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Transcript of MX - Stiff Elbow
ELBOW
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.
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
ELBOW
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 flexionThe 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.
ORTHOPAEDICS AND TRAUMA 26:6 398
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.
� 2012 Elsevier Ltd. All rights reserved.
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.
ELBOW
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 tendonrupture. 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
ORTHOPAEDICS AND TRAUMA 26:6 399
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.
� 2012 Elsevier Ltd. All rights reserved.
Figure 7 Preoperative CT-scan of anterior joint side changes in an arthritic
elbow joint in a middle-aged male.
ELBOW
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
ORTHOPAEDICS AND TRAUMA 26:6 400
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
� 2012 Elsevier Ltd. All rights reserved.
ELBOW
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.
ORTHOPAEDICS AND TRAUMA 26:6 401
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.
� 2012 Elsevier Ltd. All rights reserved.
ELBOW
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.
ORTHOPAEDICS AND TRAUMA 26:6 402
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.
� 2012 Elsevier Ltd. All rights reserved.
ELBOW
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.
ORTHOPAEDICS AND TRAUMA 26:6 403
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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ELBOW
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