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Elbow Stiffness

Introduction

Functional range of motion at the elbow: 30-130 in flexion/extension and 50 degrees of pronation and 50 degrees of supination.

Anatomy

Describe the pertinent anatomy and provide links to relevant pages

Pathogenesis

  • The elbow is predisposed to stiffness secondary to
    :
    1. the high degree of articular congruity and complexity
    2. the sensitivity of the tissue's reaction to trauma
    3. Secondarily: orientation of the collateral ligaments as well as the elbow flexors and extensors
  • Surgeon-related factors:
    • ability to obtain anatomic reduction and rigid fixation
    • length of immobilization
  • Patient-related factors:
    • rehab compliance is likely not a significant factor
  • Biology:
    • variation of tissue response to trauma among patients
    • increased numbers of myofibroblasts
    • increased production of extracellular matrix
    • increased expression of transforming growth factor beta
    • heterotopic ossification
      • incidence increased with concomitant head trauma

Natural History

Describe the natural history,epidemiology and prognosis

Patient History and Physical Findings

History:

  • Ask about ulnar nerve symptoms
  • pain with motion: potential arthrosis, ulnar nerve dysfunction
  • pain at rest: potential infection

Physical Findings:

  • Assess ulnar nerve
  • active and passive range of motion
  • Pain through central flexion arc: potential malunion, DJD

Imaging and Diagnostic Studies

Diagnostic studies:

If concerned about infection, order a ESR, CRP; If inflammatory markers are positive, aspirate the elbow.

Radiography:

  • AP and lateral radiographs
    • HO may manifest from 2-12 weeks after original injury
  • CT may be helpful, particularly in assessing heterotopic ossification
  • MRI is not typically useful
  • Technietium-999m bone scans: no longer used to assess activity of HO

Classification

Kay:

  1. soft tissue contracture
  2. soft tissue contracture with ossification
  3. undisplaced artcular fracure with soft tissue contracture
  4. displaced intra-articular fracture with soft tissue contracture
  5. invoved posttraumatic bony bars

Morrey:

  • system based on anatomic location; (most patients have a combination of locations)
  • Types:
    • Intrinsic (intra-articular)
      • adhesions
      • articular malalignment
      • loss of articular cartilage
    • Extrinsic (extra-articular)
      • capsular and/or collateral contracutres
      • heteotopic ossification
      • extra-articular malunions
    • Combined

Differential Diagnosis

Include a list with links to relevant conditions

Treatment

Heterotopic ossificaton prophylaxis:

  • NSAIDs
    • effective for preventing HO in the hip, however, there is little literature in regard to the elbow
    • Useful for prophylaxis only. Once HO is present NSAIDs nor low-dose irradiation is effective.
  • Diphosphonates
    • not indicated; may cause rebound calcification
  • low-dose irradiation
    • give witin 72 hours of trauma
    • dose: 600-1000 cGy
    • Useful for prophylaxis only. Once HO is present NSAIDs nor low-dose irradiation is effective.

Nonoperative treatment:

-Repeated , forceful manipulation will increase the risk for heterotopic ossification

-Continuous passive motion

  • typically used to maintain motion, not to attain motion
    .
  • little supportive literature

-Bracing:

  • Types:
    • Dynamic: applies a constant force to the elbow as additional motion is achieved; satisfactory results
    • Static
  • Forearm position
    :
    • Lateral ligament injuries: forearm splinted in pronation
    • Medial ligament injuries: forearm splinted in supination
    • Medial and lateral ligament injuries: forearm splinted in neutral
    • Do not splint elbow in flexion overnight as it may result in ulnar nerve palsy. Splinting in extension overnight is acceptable.

Operative treatment:

Indications:

  • As a rule, offered to those with at least 30 degree flexion or extension contracture. However, patients must be considered on an individual basis
  • Fractures must be healed

Excision of Heterotopic Ossification

  • may proceed once HO has matured on plain x-rays (smooth well-defined marigins and defined trabecular makings; typically 3-6 months after appearance)
  • HO is distinct from the capsule anteriorly but not posteriorly

Treatment of patients with significant post-traumatic arthritis:

  • Interposition arthroplasty: consider in the younger patient
  • total elbow arthroplasty: older patients

Contracture release:

  • Should be performed withing one year after stiffness onset
  • Open release
    • Indications: extensive scarring, need for articular reconstruction, need for interposition arthroplasty
    • Approaches
      :
  • Anterior
    • Indications: limited elbow extension
  • Lateral: The column procedure
    • Indications: contractures of the anterior and/or postrior capsule
  • Medial
    • Indications: Ulnar nerve involvement
  • Posterior extensile
    • Indications:
      • need for medial and lateral exposure
      • exposure of articular surface
  • Arthroscopic release
    • Indications have been extended from  mild contractures to those with more extensive contractures
    • Radial nerve is typically within 1-2mm of the capsule and at risk for injury during the release. If a shaver is used, suction should be off and outflow is to gravity. Avoid the capsule overlying the radial head
      .
    • Relative contraindications: previous ulnar nerve transposition which would preclude the use of an anteromedail portal.

Arthroplasty

  • Currently little data

Postoperative Care

  • Intrinsic involvement, cases in which interposition has been done, ligamentous reconstruction
    • Hinged external fixator and CPM for 3 weeks
    • At 3 weeks: removal of Ex fix, exam under anesthesia, and transition to Mayo Elbow Brace
  • Physical Therapy
    • controversial

Radioulnar synostosis

Can be due to

  • Trauma, e.g. gunshot
  • ORIF
  • Repair of rupture distal biceps using 2 incisions technique
  • Subperiosteal stripping / exposure of both bones, if performed through the 1 incision
  • Treatment
    • Excision when the bone has matured (bone scan)
    • Indomethacin
    • +/- radiotherapy
  • Prognosis : functional range achieved in ~ 1/2 cases

Pearls and Pitfalls

Tips and problems to avoid

Postoperative Care

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Outcome

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Complications

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References

JAAOS Articles

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