Ultrasound-Guided Percutaneous Distal Biceps Tenotomy for Fixed Spastic Elbow Contracture in Cerebral Palsy: Case Report and Technical Note

Abstract

Fixed spastic elbow flexion contracture is a frequent and disabling problem in chronic upper motor neuron syndromes, including cerebral palsy (CP), in which sustained hypertonia and long-standing immobility may lead to musculotendinous shortening, skin breakdown, pain, and major hygiene and positioning limitations. We report a 63-year-old woman with severe spastic CP (Gross Motor Function Classification System Level V) presenting with a fixed left elbow flexion posture associated with antecubital maceration and caregiver burden. Multiple cycles of botulinum toxin type A failed to improve passive range of motion, and diagnostic nerve blocks, including a musculocutaneous nerve block, produced no gain in elbow extension, supporting a fixed contracture. The patient underwent ultrasound-guided percutaneous distal biceps tenotomy in an outpatient setting under local anesthesia using an 18-gauge Nokor needle, with real-time identification of adjacent neurovascular structures. Near-complete passive elbow extension was achieved immediately after the procedure. A localized hematoma was observed without compartment syndrome or ultrasound evidence of collection. At 6 months, range of motion improved from −90° to −30°, and resistance to passive movement decreased (Modified Ashworth Scale from 4 to 1). Two predefined Goal Attainment Scaling targets were met at follow-up (0 and +1), and the Patient Global Impression of Change indicated substantial improvement (+2). Ultrasound-guided percutaneous distal biceps tenotomy may represent a feasible, well-tolerated, minimally invasive option for selected patients with fixed spastic elbow contracture when dynamic spasticity is no longer modifiable, potentially improving care-related outcomes while avoiding conventional surgery in medically complex individuals.