The post-traumatic stiff elbow: A review

Upper extremity function is highly dependent on elbow motion in order to adequately position the hand in space. Loss of this motion due to stiffness following trauma can cause patients substantial disability, leading to difficulties with performing activities of daily living. Post-traumatic elbow stiffness is challenging to treat, and therefore prevention is of paramount importance. Key measures that can be used to prevent elbow stiffness are early surgical intervention for fracture or joint instability, as well as active mobilisation, which helps to prevent oedema and an increase in viscosity of inflammatory exudates. Other options include splinting and continuous passive mobilisation.Once non-operative methods of addressing post-traumatic stiffness have been exhausted, arthrolysis of the stiff elbow can be performed via open or arthroscopic means depending on the type of pathology involved (intrinsic or extrinsic contracture) and experience of the surgeon with elbow arthroscopy. The particular open approach used depends on several factors, which include the formation and location of any heterotopic ossification present. Improvements in range of motion can be expected with both open and arthroscopic techniques, which can be effective and rewarding for patients. Post-operative rehabilitation, particularly early active mobilisation, should be considered essential in order to optimise patient outcomes following surgery.This review aims to explore elbow stiffness following traumatic aetiology, assessing its pathogenesis and prevention, as well as reviewing surgical treatment options and post-operative rehabilitation.     

Arthrolysis of the elbow joint

A stiff elbow is usually defined as having less than 30 degrees in extension or flexion less than 130 degrees. Most activities of daily living are possible if the elbow has a range of motion of 100 degrees (30-130 degrees of flexion, Morrey's arc of motion). Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation is of utmost importance for planning any surgical intervention for elbow stiffness. Current operative techniques, such as arthroscopic or open arthrolysis and closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure, but if indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved.     

Arthrolyse des Ellenbogengelenkes

A stiff elbow is usually defined as having less than 30° in extension or flexion less than 130°. Most activities of daily living are possible if the elbow has a range of motion of 100° (30–130° of flexion, Morrey’s arc of motion). Loss of motion of the elbow is not uncommon after trauma, burns, or coma and severely impairs upper limb function. Loss of motion may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation is of utmost importance for planning any surgical intervention for elbow stiffness. Current operative techniques, such as arthroscopic or open arthrolysis and closed distraction with external fixation (arthrodiatasis), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure, but if indication and techniques are used correctly and surgeon, physiotherapist, and patient are familiar with the procedure, good long-term results may be achieved.     

Techniken der Arthrolyse am Ellenbogen

Elbow stiffness usually occurs after elbow trauma. Depending on the patient’s demands, even a small loss of motion can lead to severe functional limitations of the elbow joint which are likely to substantially reduce the quality of life. If conservative treatment does not provide a satisfying result, arthrolysis of the stiff elbow can be performed either arthroscopically or using an open approach (with external fixation) or distraction arthroplasty. This article discusses the etiology and treatment options for elbow stiffness and the different arthrolysis techniques with their indications and results.     

Distraction arthroplasty for treatment of posttraumatic elbow stiffness

A stiff elbow is usually defined as having less than 30° in extension or less than 130° in flexion. Most activities of daily living are possible if the elbow has a range of motion of 100° (30?C130° of flexion, Morrey??s arc of motion). Loss of mobility of the elbow is not uncommon after trauma, burns or coma and severely impairs upper limb function. Loss of mobility may be difficult to avoid and is challenging to treat. Detailed analysis of the etiology and diagnostic evaluation is of utmost importance for planning any surgical intervention for elbow stiffness. Current operative techniques, such as closed distraction with external fixation (arthroplasty), are presented and evaluated. Elbow arthrolysis is a technically demanding procedure but if the indications and techniques are used correctly and the surgeon, physiotherapist and even the patient are familiar with the procedure, good long-term results may be achieved. Contraindications are poor compliance, poorly controlled diabetes mellitus, active hepatitis?B and C infections, HIV infection and acute articular infections.     

Managing the stiff elbow: operative, nonoperative, and postoperative techniques.

Elbow contracture may be caused by intrinsic or extrinsic limitations or a combination of both. Evaluation of the specific structures guides the development of an effective therapy treatment program. Intrinsic contractures are by definition due to joint/intra-articular incongruency, and therefore therapy and splinting cannot provide increase in joint motion. Nonoperative therapy treatment options include heat modalities, myofascial soft tissue mobilization, joint mobilization, muscle energy techniques, passive range of motion, active range of motion, extensive use of corrective splinting, and strengthening exercise. All operative candidates must participate in a preoperative therapy program of six to eight weeks to reduce extrinsic contractures as feasible and to assess patient compliance with an intensive postoperative therapy program. Corrective splinting may be needed for as long as six months to maintain gains made in surgery. The therapy following manipulation under anesthesia and open contracture release is similar. The therapist must know the details of the procedure. Operative treatment for the stiff elbow progresses in a sequential fashion to progressively release tissue structures limiting motion and reconstruct any structures as needed to provide joint stability. Postoperative therapy consists of continuous passive motion , corrective splinting, modalities, and specific exercise techniques to maintain passive gains achieved in surgery. The therapy is extensive and requires full participation from the patient to maximize motion and function. Complications of elbow contracture release include nerve palsy or nerve injury, seroma, joint instability, heterotopic ossification, and recurrence of elbow contracture.     

Posttraumatic elbow stiffness

This article outlines the nonoperative and operative treatment of posttraumatic elbow contractures. Elbow stiffness is a significant cause of disability because it results in the inability to position the hand in space. Initial treatment should be nonoperative, consisting of splinting and physical therapy. Established elbow contractures that interfere with a patient's vocation or avocations can be treated operatively by either open or arthroscopic release. The surgical release of posttraumatic elbow contractures is rewarding, with a high incidence of success and a reasonable risk of complications.     

Arthroscopic management of stiff elbow

Elbow stiffness is a common problem encountered by orthopedic surgeons. Various management options have been described in the literature, including conservative measures and open and arthroscopic surgery. Arthroscopic management of stiff elbow remains controversial. The purpose of this study was to evaluate the functional results of arthroscopic management of stiff elbow.Thirty patients with stiff elbow underwent arthroscopic release surgery and were followed up for an average of 27.3 months. Surgery included anterior and posterior capsular release, coronoid process debridement, bony spur excision, and loose body removal. Postoperative outcome was assessed using the Mayo Elbow Performance Score and range of motion at the elbow. Mayo Elbow Performance Score increased from a mean 64.5 preoperatively to a mean 83.17 postoperatively. Range of motion also improved, from a mean preoperative extension and flexion of 22.83° and 96.83°, respectively, vs a mean 10.83° and 120.84°, respectively, at final follow-up. No intra- or postoperative complication was seen in any case. Underlying etiology and timing of surgery influenced the end result, with better results seen in patients with traumatic etiology and those with a shorter duration of symptoms.Arthroscopic release allows good visualization and rectification of intra-articular pathology and is a safe and effective tool for the management of stiff elbow.     

Einteilung der Ellenbogensteifen und Indikation zur operativen Behandlung

An elbow can become stiff for a variety of reasons, such as intra-articular or extra-articular fractures, soft-tissue trauma, prolonged immobilization, thermal injury, infection, inflammatory arthritis, osteoarthrosis and heterotopic bone formation. Elbow stiffness is usually classified into extrinsic (affecting the capsule and extra-articular soft tissues), intrinsic (affecting the synovial and intra-articular structures) and mixed forms. Indications for operative treatment have to be considered in cases of failed conservative treatment with severe functional deficits. The choice of operative treatment has to be based on a thorough analysis of the underlying cause, the affected structures, the pathogenesis and the individual needs. Options are an arthroscopic or open arthrolysis, endoprostheses, hinged external fixators, interposition arthroplasty or combinations of these procedures.     

Steifer posttraumatischer Ellenbogen

Posttraumatic elbow stiffness is a common problem following fractures and dislocations of the elbow. Limitations in the range of motion can be restricting for patients, since daily activities require a high degree of elbow mobility. If mechanical obstructions of elbow movement are excluded, first non-operative treatment is indicated. If non-operative treatment does not lead to satisfactory results, especially extra-articular (extrinsic) elbow stiffness can be treated with arthrolysis operatively. Although the open procedure remains the gold-standard, arthroscopic techniques are more frequently used for arthrolysis. Also, these techniques can be used in combination in the treatment of elbow stiffness.. The presented article summarizes indications and therapeutical options for the treatment of elbow stiffness.     

Surgical treatment of extraarticular elbow contracture

The problem of the contracted elbow is well-recognized for the circumstances under which it develops and the difficulty of operative and non-operative treatment. Earlier studies report this problem in an unfavorable manner; however, current studies suggest that posttraumatic stiffness of the elbow, particularly when the articular surface is left intact, may be treated reliably. The authors present a specific surgical approach to the elbow that has posttraumatic motion limitation described as extrinsic, that is, primarily attributable to contracture of the capsule and periarticular soft tissues. The limited surgical exposure termed the column procedure allows anterior capsular exposure through an interval in the brachioradialis and extensor carpi radialis longus. Using this procedure the authors report the treatment of 38 elbows (38 patients) with sufficient followup to accurately describe the postoperative course. At a mean of 3.5 years after surgery the total postoperative arc of motion improved from approximately 50 degrees to approximately 90 degrees. There were minimal complications. A static adjustable splint rather than physical therapy is used postoperatively. It is concluded that newer surgical techniques with carefully described programs can be successful in the majority of patients undergoing surgical release for extrinsic contracture of the elbow.     

Treatment of ectopic ossification about the elbow

The surgical treatment of elbow ectopic ossification associated with elbow stiffness has progressed significantly in the past decade. Although previous reports describe inconsistent results and high complication rates, numerous recent reports document not only good results, but also lower complication rates. The current study outlines the authors' treatment of patients with ectopic bone about the elbow. Various modalities have been used for prophylaxis against elbow ectopic ossification in the patient with elbow trauma. However, despite these prophylaxis efforts, periarticular ossification may form and result in disabling elbow stiffness. If ectopic ossification and stiffness develop, operative intervention may be indicated to restore motion. It has been long suggested that operative intervention be delayed for at least 1 year, with earlier intervention thought to predispose to recurrence. Recent reports, however, have documented good results with earlier intervention, from 3 to 6 months after injury. The evaluation of posttraumatic elbow stiffness associated with ectopic ossification is described, followed by a discussion regarding anatomic and functional classifications. Surgery is based on multiple factors including the location of ectopic ossification, the plane(s) of elbow stiffness, and the presence of associated nerve compression. A limited or extended Kocher approach may be used to release most contractures; however, other approaches may be necessary. Surgical technique is described in detail. Meticulous surgical technique is necessary to avoid complications, including triceps avulsion, recurrent elbow stiffness, and hematoma.     

Arthrolyse des Ellengelenks

Elbow stiffness is an unspecific response to any of a variety of injuries of the elbow joint, so that treatment must be preceded by an analysis of the possible causes for it to be successful. It has proved helpful to classify elbow contracture according to whether extrinsic or intrinsic disease is involved, because extrinsic stiffness has a better prognosis. The pathologic mechanism that is most frequently the cause of elbow stiffness lies in contracture and fibrosis of the capsule and/or heterotopic bone formation. The main aims of treatments are resection of the fibrotic joint capsule and/or of the heterotopic ossifications. Recent reports suggest that good results can be obtained with early surgical release combined with radiation therapy. Postoperative aftercare and conservative therapy include the use of adjustable splints. Dynamic splints are of no use in the treatment of the stiff elbow, and the outcome of mobilization during anaesthesia is poor. In cases of elbow stiffness arthroscopic surgery on the elbow joint is limited to the extraction of loose bodies and the removal of scar tissue or adhesions. Distraction arthroplasty is a new concept in the treatment of elbow stiffness, involving distraction and relaxation of the capsule by means of an external fixator. No evidence documenting the usefulness or otherwise of this method is yet available.     

Endoprosthetic joint replacement of the contracted elbow joint

In a retrospective study 14 patients were reviewed 63 months after the implantation of a semi-constrained total elbow prosthesis in fourteen stiff or ankylosed elbows with a preoperative range of elbow motion of 30 degrees or less. The result, according to the Mayo Elbow Performance score, was excellent for four elbows, good for four, fair for one, and poor for five. The average arc of flexion improved from 7 to 68 degrees postoperatively with an average increase of 34 degrees in flexion, and 27 degrees in extension. There were seven complications affecting seven of the 14 elbows and four of these seven elbows underwent a revision procedure. Replacement for a stiff elbow is the least predictable, has the lowest overall rate of success and highest complication rate, than any other procedure. Nevertheless, these disadvantages must be placed in the context of alternative intervention options. The semiconstrained total elbow arthroplasty seems to be a useful option for patients older than 50 years with intrinsic stiffness involving more than 50% of the articular surface and with an ankylosed or very stiff elbow.     

The posttraumatic stiff elbow: a review of the literature

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.     

(v) Fractures of the adult elbow

Fractures of the elbow comprise 5% of fractures. Most are minimally displaced and can be managed conservatively. Displaced fractures or those associated with elbow dislocation are likely to require operative intervention. Displaced distal humeral fractures present a particular clinical challenge. Elbow stiffness is the most common complication and can follow seemingly innocuous/minimally displaced fractures.     

手术清理联合活动外固定架治疗肘关节创伤后异位骨化的疗效分析

目的:评价内外侧联合入路手术清理联合活动外固定架对创伤后异位骨化(heterotopic ossification,HO)合并肘关节僵硬患者的临床疗效。方法:2010年7月至2013年12月,采用肘关节内外侧联合入路松解结合活动外固定架固定治疗HO合并肘关节僵硬患者26例,其中男18例,女8例;年龄14~60岁,平均37.7岁;手术松解距受伤时间7~18个月,平均9.3个月。测量患者术前、术后的肘关节屈伸、前臂旋转角度,并进行Mayo评分。结果:1例术后3周出现外固定架针孔慢性感染,给予去除外固定架,余所有患者伤口Ⅰ期甲级愈合。26例均获随访,时间24~40个月,平均34个月。1例术后8个月出现2次HO。术后2年所有患者肘关节屈伸活动度、旋转活动度及Mayo评分较术前有明显改善(P0.05)。结论:采用肘关节内外侧联合入路松解结合活动外固定架固定治疗创伤后HO合并肘关节僵硬可有效改善肘关节功能,疗效满意。     

Elbow arthritis

Patients with elbow arthritis typically present with complaints of pain and stiffness. Rheumatoid arthritis is the most common cause of elbow arthritis, followed by posttraumatic arthritis and primary osteoarthritis. Nonoperative management consisting of oral analgesics, intra-articular steroid injections, physical therapy, and splinting may provide symptomatic relief in the majority of patients. If these modalities fail, operative treatment is guided by the severity of disease as well as several patient-related factors such as age, activity level, and expectations. Total elbow arthroplasty can provide satisfactory results in the majority of patients with significant degeneration of the elbow. However, due to issues regarding prosthesis longevity, this procedure is generally avoided in young active patients. Other operative treatment options for such patients include arthroscopic or open synovectomy, debridement arthroplasty, and interpositional arthroplasty. As all of these operations may provide a satisfactory outcome for the appropriate patient, a thorough preoperative evaluation is essential in choosing the suitable surgical procedure for each individual patient.     

Arthroscopic release for the severely stiff elbow

Arthroscopic release for the stiff elbow has been widely used, but there are no reports limited to severe stiffness. The purpose of this study was to investigate the outcomes of severe cases. Ten patients with 10 severely stiff elbows defined by a limited arc of ≤ 60° underwent this arthroscopic release. Causes of stiffness were post-traumatic stiffness (one patient), osteoarthritis (three patients), and rheumatoid arthritis (six patients). Using arthroscopy, the capsule contracture and the intra-articular fibrosis were removed and the impinging osteophyte and part of the radial head were resected. For four patients with preoperative ulnar nerve symptoms or contracture of the posterior oblique ligament of the medial collateral ligament, mini-open ulnar nerve neurolysis and release of the posterior oblique ligament were performed. Patients were followed up for an average of 24 months. Arthroscopic release could be performed without any intraoperative complications. Range of motion for the elbow significantly improved from 95° of flexion and − 55° of extension to 109° of flexion and − 32° of extension. The Mayo Elbow Performance Score also improved from 56 points to 80 points. Two patients underwent a second arthroscopic surgery and gained further arc of motion. One patient showed osteophyte reformation and needed revision open surgery 1 year after the initial surgery. Arthroscopic release for the severely stiff elbow could improve range of motion. Careful attention should be given during surgery to avoid complications such as intramuscular bleeding or nerve damage.     

Arthroscopic management of the stiff elbow

Elbow stiffness is a challenge to manage effectively. Elbow contractures commonly result from both intrinsic and extrinsic factors, causing limited motion. Recent technical advances in elbow arthroscopy have led to the development of minimally invasive procedures for the management of select cases of recalcitrant elbow stiffness. As with most arthroscopic procedures, a notable learning curve is associated with the safe, effective execution of these surgical techniques. Certain clinical scenarios require that special attention be paid to the ulnar nerve and the posterior bundle of the medial ulnar collateral ligament to improve motion safely. Arthroscopic capsular release of the elbow is effective for restoring a functional arc of motion in the short term in most patients with extrinsic contractures.