mx - stiff elbow

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Treatment of the stiff elbowjointBo Sanderhoff Olsen

AbstractElbow joint stiffness is a significant problem after elbow trauma, in

degenerative and arthritic elbow joint disease, and following surgery to

the elbow joint. Treatment of the disease can be difficult and it requires

a team that can access a range of conservative and surgical treatment

options.

This paper describes the clinical presentation of the disease, its

causes, diagnosis and management. The results obtained after treatment

will be discussed, based both on the current literature and the senior

authors extensive personal experience in treating patients with elbow

joint stiffness.

Keywords arthroscopy; elbow; elbow stiffness; elbow surgery; elbow

trauma

Introduction

Stiffness of the elbow joint is a relatively common problem. It

can be caused by congenital defects, trauma or degenerative joint

disease. In an increasing number of adult patients this condition

can be successfully treated with surgery, whereas congenital

elbow joint stiffness or stiffness that developed in childhood

rarely requires surgery.

In 1981 Morrey et al. described the range of elbow joint

motion needed to lead a relatively normal life.1 The authors

showed that most everyday tasks can be performed with forearm

rotation between 50� supination and 50� pronation, and a range

of flexion from 30 to 130�. This has become the reference range

of motion (ROM) that surgeons aim to obtain by surgical treat-

ment. It is important to understand that even minor elbow

motion deficits can cause major problems for patients in specific

situations, however, and the tolerance of elbow motion deficits is

individual.2

The objective of this paper is to describe current indications

and treatment options in the management of elbow joint stiffness

in adults.

Anatomy

The elbow joint is a complex trocho-ginglymoid joint, which

allows positioning of the hand inside a sphere around the body

created by shoulder movement and with the length of the arm

and forearm forming the radius. Therefore, even minor elbow

Bo Sanderhoff Olsen MD PhD Senior Consultant, Ass. Professor, Section

for Surgery on the Shoulder and the Elbow, Orthopaedic Department T,

Herlev Hospital, Copenhagen University, Denmark. Conflicts of inter-

ests: none.

ORTHOPAEDICS AND TRAUMA 26:6 397

motion deficits can severely affect the volume of this sphere by

shortening the radius.2,3

The joint consists of articulations between the humerus, the

ulna and the radius.

The humeroulnar joint is a functional hinge joint with a high

degree of congruency between the deep trochlea of the humerus

and the greater sigmoid notch of the ulna. The articulation is

stabilized through its bony anatomy and through strong lateral

collateral ligaments (LCL) and medial collateral ligaments

(MCL). Furthermore, the anterior capsule has some stabilizing

effect in the extended joint position. The articulation allows

flexion and extension movements of the forearm relative to the

humerus .

The humeroradial joint and the proximal radioulnar joint co-

operate to allow rotational or pivoting movements of the forearm

around the forearm axis. The proximal surface of the radial head,

with its concavity, and the spherical capitellum articulate with

concavity compression, with constraint from the annular liga-

ment that surrounds the radial head.3e7

Pathogenesis of stiffness

Lack of elbow joint extension: is often the most troublesome

problem for the patient. It is usually caused either by anterior

capsular stiffness, with or without calcification and/or osteo-

phytes on the olecranon, free bodies located in the olecranon

fossa or stiff synovial tissue in the same location. These causes

can often be successfully treated surgically (Figure 1).

Lack of elbow joint flexion: is usually caused by stiffness of the

posterior and posterolateral joint capsule and/or osteophytes on the

coronoid process, free bodies located in the coronoid fossa or

heterotopic/periarticular calcifications in the anterior compartment

Figure 1 Preoperative lateral radiograph of a 34 years old female 1½ years

after an operatively treated acute elbow joint dislocation treated by

external fixation initially. There is calcification extending from the olec-

ranon into the triceps tendon and a bone anchor that was used for

reinsertion of the LCL. This patient was treated with operative removal of

the posterior calcification.

� 2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.mporth.2012.09.009

Figure 2 Preoperative lateral radiograph of an arthritic elbow joint in

a 54 years old male carpenter with no history of trauma. Note anterior and

posterior degenerative changes limiting elbow range of movement. This

patient was treated with open release and radial head resection.

Figure 4 Preoperative AP radiograph of a 23 years old female with juvenile

rheumatoid arthritis. Note rheumatoid induced changes in the humer-

oulnar and radiohumeral articulations. This patient was treated with

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of the joint, blocking flexion. These causes can often be successfully

treated surgically (Figure 2).

synovectomy, release and radial head resection.
Joint changes that might impair flexion
The radial head might, through degeneration, inflammatory

change or fracture, be responsible for diminished elbow joint

motion. Simple resection may be indicated accompanied by

surgical joint release (arthrolysis) (Figure 3).

Figure 3 Preoperative lateral radiograph of a 62 years old female teacher

following a radial head fracture.


Occasionally the cause can be articular incongruency of the

elbow following trauma, degenerative or inflammatory joint

disease, leading secondarily to the above described soft tissue

changes (Figure 4). These causes can be dealt with surgically

without a prosthesis. However, on occasions a total- or a hemi-

elbow implant is indicated.

Mal-united or non-united supra or intercondylar fractures are

rare causes (Figure 5). In these cases the treatment involves

internal fixation with osteotomy and/or grafting as indicated.8

Lack of forearm rotation

Lack of rotation can impose significant disability. The condition

can be caused by a range of pathologies. In the elbow joint the

condition is usually caused by radial head fractures with result-

ing incongruence or adhesions between the annular ligament and

the radial head following trauma and immobilization (Figure 3).

Furthermore, degenerative or inflammatory joint disease in the

radiohumeral joint can cause pain and stiffness (Figure 4).

Infrequently calcifications or synostosis involving the inteross-

eous membrane of the forearm can be caused by fracture dislo-

cations or, for example, surgery for distal biceps tendon rupture

(Figure 6). Finally, forearm fractures and wrist problems can

cause a lack of forearm rotation.

Treatment can involve radial head resection or surgical lysis

of adhesions between the radial head and the capsule. In the case

of synostosis following distal biceps tendon repair, resection of

the mature bone may improve rotation. In other situations

surgical release of forearm rotation is difficult.



Figure 5 Preoperative lateral radiograph of a 23 years old male with mal-

union 2 years after a supracondylar humeral fracture. This patient was

treated with osteotomy and arthrolysis.

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Classification

There are different classification systems. The clinically relevant

systems relate to both pathophysiology and treatment. We use

the system defined by Morrey.9 This classification system deals

with extrinsic, intrinsic and mixed causes for the elbow joint

stiffness. The extrinsic causes are located outside the joint space,

the intrinsic causes inside the joint space and the mixed causes

affect both locations.

Figure 6 Preoperative lateral radiograph of a 52 years old male with
Extrinsic causes synostosis 1 year after treatment for a traumatic distal biceps tendon
rupture. The synostosis was operatively resected with the application of

a fascia lata graft.

Capsular contractures may result from prolonged immobilization

or lack of use due to pain. Often, the anterior capsule is involved

and is found to be stiff and thick. Sometimes there are ossifica-

tions around the joint, situated in either the ligaments, capsule or

muscles. Furthermore, elbow contractures can be caused by the

skin, as in severe burns, or by extra-articular painful bony mal-

or non-unions.

Intrinsic causes

Intrinsic causes include articular mal- and non-unions or joint

side destruction due to elbow arthritis. Furthermore, intra-artic-

ular loose bodies can block movement and osteophytes can

cause impingement, leading to contracture formation. Finally,

adhesions between the joint surfaces can cause lack of motion.

Mixed contractures

Contractures with involvement of intra- as well as extra-articular

structures are the most frequent of elbow contractures, since

capsular stiffness is almost always part of the condition.8


Jupiter et al. classify the contractures as either simple or

complex. Simple contractures have mild to moderate contracture,

no prior surgery, no ulnar nerve transposition, no heterotopic

ossification and preserved anatomy.10

Clinical presentation

Patients present with stiffness in the flexion axis and/or in the

forearm rotation axis. In posttraumatic cases pain, when present,

is reported in the extremes of motion, whereas in cases of

degeneration or inflammatory joint disease the condition is

characterized by periodic painful joint effusions and generalized

elbow joint pain. In the later stages, significant joint destruction

can be observed.



Figure 7 Preoperative CT-scan of anterior joint side changes in an arthritic

elbow joint in a middle-aged male.

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The history elicited from the patient is important, focussing on

the onset of symptoms, trauma, occupation, age, hand domi-

nance, night-pain etc.

We always perform a visual analogue scale (VAS) related to

pain at activity and at rest. Furthermore we always observe the

spontaneous use of the elbow during undressing and in the

consultation in general, followed by measurements of the exact

elbow ROM in flexion and rotation, specified for active and

passive motion.

Palpation for pain and crepitus is important and ulnar nerve

symptoms, including mobility of the nerve during ROM, should

be evaluated in a similar fashion to the evaluation of other upper

extremity nerves. Finally, we always examine the stability of the

elbow joint although instability is rarely present in cases of elbow

stiffness.

Certain elbow scores exists, which facilitate clinical evalua-

tion as well as measuring outcome after treatment. We use an

elbow modified Constant score: the so called Functional Elbow

Score, but better validated scores exists as the DASH and the

Oxford Elbow Score and it has been recommended to use

those.11,12

Finally, when considering posttraumatic contractures, it is

important to wait until a final ROM has been reached. In cases of

heterotopic bone formation, maturation of the bone formation is

important prior to surgery. We often wait at least 6 months, with

stable ROM at more consultations before decision on release

surgery is drawn. Improvements in elbow ROM during training

or splinting can appear late following trauma or surgery.

Diagnostic approach

In all cases of elbow joint stiffness we perform anteroposterior

and lateral plain radiographs (Figures 3 and 4). This allows

examination of the joint architecture and identifies bony causes

for contracture of the joint.

In selected cases we perform computed tomography (Figure 7)

in order to define the bony pathology that needs resection or

correction during surgery: this is particularly the case in distal

humeral mal- or non-union.8

If traumatic articular cartilage defects are suspected

a magnetic resonance imaging (MRI) scan can be helpful. With

ulnar neuropathy and ulnar nerve pain we occasionally request

neurophysiological testing (EMG) in order to evaluate the status

of the nerve. In cases with inflammatory disease or suspected

infection blood counts and microbiological examination of

articular fluid are performed.

Treatment and clinical outcome

Prevention

Measures should be taken to avoid the development of post-

traumatic elbow joint stiffness after injury.13,14 Reports increas-

ingly advocate early mobilization following dislocation or

fracture. Mehlhoff et al. reported worse results in patients

following conservative treatment of acute elbow dislocation who

had immobilization for more than 3 weeks.14 Other authors have

advocated mobilization even earlier than 3 weeks.

Following elbow joint fracture, stable internal fixation is the

aim, to allow early mobilization. Several reports document

success with immobilization as short as 8e10 days.15


Physiotherapy

Guided exercises following elbow trauma are generally recom-

mended but poorly documented.12 The majority of reports on the

surgical release of stiff elbows recommend the early onset of

guided training in order to avoid recurrence of stiffness.

Currently the use of active or passive stretching of the elbow

is debated.12,16 Several authors discuss the use of CPM (Contin-

uous Passive Motion) devices in the postoperative phase with the

aim of preventing recurrent elbow joint stiffness.17,18 The

majority of reports on the surgical treatment of stiff elbows using

open techniques advocate it’s use in the immediate postoperative

period.16,17

Splinting techniques

Splints and bandaging can be used as both treatment and

prevention in elbow joint stiffness.8,19e21 A recent study docu-

ments the use of splinting for elbow joint stiffness.19 This paper,

by Lindenhovius et al., documents the use of both dynamic and

static splinting with results that, in select cases, are comparable

to results seen following surgical release of the elbow joint.19

Other recent publications recommend the use of splints

combined with closed manipulation.20,21

Closed elbow manipulation under anaesthesia

This was previously used as a treatment in its own right and

referred to as “Brissem�ent of the elbow”. Araghi et al. described

manipulation as an adjunct to surgical release and as a possible

remedy in the early postoperative period after a surgical elbow

joint release when persistent or recurrent stiffness is

problematic.20

In 2012 a publication has advocated early manipulation in

posttraumatic cases, combined with splinting.21 Caution in cases

with ulnar nerve paresthesiae has been recommended,

however.20



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Arthroscopic release

Arthroscopic release is increasingly being used for the treatment

of elbow joint stiffness. The procedure is technically demanding

and initially severe complications were reported.22,23 In the more

recent literature the incidence of reported complications is

lower.22,24 The outcome following arthroscopic management is

comparable to the outcome obtained with open surgery, even in

complex patients.22,24,25 Current reports show significant

increases in the flexion range of up to 34�.22,24 In the extension

range significant improvements were also reported, with ultimate

deficits in extension of 6� and 7�.22,25

Open release

Figure 8 Patient positioning for elbow arthroscopy. Note the padded rest

under the mid-portion of the humerus.

This is the traditional surgical approach to the posttraumatic or

degenerative stiff elbow.8e10,12,26 Mansat reported the limited

lateral approach, named the column procedure, and reported

increases in flexion of a mean 45� with only few complications.26

Other authors reported their results with the extensive open

approach using a range of different surgical techniques and

observed increases in elbow flexion between 23� and up to

86�.12,17,20 In a few small series distraction arthroplasty with

external fixation was also noted to be successful.12

The largest improvements following open elbow release were

seen in the stiffest elbow joints. Complication rates of 15% are

reported, the majority being minor. Ulnar neuritis and residual

stiffness are the most common complications described.12

Total elbow arthroplasty (TEA)

Figure 9 Arthroscopic surgery in the posterior compartment of the elbow

joint. Note the landmarks.

TEA has been reported as a salvage procedure in selected cases of

ankylosed or fused elbow joints, especially in cases with no other

possible surgical treatment options in the old and less active

patient.8,12,27 Significant complications have been reported, with

reoperations in more than 50% of the patients. However, a good

range of elbow flexion of a mean 80� has been achieved.27

The authors approach to surgical treatment for stiffness of the

elbow joint

In posttraumatic or degenerative cases a stable degree of elbow

stiffness with significant disability has to be present. In our

practice the exact measured restriction is less important than the

resulting handicap reported by the patient.

After acute elbow trauma we introduce guided elbow mobi-

lization and physiotherapy as soon as possible in order to avoid

or minimize the elbow stiffness induced by immobilization.

Generally we avoid immobilization of the elbow joint as much as

possible and rarely would any elbow be totally immobilized for

more than 3 weeks.13,14

In the case of minor motion deficits with no significant bone

lesions to be removed, a ROM >80�, extension deficit <40� and

where a radial head resection is not indicated, we carry out an

arthroscopic joint release and synovectomy.

We place the patients in the lateral position, apply a tour-

niquet, and support the mid portion of the humerus on

a padded rest (Figure 8). This allows easy access to the front as

well as the posterior part of the joint, and multiple portals can

be employed. With this set-up the surgery can be performed

with only a nurse assistant and the joint can be moved during

the surgery. Finally this set-up allows easy conversion to an

open procedure.


We draw landmarks, marking the ulnar nerve and the portals,

and insufflate the joint with 20 ml marcaine with adrenalin. We

use a standard 45� 4 mm arthroscope and a radiofrequency

ablation device or shaver. In cases where osseous resection is

needed we also use a burr (Figure 9).

Normally, we enter the joint from the anterolateral portal and

we create an anteromedial portal using an inside-out technique,

completing the anterior compartment release before approaching

the posterior part of the joint. We normally then use two portals

centred on the olecranon fossa to facilitate posterior compart-

ment release and debridement. If severe swelling occurs or if

there is loss of the view of the posterior compartment we occa-

sionally proceed to a mini-open posterior release through a direct

posterior approach by extending one of the posterior portals,

usually the most lateral.



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Occasionally a posterior or lateral portal directly overlying the

radiocapitellar joint line is used for evaluating and handling

radiohumeral pathology.

In the case of major motion deficits and in situations where

bony release, radial head resection or ulnar nerve release or

transposition is needed, we tend to do an open procedure.

We position the patient is as described above, except that

placement of the padded rest is beneath the distal part of the

humerus. We always use a tourniquet.

A midline posterior incision is made with subcutaneous

dissection (Figure 10). Normally we carry out a staged procedure

and the first stage is a posterolateral release. This is, in our

hands, a debridement of the olecranon fossa with resection of

impinging olecranon and removal of loose bodies. We then resect

the posterolateral capsule, identify the lateral collateral ligament

(LCL) and normally release this ligament from its humeral

insertion in order to give easy and secure access to the anterior

compartment through posterolateral joint subluxation. The

anterior capsule is then released from inside out and the coronoid

fossa is debrided of calcifications and loose bodies. When needed

we resect the tip of the coronoid process. Only rarely do we

preserve the lateral collateral ligament as described by Mansat in

the column procedure26 and rarely do we resect the capsular

tissue.

If this alone is not sufficient to give free elbow motion on the

table we continue to the second stage. In this, the ulnar nerve is

released and protected before resection of the posteromedial

capsule (Figure 10). We then identify the medial collateral liga-

ment (MCL) and resect its posterior band and then try to release

the anterior capsule near the preserved anterior band of the

collateral ligament. We try to spare the anterior band of the MCL

in order to preserve elbow joint stability. Only in very rare cases

is it necessary to release the anterior band at its humeral inser-

tion in order to obtain a full ROM. In this situation the surgeon

Figure 10 The direct posterior approach for open elbow joint release. This

is the situation where both stages of the procedure are needed. Therefore

the ulnar nerve is released and protected and the joint is prepared for

a full triceps split.


has to consider if the anterior band MCL release is necessary or if

a minor extension deficit can be accepted by the patient. The

ulnar nerve is release then protected throughout, but we do not

normally transpose it at the end.

If the anterior band in the MCL is released, we reinsert the

ligament using a bone anchor applied in the origin of the MCL at

the medial humeral epicondyle. Then, the LCL is reinserted using

another bone anchor inserted in the origin of the LCL, at the

undersurface of the lateral humeral epicondyle (Figure 11).

Radial head resection is reserved for special indications

where joint stiffness in flexion or rotation is mediated by the

radial head. Occasionally we perform a capsular release and

trim or resect bony osteophytes at or around the radial head but

preserve it.12

After posterolateral release alone elbow joint instability is

rarely a problem, since the LCL is reinserted at the end of the

procedure as described above (Figure 11).12 In major releases

where the radial head is resected and/or the anterior band in the

MCL released and reinserted, elbow joint instability might be

a problem. In those cases we consider applying a temporary

external fixator.

Figure 11 A postoperative AP radiograph of the patient seen in figure 2

following an open elbow joint release, showing radial head resection and

reinsertion of the LCL using a bone anchor at the undersurface of the

lateral epicondyle.



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Postoperative treatment

Multiple postoperative rehabilitation programmes to follow

elbow joint release have been published.12 Generally the publi-

cations agree that early mobilization is important.

In order to facilitate this, early mobilization and pain

management are probably the most important components of the

postoperative regime. Usually pain is prominent in the first few

postoperative days.12,28

In minor arthroscopic releases physiotherapy is initiated

immediately after surgery. Surgery is performed under an ultra-

sound guided infraclavicular one-shot block. Physiotherapy is

initiated with the block effect still present. Most of our arthro-

scopic releases are done as day-case surgery and the patient

attends rehabilitation sessions from day one.

In major open releases we use an infraclavicular low

brachial plexus block applied through an ultrasound guided

indwelling catheter. This allows continuous infusion of ropi-

vacain at up to 20 mg/h. This block is used for 24e48 h post-

operatively to allow early application of a CPM device. CPM use

beyond 48 h is debated.12,17,18 We tend to avoid “at home” CPM

treatment.

Following the block we normally prescribe oral tramadol

50e100 mg and paracetamol 1 g four times per day. We also use

non-steroidal anti-inflammatory medications to prevent hetero-

topic bone formation when needed. At discharge from our

department at day 2, the patients are closely followed up in our

physiotherapy department to ensure maintenance of the range of

movement. We use a combination of active assisted exercises

and passive elbow stretching. The physiotherapist carries out

regular visual analogue pain scores and if intolerable pain that

prevents adequate rehabilitation the pain management regime is

changed. Rehabilitation sessions continue until elbow joint

motion has stabilized.

Our results

In 2011 we performed 26 surgical procedures for chronic elbow

joint stiffness. We did 17 open elbow joint release procedures

and nine arthroscopic procedures.

Open procedures

These were performed in 13 cases due to sequelae of trauma

(Figure 3), and in the rest the indications were degenerative joint

disease (Figures 2 and 4). There were 12 males. The mean age at

surgery was 48 years (Range 27e73 years).

The mean preoperative loss of extension was 37� (Range

15�e60�) and flexion was possible up to 105� (Range 80�e125�).The ROM arc before surgery was a mean 68� (Range 30�e110�).

After a minimum of 3 months follow up, the mean post-

operative extension loss was 15� (Range 0�e40�) and the mean

maximum flexion was 128� (Range 110�e135�). The ROM arc

was 113� (Range 70�e135�) after surgery. There was a mean gain

in flexion of 45� (Range 25�e65�).Six patients had preoperative deficits of forearm rotation. One

was unchanged at follow-up. Three were normalized and two

had improved forearm rotation at follow-up.

We observed a general decrease in pain scores and one case of

ulnar nerve paraesthesiae at follow-up. One patient needed

another open operation before the end result was reached.


Arthroscopic procedures

These were performed in seven cases for degenerative joint

disease or arthritis. Only two cases had posttraumatic elbow joint

stiffness. There were five females. The mean age at surgery was

37 years (Range 14e57 years).

The mean preoperative extension loss was 19� (Range 0�e40�)and maximal flexion was 119� (Range 100�e135�). The ROM arc

was a mean of 100� (Range 65�e120�) before surgery.

After a minimum of 3 months follow-up the mean post-

operative extension deficit was 7� (Range 0�e30�) and the mean

maximal flexion was 130� (Range 120�e135�). The ROM arc was

123� (Range 100�e135�) after surgery. There was a mean gain in

the flexion arc of 23� (Range 15e40 �). No patient had any

decrease in forearm rotation before or after surgery.

All patients had preoperative pain and four patients experi-

enced locking. At follow-up none had locking and all experienced

pain relief; only two patients reported any residual pain at

follow-up. One patient had two arthroscopic procedures before

the end result was achieved.

Conclusion

Treatment of the stiff elbow is a discipline with many possible

approaches. We have tried to review the current status, pre-

senting the different surgical and non-surgical approaches. As an

illustration of the application of the principles described, I have

described our philosophy at Herlev Hospital and the early results

that we expect, which are comparable to other studies reported in

the literature.

It is important to give the patient a realistic expectation of

what he or she can achieve after surgery. We inform the patient

that the surgery restore up to 50% of the preoperative ROM deficit

and in the majority of cases pain is decreased locking is cured.

In our department the current trend, with increasing experi-

ence with arthroscopic elbow joint release and debridement, is

that more procedures are performed arthroscopically, and our

indications for which kind of procedure we chose are slowly

changing. It is helpful in this process to always retain the

possibility of conversion from arthroscopic to an open procedure

in order to minimize the risk of serious complications and to

secure the best postoperative result for the patient.

Recommended further reading

The reader is directed to references 2,8,10,12,24,26 for much

further useful information on this topic. A

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