Shoulder & Elbow. ISSN 1758-5732
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INVITED REVIEW
Management of the post-traumatic stiff elbow
Odhrán Murray, Duncan Macdonald, Tom Nunn, Jane McEachan & Lech Rymaszewski
Department of Trauma and Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
ABSTRACT
Received
Received 31 October 2011; accepted 31
October 2011
Keywords
Elbow, post-traumatic, stiffness, arthroylsis,
contracture, ankylosis
Conflicts of Interest
None declared
Correspondence
Lech Rymaszewski, Department of Trauma and
Orthopaedics, Glasgow Royal Infirmary, Castle
Street, Glasgow G4 0SF, UK.
Tel.: 0141 211 5334.
E-mail: omurray32@gmail.com
Restriction of elbow motion after trauma is a well-recognized problem. Most cases improve with time and
use, although significant stiffness may persist and interfere with function. Over the last 20 years, surgical
procedures have been reported that can safely improve the range of motion in most patients. A wide variety
of different operative procedures and postoperative regimes have been described, with comparable results.
Surgical techniques range from arthroscopic procedures, through increasingly extensive open releases, up
to those requiring a dynamic external fixator to provide stability. Postoperative passive stretching with
manipulation or splinting is often advocated, although evidence of effectiveness is lacking. We provide an
overview of the current literature, and propose a new surgical guide to aid with the management of stiff
elbows.
DOI:10.1111/j.1758-5740.2011.00167.x
INTRODUCTION
Stiffness is the most common clinical problem after elbow trauma,
in contrast to instability, which is comparatively rare. Loss of
extension of up to 30◦ is the most common outcome, although this
is usually well tolerated, with automatic compensation by moving
closer to the object. By contrast, loss of flexion significantly affects
function if the hand cannot reach the head and mouth, and this
restriction cannot be overcome (Fig. 1). Most activities of daily
living can be performed with a 100◦ arc of movement of 30◦ to
130◦ of flexion and 50◦ to 50◦ of pronation/supination [1].
Other causes of stiffness as a result of osteoarthritis, inflammatory
arthritis, neuromuscular and congenital disorders and their
management are beyond the scope of the present review. This
review focuses on the post-traumatic elbow stiffness, and presents
a surgical guide for performing arthrolysis.
Aetiology
The pathoanatomy of elbow stiffness has been classified into ‘intrinsic’ and ‘extrinsic’ conditions [2]. Intrinsic refers to intra-articular
incongruity or adhesions, whereas extrinsic refers to heterotopic
ossification or contracture of the caspulo-ligamentous structures
of the elbow joint. However, because significant post-traumatic
stiffness usually follows intra-articular fractures, which frequently
have both intrinsic and extrinsic features, this classification system
is of limited value in the management or prognosis of these cases.
Natural history
Restriction of motion is almost inevitable immediately after elbow
trauma, although, in the vast majority of cases, movement
spontaneously improves with time and use, until a functional
range is achieved (i.e. the natural history is usually benign). Unlike
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the shoulder, which can be effectively held by the side without
impairing hand function, a fixed elbow is impractical. Most patients,
therefore, will mobilize their elbow early after trauma, simply with
the aim of performing necessary everyday tasks.
CLINICAL EVALUATION AND INVESTIGATIONS
History. A careful history is essential to establish an accurate
diagnosis and to understand the individual patient’s problems and
expectations. Information obtained and recorded should include:
•
•
•
•
•
•
•
Age, occupation and hand dominance.
The history of injury, subsequent management and
complications.
Duration of stiffness and whether static.
Degree of stiffness: impact on occupation, activities of daily
living and recreational pursuits.
Pain: qualify the nature of the pain (e.g. end of range, constant, activity related, etc.) and quantify in various scenarios
(e.g. using a visual analogue scale at rest/at night/during
lifting/performing tasks with repeated movements).
Ulnar neuropathy: pain, weakness/clumsiness, paraesthesia
or altered sensation, which may need to be addressed at
surgery.
Locking/mechanical symptoms: as a result of loose bodies.
Patient reported outcome measurements (PROMs)
PROMs are very useful to evaluate and monitor progress (e.g.
the Disabilities of the Arm, Shoulder and Hand or Oxford scores).
Evaluation of pain is important because it is well recognized as
having a very strong influence on both physician-rated and patientrated quantitative measures of elbow function. It is important to
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Murray et al.
Management of the post-traumatic stiff elbow
(A)
(B)
Fig. 2 Positive ‘grip and grind’ test. Pain on pronation/supination when
loading the radio-capitellar joint (e.g. turning a stiff handle) can be
confirmed with axial loading by clenching the fingers during forearm
rotation.
Fig. 1 (A) Loss of extension of up to 30◦ is common after elbow trauma,
although is usually well tolerated. The main effect is to limit reach, by a
few centimetres, distance y, with automatic compensation by moving
slightly closer to the object. (B) By contrast, a 30◦ loss of flexion from
130◦ to 100◦ greatly affects function because the hand cannot reach the
head and mouth: distance x is three times greater than distance y and this
restriction cannot be overcome.
appreciate that pain may be strongly influenced by psychosocial
aspects. Doornberg et al. therefore recommend evaluation of pain
separately from objective measures of elbow function in physicianbased elbow ratings [3].
Examination
Inspection may reveal deformity, muscle wasting, previous scars,
prominent metalwork or signs of inflammation. The elbow is
largely subcutaneous and its anatomy can be palpated intimately
for abnormalities. If a patient is being assessed for surgery, the
range of motion (ROM) should be accurately assessed on serial
visits, preferably with a long-arm goniometer [4] by the same
examiner, to ensure that improvement is not gradually occurring.
Hard endpoints ± pain at the extremes of motion indicate a
bony block, whereas soft endpoints are indicative of soft-tissue
contracture. Restriction of forearm rotation and/or ‘grip and grind’
pain at the radiocapitellar joint elicited by axially loading and
rotating the forearm (Fig. 2) is usually the result of a previous radial
head fracture, which may need to be excised at surgery.
Investigations
Routine anteroposterior and lateral X-rays are the mainstay
of imaging. Osteophytes, loose bodies, heterotopic ossification,
malunion/non-union and erosion are easily identified on a plain
X-ray. Although computed tomography and magnetic resonance
imaging are increasingly being used to investigate complex contractures, the actual surgical procedure usually remains unaltered.
The initial approach is determined by the original injury and subsequent surgery, including the presence of metalwork, and the
definitive pathology only determined at operation. Occasionally,
imaging may be helpful to establish the relationship of neurovascular structures with heterotopic bone. Nerve conduction studies
should be undertaken in the presence of neurological dysfunction.
TREATMENT
Conservative
Early, active mobilization is essential for preventing post-traumatic
elbow stiffness. Most elbow injuries are stable, and spontaneously
achieve a functional ROM through early mobilization and resumption of daily activities within the limits of discomfort. Most unstable
injuries can be similarly mobilized after stabilization with a variety
of techniques, including internal fixation, soft-tissue repair, radial
head (or occasionally total elbow) replacement or dynamic external
fixation. Immobilization for more than 2 weeks is rarely required,
even after closed reduction of dislocated elbows demonstrating
instability during examination under anaesthesia [5]. Prolonged
immobilization should be avoided (>3 weeks) because the chances
of developing significant stiffness are increased [6,7].
Physiotherapy is often routinely prescribed, although this frequently only consists of reassurance and advice regarding active
exercises. Passive stretching with manipulation or a variety of
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Murray et al.
Management of the post-traumatic stiff elbow
splints have been promoted [8], although this remains controversial. Splinting regimens include:
•
Static splints. Resting splints can be manufactured to
maintain the elbow at the end-point of extension and/or
flexion, and are used during the rehabilitation period when
resting, especially at night. The patient can then start to
mobilize from the end of range position in the morning
rather than spend several hours getting back to this point.
• Turnbuckle splints. These have been designed on the
principle of incremental displacement, which causes stress
relaxation of the soft tissues through plastic deformation [9].
A major disadvantage is that the patient has to wear a splint
for a significant period of time during the day and night, thus
restricting normal function, and possibly the ability to work
for several months. Gelinas et al. recommended splinting for
18 hours out of 22 hours, although many of their patients
could not fully cooperate with this rigorous regime [10].
• Dynamic hinged splints. These splints use adjustable springs
to apply constant load, initially applying very low forces,
which are gradually increased within the limits of the
patient’s symptoms. In theory, the soft tissues can be
stretched very gently over a maximum period of time,
avoiding pain and spasm. However, evidence to the benefit
of this device in the elbow is very limited.
There is considerable variation in the degree of force applied to
the elbow during passive stretching, ranging from rapid application
of significant force (i.e. a manipulation) to a splint applying a
very small force over a prolonged period. The problem is that
this method may produce soft-tissue tearing, or at least plastic
deformation of the soft tissues, to produce greater motion. Caution
is required to avoid provoking pain, inflammation and muscle
spasm, which are all counterproductive to effective rehabilitation
and may result in increased stiffness. Elbow splints tend to slip
down and require constant adjustment to allow unconstrained
elbow flexion in the correct axis. Passive stretching techniques can
therefore be expensive, labour intensive and time consuming for
the patient.
In addition, genetic factors must influence the tendency to
scar, although the effect cannot be quantified as yet. Clinical
measurement, even with a long-arm goniometer, has a significant
inter-observer error band of 7◦ of extension and 6◦ of flexion [4],
which raises the possibility of some reports overstating claims of
effectiveness of a particular treatment or subsequent arthrolysis.
Only small cohort series reporting good results with passive
stretching exist, with no control groups to compare to the
improvement with natural history. The evidence for such modalities
adding value over active movement alone is therefore weak,
although patients often choose a particular regime according to
their own preferences and recommendations of others.
Surgical
Indications and contraindications. Surgery should be considered
in the presence of significant stiffness and functional limitation
that is not improving after at least 6 months of conservative
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management. There are few absolute contraindications to
arthrolysis as long as the patient is fit enough to undergo surgery
and has been fully appraised of the potential risks and benefits. A
functional hand is essential because the elbow is merely a link in a
lever system that positions the hand in space. Patients who have
had a neurological injury and lack sufficient power of elbow flexion
and extension are unlikely to benefit from arthrolysis.
Surgical release of post-traumatic stiff elbows was rarely
performed until approximately 15 years to 20 years ago because
the procedure was generally considered to be ineffective in
restoring motion. However, subsequent to numerous reports of
successful procedures [11–40], arthrolysis is now regarded as a
reliable, rewarding, evidence-based operation, with low risk of
complications. The results in the recent literature are broadly
similar, reporting that elbow motion improves in almost all
patients, with a mean gain of approximately 50◦ , and that the
majority achieve the functional arc of 30◦ to 130◦ [20–39]. The
key principles common to almost all studies are the achievement
of as much movement as possible at surgery and early motion
postoperatively, which requires adequate pain control (Fig. 3).
Arthroscopic surgery
Arthroscopy of the elbow has been gaining popularity and
there are increasing reports of arthrolysis being performed
using this technique. Advocates of this technique consider
that it offers the advantages of improved visualization of the
anatomy, minimal incisions, reduced pain, shorter hospital stay and
accelerated rehabilitation [41–43]. It does, however, have several
disadvantages. Early reports frequently show evidence of iatrogenic
injury to neurovascular structures around the elbow [44–46]. The
ulnar nerve is at particular risk because it passes through the cubital
tunnel and in close proximity to the capsule of the medial joint
line. Within this tightly confined space, it is at risk from shavers,
debriders, increased pressure and thermal injury [43]. Other nerves
that have been damaged include the radial, median and the
posterior and anterior interosseous nerves [44,47]. In addition,
there are limitations to arthroscopy, such as the inability to remove
metalwork, perform ulnar nerve release or transposition, and
Fig. 3 The key factors for a successful arthrolysis: achievement of as
much movement as possible at surgery and early motion postoperatively,
which requires adequate pain control. Intra Op, intra-operative; Post Op,
postoperative.
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Management of the post-traumatic stiff elbow
difficulty in dealing with heterotopic ossification, joint incongruity
or intra-articular adhesions.
O’Driscoll classified contractures as simple or complex [48].
Simple contractures have normal anatomy and a mild/moderate
contracture (≤ 80◦ ), and had no or minimal prior surgery, no prior
ulnar nerve transposition, no or minimal metalwork or heterotopic
ossification. O’Driscoll emphasizes that most post-traumatic elbow
stiffness fail to meet one or more of these criteria and arthroscopic
release of complex contractures should only be performed by
surgeons with substantial experience in this field in view of the
high likelihood of complications [48].
Ulnar neuritis is common in association with elbow contracture
either pre- or postoperatively once elbow flexion improves [27,30]
and should be addressed with an ulnar nerve release via an open
approach.
Although rehabilitation is potentially quicker after arthroscopy,
there is little evidence of improved results, with a possibility of less
improvement compared in open surgery [49], unless performed by
an expert.
Open arthrolysis
The primary aim of arthrolysis is to achieve as much ‘on-table’
movement as possible; ideally full because the final ROM is likely
to be slightly less and never more than achieved at surgery. Maximum ROM is achieved by using an extensile approach, using
supplementary incisions, if necessary. A variety of open surgical
approaches have been reported [20–40], each with specific advantages and disadvantages. The specific approach is determined by
the pre-operative assessment of the pathology and the personal
preference of the surgeon. The exact location and extent of any
soft-tissue contracture, bony impingement, joint incongruity and
intra-articular adhesions are defined at surgery. All constraints
must be addressed with an extensile approach until, ideally, a full
range of congruous movement is achieved.
A direct posterior approach, taking care to raise thick, viable skin
flaps, will give access to both the medial and lateral ‘columns’.
Alternatively, a lateral skin incision will also allow adequate
exposure and can be supplemented by a small medial incision to
decompress the ulnar nerve and, if required, release the posterior
band of the medial collateral ligament.
We have recently introduced a new surgical guide [50] EFG system (‘extension, flexion, grip and grind’) to help identify and address
the pathology in a sequential manner (Fig. 4), as well as record it in
a systematic way that allows comparison between different series.
Access to the anterior compartment is usually gained through
a lateral ± medial approach, according to the preference of the
surgeon. Contraction of the anterior capsule is almost universally
present and requires release (‘E1’), so that a finger may easily be
permitted beneath the lax anterior tissues of the fully extended
elbow. The anterior capsule can simply, safely and effectively
be released from the distal humeral ± its coronoid attachment
as necessary. By contrast, partial or complete capsulectomy risks
radial nerve injury because it passes anterior to the radial head
at the lateral edge of brachialis, separated only by a thin layer of
fat [51] and offers no advantage to capsulotomy alone.
If restriction to full extension persists, bony impingement in
the posterior compartment must be addressed (‘E2’). Access may
be gained laterally ± medially under the triceps or by splitting
the triceps. Olecranon tracking within its fossa is assessed, and
osteophytes around the olecranon and fossa removed. (Removal
of 6 mm of osteophyte from the olecranon/coronoid tips will
improve extension/flexion by 30◦ respectively; millimetres become
centimetres). Additional scar tissue, loose bodies and callus may be
removed from the distal humerus to deepen and widen the fossa
to accept the olecranon in terminal extension.
Finally, if a satisfactory ROM cannot be achieved, a complete
release of the lateral ligament allows the joint to be subluxed with
supination and any intra-articular pathology addressed (‘E3’). It is
safe to sublux the elbow joint [50] provided that the soft tissues
are reattached to the lateral condyle. Adhesions are debrided and
articular congruity restored by contouring with a high-speed burr.
Motion should be then be checked by fully pronating the forearm
to stabilize the elbow, and ensuring a full, smooth and congruous
arc, as even minor impingement(s) tend to be unforgiving.
Limitations to flexion are addressed in a similar manner. Because
the anterior compartment is opened before the posterior compartment, bony impingement is addressed first (‘F1’). Osteophytes and
abnormal bone are excised from the tip of the coronoid with care.
Excessive removal of the true coronoid, especially if the radial head
has also been excised, may result in instability. The coronoid fossa
and supra-capitellar region are cleared in a similar fashion to the
olecranon fossa, as noted above.
Further gains in flexion are achieved by releasing posterior soft
tissue contractures (‘F2’). The posterior capsule is released from
its origin at the distal humerus and olecranon fossa. Additionally,
the posterior band of the medial collateral ligament may restrict
flexion. The posterior band forms part of the cubital tunnel floor
and can only be accessed by ulnar nerve decompression and gentle
mobilization, or formal transposition.
After bony and soft tissue correction of the anterior and posterior
compartments, intra-articular limitations to flexion (‘F3’) are
addressed simultaneously with extension (‘E3’), with subluxation
of the joint after a complete lateral ligament release.
Restriction of forearm rotation or a positive pre-operative
‘grip and grind’ test is addressed by radial head excision (‘G1’).
Debridement of the radial head alone may result in adhesions
and/or maltracking with a poor outcome. If forearm rotation
remains limited, stripping radial neck adhesions may on occasion be
successful (‘G2’). A proximal radioulnar synostosis may be excised
with the radial head intact (‘G3a’) or absent (‘G3b’). Removal of scar
tissue or bone between the radial tuberosity and ulna in the absence
of the radial head carries the highest incidence of recurrent stiffness
because the supinator tends to draw the radius and ulna together.
Ulnar nerve management. A cubital tunnel release is routinely
performed to formally decompress the ulnar nerve if a medial
approach is used. Access to the posterior band of the medial collateral ligament and posterior capsule is gained through the bed of the
ulnar nerve. It is important to retain fascial attachments of the fat to
the medial epicondyle aiming to prevent subluxation of the nerve
postoperatively. Extension of the medial approach for access to the
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Management of the post-traumatic stiff elbow
Murray et al.
Fig. 4 EFG surgical guide. E, Extension; F, Flexion; G, Grip and Grind. The pathology responsible for elbow stiffness is addressed sequentially with an
extensile approach until, ideally, a full range of motion has been achieved.
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Murray et al.
Management of the post-traumatic stiff elbow
anterior capsule on the medial side can be performed by elevating
a flap of brachialis/pronator teres, which will allow visualization of
the anterior capsule, anteromedial humeroulnar joint and coronoid
process. Transposition of the ulnar nerve is performed if the bed of
the ulnar nerve is distorted or the nerve subluxes on flexion.
Interpositional arthroplasty. Interposition arthroplasty involves
resurfacing the elbow joint with an allograft, such as achilles
tendon or fascia lata. The distal humeral articular surfaces are
deepened and contoured after an extensive soft-tissue release. A
dynamic external fixator is then applied to protect the graft for
approximately 4 weeks [52].
Interpositional arthroplasty is considered to be useful in the
younger patient with more than 50% loss of the articular
surface, although significant complications have also been
reported, especially instability [33,52]. There is no evidence that
interpositional arthroplasty adds value over arthrolysis alone in
terms of ROM, functional scores or pain relief at midterm follow-up
at 4 years and 5 years [23,33,52].
Total elbow replacement (TER)
TER should be viewed as a salvage procedure, which is only to
be used in the older, less active patients. The techniques of TER
are beyond the scope of the present review, although a linked
prosthesis is recommended in the presence of severe deformity,
poor bone stock or instability. Mansat and Morrey demonstrated
that improvements in ROM can be obtained using TER, although
with high complications rates (seven of thirteen), including two
deep infections [53]. Implant survival rates for TER in the stiff
elbow are worse than those for rheumatoid arthritis, especially in
younger patients, with 75% of failures occurring in those aged
<65 years [54].
REHABILITATION
There is wide agreement that early mobilization after elbow
arthrolysis is important. This requires adequate pain control and
a stable elbow. If there is a risk that the elbow will be unstable
postoperatively, then a dynamic external fixator can be used
for 1 weeks to 2 weeks until the elbow regains stability. In the
immediate postoperative period, the pain can be considerable and
will inhibit early movement unless adequately controlled. Brachial
plexus blockade allows prolonged analgesia when administered
continuously through a catheter for 48 hours to 72 hours [55].
Adjuvant pain control can be delivered via a patient-controlled
analgesia system with opiates. These methods have been shown
to be very effective, although they require a 24-hour team approach
to pain control.
Whenusingabrachialplexusblockforpostoperativepaincontrol,
a degree of motor blockade often results, and active movement is
not possible. Continuous passive movement (CPM) is an excellent
way of ensuring early mobilization of the elbow. A major benefit
may be psychological because the patient can see their joint moved
painlessly through an improved arc of movement. However, there
is little evidence that the use of CPM improves the overall outcome.
There can be no further gain in ROM from that obtained on the
operating table.
Physiotherapy is not considered to be essential in the recovery
period, apart from offering support and reassurance to patients that
it is safe to use their arm in activities of daily living. On discharge
from hospital, the ROM is likely to be less than achieved in theatre
as a reselt of swelling restricting the end of range movement.
Passive stretching has been used by some surgeons, although
there is no evidence that it alters the eventual outcome; the most
important factor is the ROM obtained at surgery. In a series by
Higgs et al., 70 patients underwent open arthrolysis followed by
inpatient CPM with brachial plexus blockade for 48 hours [40]. No
passive stretching was used, and the arc of movement continued
to improve over the next 12 months by a mean of 40◦ compared
to the pre-operative measurement. These results are similar to
other series that use passive stretching. Other aids to rehabilitation
include static, dynamic and turnbuckle splints; however, there is
little evidence of any benefit, with similar risks to splinting as
outlined above.
OUTCOME/COMPLICATIONS OF OPEN ARTHROLYSIS
Arthrolysis improves the range of elbow movement between
21◦ and 66◦ [50,51,56], as well as health status and disability
scores. However, the degree of improvement does not necessarily
correlate with the improvement in ROM because final pain levels
are an important predictor of general health status and disability
scores in this population [50,51,56].
Reports of complications from open arthrolysis vary from 0%
to 44%, although most of the complications reported are relatively minor [18,22,24–36,50,51]. Wound infection, dehiscence,
haematoma and seroma are the commonest problems and are
more likely in more complex cases. Patient disappointment in their
gain in movement may occur, although this should be minimized
with adequate pre-operative information. Limited further gain may
be obtained with a revision arthrolysis, although lower outcome
and functional scores have been reported [28,29].
Ulnar neuritis can occur after improvement in flexion is
obtained [27,30]. It has been suggested that asymptomatic ulnar
compression may be present prior to elbow release and, with
the sudden increase in elbow flexion, tension on the tethered
nerve can give rise to clinical neuropathy. Although there is no
conclusive evidence, routine decompression of the ulnar nerve
is recommended if pre-operative flexion is less than 120◦ [48].
Instability rarely occurs after arthrolysis after complete release of
the lateral ligament. If subluxation occurs, a dynamic external
fixator will restore stability and allow mobilization.
CONCLUSION
Most patients will achieve a functional ROM within 9 months to
12 months after elbow trauma, although, if significant stiffness
with restriction of function persists, surgery may be indicated.
The simplest, safest surgical approach should be chosen that
allows access to the soft tissue and bony pathology for
release/debridement. The EFG surgical guide provides a simple
method of addressing the stiffness in a systematic manner and
allows grading of the pathology. There is little evidence of
added value with arthroscopic surgery or interposition arthroplasty
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compared to open surgery. The choice of skin incision(s) will vary
according to previous surgery and the personal preference of the
surgeon. A lateral surgical approach is safe and reliable and a
medial approach can be added to address medial side pathology,
as well as release/transposition of the ulnar nerve. Postoperative
pain control is imperative to allow early mobilization. Functional
improvement in ROM is usually obtained and maintained in the
medium term.
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