A Modular, Prefabricated Orthosis for
1
Treatment of Elbow Flexion Contractures
2
S.I. REGER, P H . D . , C.P.
2
J. O'REAGAN
M.H. BO-BLITZ2
2
R . W . ROSENBERGER, C.P.
A simple a n d adjustable orthosis has
been designed a n d several proto­
types have been built to aid in increasing
the limited range of extension available
in disability involving flexion contracture
at the elbow. T h e present prototype,
positioned 5 degrees larger t h a n the a n ­
gle of m a x i m u m passive extension, a p ­
plies a small extension m o m e n t to the
a r m , slowly lengthens the m u s c u l a t u r e ,
a n d leads to a g r a d u a l decrease of the
contracture. W h e n used in conjunction
w i t h t h e r a p y it helps m a i n t a i n the bene­
fits achieved by daily stretching exercises.
Key design features include modularity
w i t h discrete, easy to fit a n d adjustable
components that a r e compatible with
anatomical c o n s t r a i n t s — w i t h o u t left or
right sided parts—simplicity, cosmesis,
a n d low cost.
As a result of research a n d develop­
ment in u p p e r - l i m b orthotics in the past
two decades, restoration of useful func­
tion in u p p e r extremity motor i m p a i r ­
ment has been m u c h improved. Efforts
at such institutions as the T e x a s Insti­
tute for Rehabilitation a n d Research, the
Rehabilitation Institute of Chicago have
resulted in the development of the m o d u ­
lar concept with e m p h a s i s on lightweight
finger prehension orthoses. However,
despite the m a n y available functional de­
vices an acceptable orthosis for the pre­
vention of u p p e r limb deformity d u e to
elbow contracture has not yet been
achieved. Flexion contracture at the el­
bow in p a r t i c u l a r is disabling in itself
a n d is a difficult p r o b l e m to correct (6).
In certain spinal cord injuries this con­
t r a c t u r e m a y lead to reduced patient
mobility by preventing reach to the p r o ­
pulsion h a n d r i m of the wheelchair.
T h i s p a p e r presents the design a n d the
application of a simple adjustable or­
thosis designed to prevent and help cor­
rect contractures at t h e elbow. T h e p r o ­
totype has been fabricated in three sizes
for application by clinicians. Clinical
trials a r e now u n d e r w a y .
M e t h o d s of t r e a t m e n t of elbow flexion
contractures m a y be surgical or they may
be non-operative. Surgery involving
tenotomy to lengthening the biceps ten­
d o n has been successful in improving
a r m function in paralytic diseases other
t h a n spinal cord injury (5). A n o t h e r
surgical technique, using percutaneous
electrodes, has also been successful.
Mooney (4) i m p l a n t e d electrodes to
stimulate the extensor muscle g r o u p a n d
reduce the muscle imbalance that caused
the flexion contracture at the joint.
 A m o n g the non-operative methods,
serial or wedge casting of the p a t i e n t ' s
a r m in forced extension has been used
with success. H o w e v e r , the weight a n d
bulk of the cast, the pressure sensitivity
a n d inaccessability of the skin a r e real
shortcomings of this method. T r a c t i o n is
another non-invasive t r e a t m e n t t h a t has
been tried (7). U n f o r t u n a t e l y , traction
requires stationary positioning of the
patient in a bed or chair which in spinal
cord injury cases, m a y encourage forma­
tion of pressure sores a n d t h u s is seldom
used.
O r t h o t i c devices to correct elbow flex­
ion contractures have been described as
well. Goller and E n d e r s (2) have used a
dynamic plastic elbow-extension orthosis
on five patients with m o d e r a t e success for
an average of 15 degrees reduction in
flexion contractures. More recently
G r e e n a n d M c C o y (3) have described a
turnbuckle orthosis which accomplished
in 12 patients a n average reduction in
deformity of 37 degrees in a n average
t r e a t m e n t period of 20 weeks. T h i s
Fig. 1. Elbow extension orthosis used by a C5-6
custom-fitted orthosis has been tried in tetraplegic individual.
existing short t e r m contractures of t r a u ­
matic fracture origin w h e r e little or no
impairment of skin sensation was
present. therapy. T h e orthosis is expected to
benefit any disability involving a flexion
Expected Benefits
contracture at the elbow with p a r t i c u l a r
T h e orthosis at the University of Vir­ emphasis on C4-6 quadriplegia, b r a i n
ginia Rehabilitation Engineering Center injury, b u r n s , and some forms of r h e u ­
w a s developed with the expectation that matic diseases.
this m o d u l a r system will m a k e the cor­
rection a n d prevention of a n elbow flex­
ion deformity easier to be resolved by the Description
therapist. It is hoped that the availability T h e m o d u l a r orthosis (Fig. 1) consists
of three sizes in stock components will of a biceps cuff and a forearm cuff, each
m a k e possible the application and fitting with Velcro straps, a leaf hinge with a
of the orthosis by the therapist immedi­ protective sleeve, and two " b o o k - b i n d e r "
ately u p o n need in the hospital setting. screws. T h e cuff type can be distin­
It is assumed that this orthotic system guished by its shape and the n u m b e r of
will be w o r n by the patient d u r i n g non- Velcro straps. T h e biceps cuff has only
therapy sessions and, thus, m a i n t a i n the one s t r a p while the two straps of the
increased elbow extension achieved in forearm cuff are fastened to each end.
Fig. 2. Three sizes and interchangeable components of the modular adjustable orthosis.
E a c h cuff type is available in three sizes;
small, m e d i u m , and large.
T h e leaf hinge is a thermoplastic m a ­
terial also available in three sizes. T h e
large leaf hinge (46 centimeters long)
w i t h four screw holes at each end are
m a d e of acrylic a n d available in t w o
lengths of 38 and 30 centimeters. F i g u r e
2 shows a n assembly a n d the inter­
changeable three sizes of the compo­
nents. T h e " b o o k - b i n d e r " screw is a two
piece fastener consisting of a slotted
threaded screw a n d its base n u t .
Initial designs used the three-point
principle for application of correcting
forces to the u p p e r limb with the ole­
c r a n o n a r e a as the central point. T h i s
principle w a s a b a n d o n e d because the
pressure applied at the center w a s such
that it could result in skin b r e a k d o w n .
T h e current design uses force couples
based on the four-point principle acting
on the a r m segments and produces a con­
stant extension force from the spring
action of the plastic hinge. T h e force
application is shown on F i g u r e 3. It can
be seen that elbow extension is m a i n ­
tained by application of slight pressure
to the a r m .
T o prevent tissue ischemia, the a p ­
plied pressure must be less t h a n the
capillary pressure of 40 m m H g . W h e n
the angle of the brace is larger t h a n the
angle of the a r m w i t h the contracture
a r m the brace must bend w h e n applied.
T h e resulting deflection of the leaf hinge
will generate the applied force necessary
for the extension m o m e n t across the el­
bow j o i n t . F o r a brace angle of 5 degrees
greater t h a n the contracture angle, the

Fig. 3. Four point principle of elbow extension
1 2
orthosis, showing moments M and M main­
taining extension The orthosis can be adjusted
by heating the hinge strap with a heat gun.
applied force, using m e d i u m size com­
ponents, was measured to be 4 lbs. and
was calculated to be less t h a n 20 m m H g
of pressure applied to the skin.
Application
Patient Selection
T h e orthotic system is a n adjunct to
t h e p a t i e n t ' s t h e r a p y t r e a t m e n t of
stretching and will assist in the mainte­
nance of the newly acquired r a n g e of
motion. T h i s orthotic system will be a n
aid to those patients with flexion con­
tractures at the elbow of 60 degrees or
less as defined by the American Academy
of O r t h o p e d i c Surgeons (1).
Because this system utilizes direct
pressure from the cuffs to the underlying
skin, the therapist must take precautions
to periodically check the skin for pres­
sure sores. It is recommended that the
therapist applies this device for half an
h o u r at the first application and g r a d u a l ­
ly increases the wear time if no problems
are a p p a r e n t .
Patient Measurement and
Components Selection
T h e p r o p e r cuff size is determined
from four circumferences a n d length
m e a s u r e m e n t s of the fore a n d u p p e r a r m .
T h e m e a s u r e m e n t s are to be m a d e with
the elbow flexed at 90 degrees with the
wrist rotated to its neutral position as
shown in F i g u r e 4. T h e therapist is then
able to choose the small, m e d i u m or large
cuffs for the orthotic assembly from the
conversion chart shown in T a b l e 1.
H i n g e length a n d stiffness selection
are determined by the s u m m a t i o n of
length m e a s u r e m e n t s .
Flexion Contracture
Angle Measurements
M e a s u r e the flexion contracture angle
passively u n d e r the effect of gravity. T h i s
m e a s u r e m e n t is used to establish the
extension angle of the orthosis. Once
this procedure has been accomplished,
add a p p r o x i m a t e l y 5 degrees to the ex­
tension angle to compensate for the leaf
hinge flexibility. T h e result will be the
initial extension angle of the orthosis.
Setting The Leaf Hinge Angle
W h i l e the elbow is passively extended
to the contracture angle, place one end
of the leaf hinge on the volar surface of
the a r m proximally to the radial styloid.
T h e other end of the hinge should be
lateral to the antecubital fold of the el­
bow. M a r k the leaf hinge in line with the
antecubital fold. O n c e this has been ac­
complished, m a r k the hinge 3 cm proxi­
m a l and 3 cm distal to the fold line.
H e a t the leaf hinge between the m a r k s
with a heat gun until the plastic is soft
and pliable in this region. Place the
Fig. 4. Measurement Chart. Measure arm dimensions in centimeters. Measurements A and D are lengths,
C, B, F and E are circumferences as indicated below. Record values in circles, and refer to Table 1, Con­
version Chart.

heated hinge flat o n a table surface.
W h i l e holding the distal (longest) end on
the table proceed to lift or bend the other
end until the orthotic extension angle is
achieved. H o l d this angle until the hinge
cools (about 3 minutes).
the screw holes in b o t h cuffs w i t h the
nearest screw holes in the hinge. M a r k
the position of the aligned holes on the
hinge. Remove the orthosis a n d fasten
the cuffs to the hinge w i t h the book­
binder screws.

Fitting and Check Out

Assembly
First, slide the distal end of the hinge
into the forearm cuff tunnel. N e x t slide
the p r o x i m a l hinge end into the - biceps
cuff such that the cuff tunnel is n e a r the
hinge bend. Position both cuffs on the
hinge to fit the contour of the a r m . Align
R e a p p l y the assembled orthosis to the
patient. T e s t for excessive pressures a n d
cuff misalignments. M a k e any necessary
adjustments. Finally, trim the velcro
s t r a p s to the p a t i e n t ' s need. Again, r e ­
move the orthosis a n d apply the protec­
tive sleeve to the hinge.
Readjustment
Periodic readjustment of the hinge a n ­
gle is r e q u i r e d w i t h changes of the con­
t r a c t u r e angle of the elbow. It is rec­
o m m e n d e d t h a t the hinge angle be
changed with each 5 degree change of el­
bow contracture. T o achieve a change in
the hinge angle, remove the protective
sleeve from the hinge a n d r e h e a t the
area w i t h a heat g u n . It is necessary to
disassemble the orthosis to accomplish
this task.
Summary
An orthosis has been designed to aid
in increasing the limited r a n g e of a r m
extension available in disability involving
flexion contracture at the elbow. W h e n
used in conjunction w i t h t h e r a p y it helps
to m a i n t a i n the benefits of daily stretch­
ing exercises.
I m p o r t a n t contributions of the ortho­
sis are modularity w i t h interchangeable
components in t h r e e sizes, simplicity,
cosmesis and low cost. Copies of the
prototype have been fabricated for a p ­
plication by clinicians, and clinical trials
are n o w u n d e r w a y .
Footnotes
1This work was supported by National Institute
for Handicapped Research Grant No. 23-P-55690.
2Rehabilitation Engineering Center, University
of Virginia, Charlottesville, Virginia 22903.
References
(1) American Academy of Orthopedic Surgeons.
"Joint motion method of measuring and record­
ing", Chicago, Illinois, 1965.
(2) Goller, H. and M. Enders. "A dynamic
plastic elbow-extension orthosis for reduction of
flexion contractures", Orthot. and Prosthet.,
30(47), 1976.
(3) Green, D . P . and H. McCoy. "Turnbuckle
orthotic correction of elbow-flexion contractures
after acute injuries", Journal of Bone and Joint
Surgery, 61-A(7), 1979.
(4) Mooney, V. and A. Roth. "Advances in
percutaneous electrode systems", Med. Dev. and
Art. Org., 4(2), 1976.
(5) Parks, D. H. "Late problems in burns",
Clinical Plastic Surgery, 4(4), October, 1977.
(6) Perry, J. "Prescription principles", Ameri­
can Academy of Orthopedic Surgeons: Atlas of
Orthotics, C . V . Mosby Co., St. Louis, 1975.
(7) Strang, M. "The use of dynamic slings to
correct elbow flexion contracture", Orthopedic
Nursing Assoc. Journal, 4(9), 1977.