the SHEDS-T and PCS-12 (r = .65, p = .01) and a weak positive correlation between the SHEDS and the MCS-12 (r = .40, p = .03). The SHEDS-T has sufficient reliability and validity to measure elbow-related symptoms and elbow motion capacities for Turkish-speaking individuals with post-traumatic elbow stiffness.

Anxiety and depression are associated with poor outcomes in open elbow arthrolysis

BackgroundOpen elbow arthrolysis (OEA) is an established treatment for posttraumatic elbow stiffness (PTES); however, its efficacy is debatable for some patients. Poor surgical outcomes have been associated with anxiety and depression in other orthopedic conditions, but no studies have examined this association in OEA. In this study, we aimed to determine whether a high preoperative anxiety and depression score is associated with a worse functional outcome in OEA for PTES. MethodsA retrospective review of prospectively collected data was carried out in patients undergoing OEA between April 2021 and March 2022. Mental state evaluated by Hospital Anxiety and Depression Scale (HADS), subjective elbow function valued by Disabilities of the Arm, Shoulder, and Hand (DASH) score, objective elbow function valued by Mayo Elbow Performance Score (MEPS), pain score measured by visual analog scale (VAS) and the flexion-extension range of motion (ROM) of the affected elbow were collected before and after surgery in outpatient clinic follow-up at 3 months and 6 months. Patient satisfaction was only recorded 6 months postoperatively. All patients were divided into 2 groups based on the preoperative HADS score for analysis: Group A was the nonanxiety-depression group, and Group B was the anxiety-depression group. ResultsA total of 49 patients were included. Both groups improved in DASH, MEPS and ROM at 3 months and at 6 months. The HADS score in Group B decreased significantly at 6 months, showing that the mental state of patients in Group B improved after surgery. Group A had a lower DASH at 3 months and 6 months, larger 6-month ROM and higher satisfaction rate than Group B. Comparing the differences between preoperative and postoperative measurements, Group A improved more in ROM at 6 months. There was no significant difference in other outcome measures between the two groups. ConclusionsOEA is a safe and effective treatment for PTES, and can achieve good clinical outcomes in the short-term follow-up, regardless of whether the patients suffer from anxiety or depression. Patients with a HADS score ≥11 before OEA, however, have worse outcomes than those with a HADS score <11. Level of evidenceLevel II; Retrospective Design; Prognosis Study

Management of Post-traumatic Elbow Stiffness

Management of Post-traumatic Elbow Stiffness

Internationale Studienergebnisse

Birinci T, Mutlu EK, Altun S. The efficacy of Graded Motor Imagery in post-traumatic stiffness of elbow: A randomized controlled trial. J Shoulder Elbow Surg 2022; S1058–2746(22): 00554–00557

Open arthrolysis versus arthroplasty in the treatment of posttraumatic elbow stiffness

Elbow stiffness is a common problem following trauma to the elbow. Sixty-seven patients with posttraumatic elbow stiffness were surgically treated between 1985 - 2000. Sixty-one were clinically reviewed after a mean follow-up of 15 years (range: 7 to 19 years). The initial trauma had resulted in 8 intrinsic, in 31 extrinsic and in 28 mixed lesions. The mean preoperative flexion – extension arc of motion, was 46°. After an unsuccessful conservative treatment, open surgical arthrolysis was performed in 59 patients with exclusively extrinsic or mixed lesions, through a lateral approach combined with a medial approach when deemed necessary. In patients with complex intrinsic lesions was performed 3 resection arthroplasty and 5 total elbow arthroplasty. At final follow-up, the mean arc of motion of the elbow was significantly improved to 100° in 56 patients who had undergone open arthrolysis; 3 were lost to follow-up. Among the 3 patients who had undergone arthroplasty resection, only one had a markedly improved elbow function with a 90° arc of motion; elbow stiffness had recurred in the other two patients. Of the 5 patients who underwent total elbow arthroplasty, 3 were lost to follow-up; the other 2 patients had a stable elbow, with a fair arc of motion of 60° and 70° respectively, both with a flexion contracture of 20°. Complications included 2 superficial infections, which healed following conservative treatment, and one fracture following remodeling of a malunited distal fracture of the humerus. In the treatment of the posttraumatic stiffness of the elbow, the arthrolysis and the arthroplasty are indicated in dependence on the existent (extrinsic or intrinsic) lesions and on their severity.

Evaluation of outcome in arc of motion of elbow after arthrolysis in post-traumatic stiff elbow through posterior triceps reflecting anconeus pedicle approach

Background: The elbow is a synovial hinge joint, with a high chance of stiffness. A stiff elbow is an elbow with a loss of extension of &gt;30° and flexion of &lt;120 which can result due to post-traumatic events around elbow. Surgical intervention is required if conservative treatment fails. The arthrolysis of the elbow by posterior approach has been reported less widely. Aims and Objectives: This study aims at reporting the arc of motion of the elbow after arthrolysis by posterior approach by TRAP approach. Material and Methods: This study was done on 26 patients with post-traumatic elbow stiffness through posterior triceps reflecting anconeus pedicle graft approach. The mean age of patients in our study is 30.8, ranging from 15 to 54 years. After surgery, patients were reviewed to assess arc of motion and fixed flexion deformity (FFD) improvement, MAYO and oxford score. Results: Our study showed increase in arc of motion from 50.7° to 90.7°, FFD decrease from 31.3° to 18.2° and MAYO score which had a pre-operative mean of 77.3, increased to 90 postoperatively with excellent result in 18 cases (69.2%) and good in eight cases (30.8%). Oxford score had an improvement from 21.8 to 40.3 showing satisfactory result in 11 cases. Conclusion: The approach described in our study is ideal for posterior bony blocks with maintaing intact extensor mechanism and less chance of neurovascular damage. Stability of the joint is maintained with feasability to do ulnar nerve transposition.

Anterolateral Thigh Flap Coverage for Large Posterior Defects of the Elbow.

This study highlights the advantages and disadvantages of Anterolateral Thigh (ALT) free flap using the brachial artery as the recipient vessel in large posterior defects of the elbow with early mobilization. Eight patients with a soft tissue defect on the posterior elbow underwent reconstruction with an ALT free flap. Average age and follow-up were 29.5years (range, 18-43years) and 54months (range, 35-76months), respectively. All defects were on the posterior side, and brachial arteries on the anterior side were used as the recipient artery in all cases. Four defects were created by tumor excision, four were exposed with hardware after fixation of distal humeral and/or proximal ulna fractures. The dimensions of defects were between 80 and 352cm2. Cases were evaluated according to function (ROM), complications, tissue quality anticipated from reconstruction and immobilization time after the reconstruction. All flaps except one survived and met the tissue quality anticipated from this reconstruction. In the bigger flaps, an apparent ugly scar at the donor site was the main problem. The flap on the posterior, and recipient artery on the anterior had no adverse effects on early motion of the elbow. Two cases with fractures had minimal restriction of elbow movement due to post-traumatic stiff elbow. There was one case of partial flap loss after myocardial infarction. After the patient was medically stable, the remaining distal defect was closed with a pedicled radial forearm flap. ALT free flap has numerous advantages in covering defects at the posterior elbow such as being pliable, thin and durable skin, with a long and reliable pedicle reaching the brachial artery without causing any problem in early motion and surgical reconstruction can be easily completed in the supine position.