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Introduction
  • Stiffness and contractures of the elbow result in loss of motion and difficulty performing activities of daily living
  • Pathophysiology
    • causes of elbow stiffness and contractures include
      • osteoarthritis
      • trauma (fractures)
      • surgery
      • cerebral palsy
      • traumatic brain injury
      • burns
      • prolonged immobilization
      • congenital conditions
        • arthrogryposis 
        • congenital radial head dislocation  
    • pathoanatomy
      • intrinsic causes
        • joint incongruity
        • synovitis
        • loose bodies
        • intra-articular fractures
        • malunions
        • osteochondritis dissecans
        • post-traumatic arthritis
          • coronoid osteophytes
          • olecranon tip osteophytes
          • radiocapitellar joint space narrowing
      • extrinsic causes
        • formation of eschar following a burn
        • heterotopic ossification
        • adhesions/contraction of the capsule
        • ligament contractures
          • scarring of posterior oblique portion of medial ulnar collateral ligament 
      • mixed (intrinsic + extrinsic)
        • late effects of intrinsic conditions can lead to extrinsic stiffness
  • Prognosis
    • patients are able to perform activities of daily living if elbow ROM of 30° (extension) to 130° (flexion) is achieved
      • most activities require a 100° arc of motion at the elbow to be functional
      • a 30° loss of extension is well tolerated by most patients 
      • flexion loss causes more dysfunction than extension loss
Anatomy
  • ROM
    • functional motion
      • 30° - 130° (extension-flexion)
        • most activities require a 100 degree arc of motion at the elbow to be functional
        • a 30 degree loss of extension is well tolerated by most patients 
      • 50° - 50° (pronation/supination)
  • Elbow ligaments and biomechanics  
    • primary ligaments of elbow include
      • medial ulnar collateral ligament
        • anterior bundle
          • is most imporant stabilizer to both valgus and distraction forces
        • posterior bundle
          • posterior oblique portion of medial ulnar collateral ligament
      • radial collateral ligament
      • annular ligament
  • Nerves  
    • ulnar nerve 
      • proximity to the elbow joint places nerve at risk if joint is contracted 
Presentation
  • Symptoms
    • pain
      • pain in mid-arc of motion may indicate intra-articular pathology
      • extrinsic soft tissue contractures typically painful at the extremes of flexion and extension where bone impingement and soft tissue stretching may occur
    • decreased motion
      • often limits activities of daily living
  • Physical exam
    • inspection
      • examine the skin around the elbow
        • look for scars from previous surgeries
        • inflammation
    • range of motion
      • measure elbow 
        • flexion/extension
          • if <90-100° of flexion, posterior band of MCL is likely contracted and should be released
        • pronation/supination
    • neurological 
      • assess median, radial, and ulnar nerve function
Imaging
  • Radiographs
    • recommended view
      • AP, lateral and oblique views
      • serial radiographs
        • if heterotopic ossification is noted 
    • findings
      • dependent on pathology causing stiffness/contractures
  • CT scan  
    • indications
      • loose bodies in joint
      • non-unions
      • joint incongruity 
      • abnormal bony anatomy  
  • MRI
    • rarely indicated
Treatment
  • Nonoperative
    • NSAIDs, physical therapy with active and passive range of motion exercises
      • indications
        • first line of treatment in most cases
        • contractures <40°
    • static splinting  
      • indications
        • failed trial of physical therapy with
          • elbow flexion contractures greater than 30° OR
          • elbow flexion less than 130°  
  • Operative
    • capsular release +/- release of posterior band of MCL 
      • indications
        • extrinsic capsular contractures with normal joint surface congruency
          • most predictable beneficial results
        • patients with arthritis
          • less predictable once joint surface is incongruous
      • outcomes
        • compliance with postoperative rehabilitation is critical
        • less predictible outcomes when ankylosis present preoperatively
      • contraindications
        • charcot elbow joint
        • neurologic elbow disorder
        • poor skin
          • relative contraindication, may need plastic surgery (rotational flap)
    • osteophyte excision
      • indications
        •  intrinsic contractures with arthritis confined to olecranon fossa
        • perform in conjuction with capsular release of bony block to terminal range of motion
          • bone typically should be removed from coronoid, coronoid fossa, olecranon, olecranon fossa
    •  distraction interpositional arthroplasty 
      • indications
        •  intrinsic contractures with diffuse arthritis in high demand younger patients
    • total elbow arthroplasty
      • indications
        •   intrinsic contractures with diffuse arthritis in low demand elderly patients
      • outcomes
        • high failure rate in young, active patients
        • permanent 5-lb lifting restriction 
    • musculocutaneous neurectomy
      • indications
        • neurogenic contractures with a flexion deformity of less than 90 degrees
Techniques
  • Capsular release +/- release of posterior band of MCL
    • approaches 
      • arthroscopic
        • technically demanding, radial nerve most at risk with portal placement, followed by ulnar and median nerves
        • posterior compartment - debridement of olecranon fossa/osteophytes with posterior capsular release
          • caution using suction medially due to proximity of ulnar nerve
        • anterior compartment - debridement of coronoid fossa/osteophytes with anterior capsulotomy or capsulectomy
      • open 
        • lateral column approach (Morrey)
          • can be performed thorugh lateral or posterior skin incision
          • elevate ECRL and BR anteriorly, triceps posteriorly
          • mobilize brachialis off of anterior capsule
          • debride/release anteriorly and posterly, including coronoid tip/fossa, olecranon tip/fossa, anterior and posterior capsule, and radiocapitellar joint
        • medial "over the top" column approach (Hotchkiss)
          • best for patients with extrinsic contractures, MCL calcifications, and/or baseline ulnar nerve symptoms
          • perform with decompression or transposition of ulnar nerve
          • release posterior band of MCL to increase flexion
          • working anterior to flexor-pronator mass, debride/release anteriorly, including coronoid tip/fossa and anterior capsule
        • combined medial and lateral approach 
          • single posterior incision allows for medial and lateral column approaches
          • if <90-100° of flexion, posterior band of MCL is likely contracted and should be released with consideration of concomitant ulnar nerve decompression or transposition
    • timing of contracture release
      • consider contracture release 4 to 6 months post-injury/surgery if range of motion has plateaued and appropriate splinting/therapy has been performed
      • heterotopic ossification can be resected at maturity 
        • determine based on visualization of well-corticalized margins of new bone (with lack of changes on serial radiographs)
        • laboratory studies not necessary to determine heterotopic bone maturity
    • rehabilitation
      • surgery performed under regional block can be helpful for pain control postoperatively
      • continuous passive motion through full range of motion
      • compressive dressing to help with swelling
      • therapy with active, and active-assist range of motion
      • use extension splinting as needed
      • use dynamic or static progressive splinting as needed
    • outcomes
      • improvement in range of motion can be variable
      • Most patients will retain two-thirds of the motion gained at the time of surgical release
Complications
  • Post-operative heterotopic ossification
    • may treat prophylactically with low-dose radiation therapy or indomethacin
    • low-dose radiation may be contra-indicated with acute fractures due to risk of nonunion
  • Transient ulnar neuropraxia
  • Ulnar nerve damage 
    • ulnar nerve transposition should be considered to reduce risk of ulnar nerve injury if preoperative flexion is less than 100 degrees
  • Recurrent contracture
 

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Questions (5)
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(OBQ13.131) A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion? Review Topic

QID: 4766
FIGURES:
1

Self-directed exercise therapy

3%

(158/4553)

2

Supervised exercise therapy

9%

(392/4553)

3

Supervised exercise therapy with static progressive elbow splinting

77%

(3505/4553)

4

Continuous passive motion device

1%

(44/4553)

5

Closed manipulation under anesthesia

9%

(397/4553)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ13.66) A 49-year-old man sustains a dislocation of his left elbow that is successfully reduced and splinted. He misses his scheduled follow-up appointments and returns 6 weeks later. He is immediately enrolled in a course of vigorous physical therapy. At a repeat visit at 6 months, examination reveals that he lacks 40 degrees of elbow extension, and has flexion to 80 degrees. He is taken to the operating room for surgical release. Figures A and B are diagrams depicting the ligamentous attachments about the elbow. To restore elbow flexion, in addition to releasing the articular capsule, which ligament should be released? Review Topic

QID: 4701
FIGURES:
1

Ligament A

11%

(427/3971)

2

Ligament B

67%

(2661/3971)

3

Ligament C

7%

(289/3971)

4

Ligament D

8%

(307/3971)

5

Ligament E

6%

(223/3971)

ML 4

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ12.96) Which of the following statements is true regarding the posterior oblique portion of the medial collateral ligament of the elbow? Review Topic

QID: 4456
1

Can be released to gain flexion in patients with post-traumatic contracture

76%

(3758/4951)

2

Has the highest tensile strength of any elbow ligament

4%

(201/4951)

3

Is reconstructed in the Tommy John procedure

3%

(164/4951)

4

Is the primary ligamentous restraint to valgus force during throwing

11%

(560/4951)

5

Is responsible for the pivot shift of the elbow

4%

(186/4951)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ09.213) Static progressive turnbuckle splinting is most appropriate for which of the following patients? Review Topic

QID: 3026
1

3 months after ORIF of a distal humerus fracture with a flexion arc of 45° to 100° with no further improvement with physical therapy

71%

(839/1174)

2

4 weeks after nonoperative treatment of a displaced radial head fracture with block to supination

7%

(87/1174)

3

1 week after simple elbow dislocation with flexion arc of 10° to 140°

11%

(124/1174)

4

Presence of extensive heterotopic ossification after a complex elbow dislocation with associated ankylosis of the joint

5%

(58/1174)

5

Immediatly after elbow arthroscopy for loose body removal and debridement

4%

(52/1174)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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