Elbow Resources

Elbow stiffness (R) Elbow stiffness (R)


Introduction
The function of the elbow is to place the hand in space. Elbow stiffness reduces this capacity, resulting in functional deficit.

Required range of motion
The normal range of motion in the elbow is from 0 to 140 degrees, plus or minus 10 degrees.
The functional arc of motion as described by Morrey is from 30 to 130 degrees
Hotchkiss states that one needs 110 degrees to shave, fasten collars and tie scarves.
Lack of extension is much more easily accommodated than loss of flexion because the body can be moved towards an object.

Why does the elbow joint get so stiff post injury?
Intrinsic congruity of joint and unique response of joint capsule to trauma; there is a propensity for the capsule to fibrose and for the collateral ligaments to calcify.
Three articulations in a single capsule.
Proximity of articular surface and capsule to intracapsular ligaments and extracapsular muscles. In particular the brachialis muscle is often torn during an elbow dislocation and develops severe scarring or ectopic bone.
Classification
Elbow stiffness can be intra-articular or extra-articular.

Intrinsic causes of stiffness
Lesions of the surface of the cartilage, joint incongruity or intra-articular adhesions.
• Primary osteoarthritis
• Intra-articular fracture
• Rheumatoid arthritis
• Haemophilic arthropathy
These lesions are often painful.
Extrinsic causes include:
• Congenital contractures eg arthrogryposis
• Congenital synostoses
• Acquired contractures eg burns
• Heterotopic ossification, usually post head injury
• Trauma – particularly post dislocation
• Iatrogenic eg excessive immobilization post biceps repair
These may spare the joint space or be associated with intrinsic causes of stiffness. They are often painless.

Patient evaluation

History
Aetiology and duration of contracture
Past treatment
Work and leisure requirements
Potential to comply with rehabilitation

Examination
Condition of soft tissue envelope
Active and passive ROM
Stability of elbow
Motor strength and coordination
Neurological examination – particularly interested in ulnar nerve

Imaging
Requires AP, lateral and oblique plain X-rays, and often fine cut CT scans with coronal and sagittal reconstructions
Important features to assess are:
• Status of the joint
• Is hardware impeding motion?
• Are any fractures healed? (May require tomograms)
• Is there any heterotopic ossification? Is it mature (evidence of well delineated cortical and trabecular markings)
• Is the ulnar nerve encased in heterotopic bone?

Treatment

Avoidance of contracture
When fixing intra-articular fractures strive for stability to allow early movement. However, if early movement would compromise stability it is preferable to allow union to occur and then to proceed to treatment of the stiffness if required.
Patients that are doing poorly in the early postoperative period should be considered for turnbuckle splints early.

Prevention of heterotopic ossification
HO occurs in 4.5-20% of cases following elbow trauma.
Risk factors for HO include head and spinal cord injury, severe burns and delayed operative treatment.
There is no good scientific evidence that NSAIDS prevent heterotopic ossification but anecdotal evidence exists and they should be instituted after surgery and continued for 2-3 months postoperatively in high risk situations. The standard dose is Indomethacin 25mg tds.

Nonsurgical
Nonsurgical treatment usually is most successful for extrinsic stiffness present for 6 months or less but the results are unpredictable, according to Marrat and Morrey.
Treatment modalities:
• Physiotherapy
• Turnbuckle splints
• Form of static progressive splinting; the patient puts his arm into a position of maximal flexion or extension and holds it there, increasing the stretch as stress relaxation occurs
• Patient compliance can be a problem, and the splint is often not worn for the prescribed period of time
• The arm is held in the most-required position at night and the direction of stretch reversed during the day
• MUA – high risk of fracture, creation of new heterotopic bone and neurological injury hence is rarely performed.
Concurrent with these modalities ice and NSAIDS are used to minimize inflammation.

Surgical
Indications for surgery
• Failure to respond to non-operative therapy
• Motivated, cooperative patient able to comply with rehabilitation
• Patients with more than a 35-40 degree loss of extension or less than 105-115 degrees of flexion
Types of surgical treatment

Extrinsic contracture
Capsular release with removal of osteophytes or loose bodies as required. No studies compare the results of anterior, lateral and medial release.

Intrinsic
Interposition arthroplasty is required for stiff elbows with articular damage; in older patients total joint replacement is the preferred option
Hotchkiss emphasizes that the surgeon must be prepared to move on to a more extensive procedure if required.

Extrinsic releases

Arthroscopic
Most appropriate in a young athlete with loose bodies or middle-aged patients with primary osteoarthritis and osteophytes projecting from the coronoid, and in patients with a pure flexion contracture.
Inappropriate in cases of ulnar neuropathy, heterotopic ossification, burns contracture, spasticity and muscle contracture.
Need a low threshold to abandon arthroscopic release and proceed to open release if not succeeding.
The anterior capsule is removed with a shaver until brachialis fibres are on view, then the olecranon fossa is debrided via posterior portals.
Possibility exists for significant neurovascular injury with numerous accounts of shaver damage to nerves. The capsule is contracted in these patients, which prevents capsular distension, and consequently neurovascular structures are very close to the entry portals.

Lateral
Common approach for patients with anterior and posterior capsular pathology and no ulnar nerve symptoms.
Espoused by Morrey and Hastings. In the lateral approach a Kocher type incision is made. The brachioradialis and ECRL are elevated to give direct exposure to the supero-lateral aspect of the capsule. A laterally based wedge of capsule is removed after the interval between it and brachialis is defined. The LCL ligament complex is retained. If required, access to the posterior aspect of the joint is obtained by stripping anconeus and triceps from the posterior aspect of the humerus. This provides access to the coronoid fossa. If the radial head needs to be exposed the dissection is extended between anconeus and ECU.

Medial
An incision is made over the ulnar nerve. The posterior oblique branch of the MCL is dissected out and removed, while the anterior oblique branch is preserved. The flexor/pronator mass is subperiosteally elevated, as is the triceps.
Proponents of this technique believe it allows close inspection of the posterior oblique branch of the MCL and the ulnar nerve.
The main disadvantages of the technique are: difficulty in removing heterotopic bone on the lateral side of the joint, and poor access to the radial head.

Anterior
This technique, described by Urbaniak, involves an anterior (Henry) approach with release of the biceps aponeurosis, Z-lengthening of the biceps tendon, release of brachialis then capsulectomy. May be particularly useful in the approach to heterotopic ossification, but doesn't allow posterior pathology to be addressed through the same incision.
In all of the approaches additional work may be required occasionally to obtain a useful ROM, including removal of metalwork, excision of the radial head, lengthening of the biceps tendon and brachial myotomy.

Which way to approach the release?
If the radiohumeral joint is involved, or if a simple release only is required this can be done laterally.
If the ulnar nerve is involved or there is extensive medial or coronoid arthritis the joint is approached medially.
A posterior incision allows both sides of the elbow to be approach by elevating skin flaps.

Interposition distraction arthroplasty
Fascia lata is interposed between the damaged joint surfaces in patients who are too young or too high demand for total joint arthroplasty.
The lateral collateral ligament needs to be divided to provide access to the articular surfaces of the humerus and ulnar. The ends of the humerus and ulnar are covered with triple layer of fascia lata. The radial head is retained if possible to prevent further instability.
Loss of the collateral ligament mandates use of a hinged fixator for stability; the distraction of the joint obtained by the fixator allows early ROM without dislodgment of the graft.
A pin is drilled through the centre of rotation of the humerus (anteroinferior aspect of medial epicondyle and centre of lateral epicondyle); further pins are placed in the ulna and humerus and the joint distracted by 3-5mm.

Hinged fixation after contracture release
Hinged fixation may also be necessary if there is instability after release of the contracture.
Instability is common after operations for massive HO because the collateral ligaments are often sacrificed within the mass of heterotopic bone.
The hinged fixator normally allows a range of movement of 30-120 degrees.
It is typically used for 4-6 weeks and then replaced by a hinged elbow brace

When to operate in HO?
In this setting some authors recommend operating when the HO has matured as determined by bone scan. Hotchkiss recommends operating when there is a failure to improve at 6-8 months post surgery, stating that the bone scan can sometimes remain hot for years.

Postoperative management
Prophylactic antibiotics – Hughes uses regional intravenous cephalosporin, which delivers a high concentration for 24 hours.
Elevation and intermittent icing or cold compression cuff.
Most authors institute CPM immediately postoperatively, which is less painful if a regional anaesthetic technique such as a brachial plexus block is used. The postoperative physical therapy regimen is crucial.
Static turnbuckle splints may be used once the pain and inflammation has settled post surgery, and continued for 8-12 weeks in an effort to retain the ROM achieved intraoperatively. They are particularly useful in regaining extension.
Indomethacin is used by some authors for six weeks as HO prophylaxis but there is no proof of its utility. Jesse Jupiter has abandoned the use of NSAIDs without an increase in the rate of HO.
There is no proof of the efficacy of radiotherapy.

Complications
Ulnar nerve palsy
Radial nerve palsy
Heterotopic ossification
Elbow instability
Pin tract infection
Septic arthritis
Recurrence of contracture

Results
Results are much poorer in young patients, who have a high proportion of recurrence.
In older patients approximately 80%of patients achieve a functional arc of motion (30-130) and 90% achieve within 10 degrees of this goal.
Recurrence of contracture occurs in 5% of adult patients.
To summarize some articles:
Gelinas in 2000 using a turnbuckle splint had a mean increase of movement of 24 degrees with 11 of 22 patients gaining a functional arc of movement. Only 3 patients required surgical release.
Timmerman in 1994 reported on 19 patients who had an improvement of elbow flexion contracture from 29 to 11 degrees without neurovascular injury.
Cohen in 1998 with a lateral release had a mean increase in arc of movement of 55 degrees with no significant complications
Wada in 2000 with a medial release had mean increase in arc of 64 degrees but required lateral exposure in 5 of thirteen patients.
Morrey obtained an improvement of 62 degrees in arc of movement for his patients treated with distraction arthroplasty. The main complication in his series was loss of strength, with a loss of up to 50% of wrist extension. Complications such as poor wound healing and neurological injury were seen in up to 25%.

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