Summary Elbow Stiffness and Contractures of the elbow result in loss of motion and difficulty performing activities of daily living and may occur as a result of trauma, osteoarthritis, elbow surgery, or a congenital condition. Diagnosis is made clinically with assessment of active and passive elbow range of motion with a comparison to the contralateral side. Treatment is a trial of aggressive physical therapy to achieve functional range of motion. Operative management is indicated in the event of bony block to motion, congenital disease and lack of improvement with physical therapy. Etiology Pathophysiology causes of elbow stiffness and contractures include osteoarthritis trauma (fractures) surgery cerebral palsy traumatic brain injury burns prolonged immobilization congenital conditions login to view 2 more bullets pathoanatomy intrinsic causes login to view 10 more bullets extrinsic causes login to view 5 more bullets mixed (intrinsic + extrinsic) login to view 1 more bullet Anatomy ROM functional motion 30° - 130° (extension-flexion) login to view 2 more bullets 50° - 50° (pronation/supination) Elbow ligaments and biomechanics primary ligaments of elbow include medial ulnar collateral ligament login to view 4 more bullets 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 login to view 2 more bullets range of motion measure elbow login to view 3 more bullets neurological assess median, radial, and ulnar nerve function Imaging Radiographs recommended view AP, lateral and oblique views serial radiographs login to view 1 more bullet 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 login to view 2 more bullets static splinting indications login to view 3 more bullets Operative capsular release +/- release of posterior band of MCL indications login to view 4 more bullets outcomes login to view 2 more bullets contraindications login to view 4 more bullets osteophyte excision indications login to view 3 more bullets distraction interpositional arthroplasty indications login to view 1 more bullet total elbow arthroplasty indications login to view 1 more bullet outcomes login to view 2 more bullets musculocutaneous neurectomy indications login to view 1 more bullet Techniques Capsular release +/- release of posterior band of MCL approaches arthroscopic login to view 4 more bullets open login to view 13 more bullets 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 login to view 2 more bullets 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 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