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

QID: 3026

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




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




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




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




Immediatly after elbow arthroscopy for loose body removal and debridement



ML 3

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