Stiff Elbow (Elbow Contracture)


Article Author:
Juan Patiño


Article Editor:
Victoria Saenz


Editors In Chief:
Sisira Reddy
Joseph Nahas


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/10/2019 12:07:14 AM

Introduction

Elbow stiffness is a relatively common condition and represents a significant disability. There are multiple causes of loss of elbow range of motion. Therefore, a proper clinical history is important for therapeutic surgical or non-surgical planning.[1]

Etiology

Its etiology is considered to be multifactorial, including post-traumatic arthritis, heterotopic ossification, non-union or malunion with soft tissues around the elbow contracture. Regan and Reilly recognized three factors that may contribute to elbow contracture: 1) its complex anatomy, 2) the anterior brachial muscle that covers the anterior capsule leading to ossification and 3) sustained immobilization due to difficulties in achieving a stable osteosynthesis, especially in complex fractures.

Elbow stiffness is mainly determined by the degree of the joint injury. However, it is also influenced by periosteum loss and immobilization time. These causes may explain why major contractures are observed, despite obtaining adequate reduction and stability, or even in fractures without displacement. Other non-traumatic causes of stiffness are hemophilia, sequelae of infections, rheumatoid arthritis, and osteoarthritis. Among congenital causes, the arthrogryposis and congenital dislocation of the radial head are distinguished.

Stiffness due to Heterotopic Ossification

These formations of mature bone in non-bony locations frequently present in the elbow. Its cause remains unknown. Amorphous calcium deposits that affect the capsule and the collateral ligaments may consolidate in periarticular calcifications. Distinguishing this phenomenon from the heterotopic ossification is important.   

Heterotopic ossification presents after direct elbow trauma. Post dislocation incidence rises 3% according to literature reports, and up to 20% is associated with fractures and complex dislocations. They occur in 5% to 10% in patients with isolated encephalic trauma, more frequently on the hemiplegic side. When encephalic trauma occurs together with elbow trauma, the percentage reaches to 75% to 90%. They have also been associated with specific surgical approaches. Available medical treatment is not completely effective; therefore prevention is a key element. The utility of NSAIDs was demonstrated during the first 3 to 5 days of its development. Indomethacin, ibuprofen, naproxen, and aspirin have proved to be the most effective.

Elbow Stiffness Secondary to Malunion and Nonunions

The particular etiology will determine the treatment of these entities. It can originate as a sequel of articular fractures and malunions. These conditions disrupt the elbow biomechanics. No union of the distal humerus produces limitation due to pain and instability.  In these cases, in addition to the treatment of nonunion, procedures, such as arthrolysis, should be added. It is important to evaluate the complete affected limb and identify any associated injuries, such as burns, infections, and neurovascular lesions, among others.

Epidemiology

The loss of elbow mobility after a traumatic event occurs in 5% of cases.

Pathophysiology

Acute or repeated traumas represent the most frequent causes of elbow stiffness. Extension loss is more common than flexion loss.[2][3]

Cellular events occurring after trauma and its implications in stiffness are currently being studied. Participation of relaxin in capsular laxity together with the increase of cross-collagen bridges and decreased proteoglycans and water content are findings involved in an abnormal tissue of induced contractures.

Decrease range of motion depends on factors related to the type of joint trauma and soft tissue, treatment, rehabilitation and patient response. During the evaluation, it is important to consider previous surgeries, type of initial trauma and surgery, an affection of soft tissue, time of immobilization, and type of rehabilitation.[4]

History and Physical

The normal arc of flexion-extension is 145 degrees (0 to 145 degrees), and 75 to 85 degrees for pronosupination. An arc of movement between 30 and 130 degrees in flexion-extension and 50 degrees in pronosupination provides sufficient range for most daily life activities. It is important to individualize the degree of compromise in the range of motion, because it may vary through activity level. For example, an arch suitable for most of the general population may not be sufficient for athletes and musicians.

Pain is rare in stiffness. It may be present during flexo-extension when related to arthritis and at rest during infectious process. 

Heterotopic Ossifications

Local inflammation, pain, and an increase in local temperature are the most common manifestations. This inflammatory phenomenon should not be confused with an infection. Pain may not always be present and usually appears at the end of the arc of movement. Regarding laboratory findings, decreased calcium and increased phosphates may be observed. Serum alkaline phosphatase rises between 2 and 4 weeks after the beginning of the symptoms and reaches 3 or 4 times above normal limit after 3 to 10 months. Bone centellogram with TC 99 shows increased metabolic activity during the first week and is prolonged for one year. X-rays are the adequate study for evaluation and monitoring. Mature bone is described as well-defined cortical presence. This maturation usually occurs after 3 to 5 months, after which it is possible to proceed with a surgical approach.

Evaluation

Anteroposterior (AP) and lateral x-rays are useful in most cases. When the decrease range of motion is 45 degrees or greater, the AP incidence is difficult to obtain. CT scan is useful in sequelae of complex fractures and when there are doubts about treatment planning.

Classification

For an optimal evaluation and understanding of the eventual treatment, stiffness can be classified as:

  • Extrinsic, without joint affection (ligaments, muscular and capsule)
  • Intrinsic, with compromise of the articular surface, possibly due to adhesions, osteophytes, chondrolysis, or trauma
  • Mixed: combined intrinsic with extrinsic injuries. These are more frequent. Most of the times, intrinsic causes envolve to an extrinsic stiffness.

According to the arc of movement (flexion, extension), stiffness can be classified in mild, less than 90 degrees of range, moderate between 60 to 90 degrees,  serious between 30 to 60 degrees and severe less than 30 degrees.

The following guide has been proposed to differentiate simple from complex contractures. Simple compromise should meet the following features: 

  1. Mid or moderate contracture: the movement range of 80 degrees or greater
  2. Non-existent or minor previous surgery
  3. Without prior transposition of the ulnar nerve
  4. Without osteosynthesis or minimum material
  5. Without heterotopic or minimal ossifications
  6. Normal bone anatomy.

If at least one of these criteria is absent, the contracture is considered complex.

Treatment / Management

Treatment can be surgical and non-surgical: arthrolysis (open or arthroscopic), interposition arthroplasties, and prosthetic replacements. It is considered essential to address the treatment related to an adequate clinical evaluation, determining the decrease and disability for the patient since it may vary according to activities and expectations. The time of evolution and cause of stiffness are also relevant components needed to plan the treatment strategy.

Non-surgical treatment

Among the non-surgical options, supervised stretching, dynamic and static splints, the serial plasters, and the physical therapy were described to be effective. Splint treatment shows better outcome results when the time of the clinical evolution of the contracture is shorter and does not present large joint conditions (extrinsic causes).

Mobilizations, under anesthesia, have been associated with heterotopic ossification. For some authors, extrinsic causes of stiffness are better treated with a  non-surgical approach with good results.[5][6]

Surgical Treatment

Indications: intrinsic causes that will not improve with non-surgical treatment, serious stiffness (i.e., less than 30 degrees of range), poor outcomes with rehabilitation, for example, heterotopic ossification. As mentioned above, knowing the cause of the stiffness is necessary for an adequate pre-operative planning. According to the information obtained, type of surgery, open or arthroscopic, the proper approach and procedure will be planned.

Surgical Approaches

The choice depends on the location of previous scars, the need for nerve decompression and the presence and extension of ossification.[7][8][9]

Medial approach: Indication. Medial articular injuries, ulnar nerve disease, medial ectopic bone, ossification, or ligament insufficiency.

Lateral or column procedure: Lateral approach allows anterior and posterior capsulectomy.  Afterwards, mobility should be evaluated.[10]

Collateral Ligaments: During lateral and medial approaches, ligaments are retained. Sometimes it is necessary to release them. In severe and long-term contractures it may be necessary to partially release the ligaments. If the pre-operative restriction is less than 110 to 120 degrees, the posterior fascicle of the medial collateral ligament and the posterolateral capsule must be released to restore flexion.

Posterior approach: It is possible to have access to the posteromedial and posterolateral capsule. The cutaneous incision is in the posterior midline lateral to the olecranon. The ulnar nerve should be identified and protected.

Arthroscopic release: The capsular contracture causes a notable decrease in capsule volume. This makes it difficult to enter in the joint. Several portals must be considered. Based on a clinical experience, some authors have proposed the procedure in four steps.[11][12][13]

  1. Entrance
  2. Preparation
  3. Bone removal and free bodies
  4. Capsulectomy

Surgery on Heterotopic Ossification

Surgical treatment is indicated when ossifications represent a functional limitation. The approach will be planned according to the location and the area of extension.[14]

Postoperative Care

Perform an immediate evaluation of neurological integrity. Place a padded bandage with a  splint to decrease bleeding and immediate post-op edema. The placement of an axillary catheter or anesthetic blockade has been proposed.

Continuous passive mobility is recommended. Evaluation of the continuity of the continuous motion splint is performed according to the capacity of patient’s mobilization without it (3 to 4 weeks). It can be continued with static splints.

It has been recommended the use of indomethacin to avoid the ossification.

Surgical Result

Both, open techniques and arthroscopic approach showed good outcome results. Bibliographic reviews suggest up to 90% increase the mobility range of at least 10 degrees and approximately 80% achieve functional range (between 30 and 130 degrees). Mobility acquired by surgery may be often lost.

There is not enough evidence through randomized clinical trials about advantages of arthroscopic technique over the open approach.

Rehabilitation

The postoperative program should be individualized, according to etiology and patient preferences. However, certain objectives can be determined: 1) Restore a functional arc of motion, 2) Regain muscle strength, 3) Incorporate the limb to functional activities. Regarding the beginning of the mobilization, some authors recommend starting after two days of the Arthrolysis, as long as adequate control of the pain is achieved. Continuous passive motion (CPM)  presents the advantage of reaching the limits of extension and flexion achieved in the surgery. This strategy is not recommended in cases in which ligaments have been reconstructed or repaired. Rehabilitation efforts should be maximised until the patient gains adequate degrees of movement. Static or dynamic splints are also useful.[10]

Some authors recommend the use of NSAIDs or low doses of radiation in the prevention of ossification.

Pearls and Other Issues

The incidence of surgical complications varies depending on the causes of the contracture and its complexity, from 10% to 30%. Hematoma, infections, ulnar nerve neuritis, ossification, hypertrophic scars, and pain are the most frequent complications of the procedures. Late ulnar neuropathy has recently been observed due to elongation after recovering degrees of extension in flexion contractures. Iatrogenic neurological injuries have been reported in both, open techniques and arthroscopic procedure. However, its frequency depends on experience and complexity. The following suggestions have been proposed to diminish the risk of complications: use of retractors, avoid the aspiration near the nerves (disconnect the shaver), careful use of the shaver close to the nerves to avoid traction and recognizing surgeons limitations regarding the surgical experience.[15]

Enhancing Healthcare Team Outcomes

Stiff elbow is best managed by a multidisciplinary team that includes a therapist and an orthopedic nurse. In most cases, conservative treatment with exercise is the first step. Surgery is often undertaken for recalcitrant conditions that do not respond to conservative measures. However, surgery does not guarantee a positive result and is also associated with serious complications.

The outcomes for patients with stiff elbow depend on the cause. Those who comply with rest, stretching and regular exercise tend to have good outcomes.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Stiff Elbow (Elbow Contracture) - Questions

Take a quiz of the questions on this article.

Take Quiz
A 40-year-old male presents after simple dislocation with a 45-degree arc of elbow flexion-extension. X-rays reveal no joint injury. How is this elbow contracture classified?

(Move Mouse on Image to Enlarge)
  • Image 5760 Not availableImage 5760 Not available
    Contributed by StatPearls
Attributed To: Contributed by StatPearls



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 40-year-old, male presents an arc of elbow flexion-extension of 70 degrees. X-rays are without joint injuries. Which would be the initial treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
With which of the following studies would help diagnosis an elbow stiffness due to heterotopic ossification?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 55-year-old male presents after articular distal humerus fracture, treated surgically has a 35-degree arc of elbow flexion-extension. How is this elbow contracture classified?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the so call column procedure for surgical treatment of elbow contracture?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Stiff Elbow (Elbow Contracture) - References

References

Release of the stiff elbow with mini-open technique., Kruse KK,Papatheodorou LK,Weiser RW,Sotereanos DG,, Journal of shoulder and elbow surgery, 2016 Mar     [PubMed]
Open surgical release for contractures of the elbow., Streubel PN,Cohen MS,, The Journal of the American Academy of Orthopaedic Surgeons, 2015 Jun     [PubMed]
Surgical treatment of elbow stiffness caused by post-traumatic heterotopic ossification., Koh KH,Lim TK,Lee HI,Park MJ,, Journal of shoulder and elbow surgery, 2013 Aug     [PubMed]
Arthroscopic arthrolysis for posttraumatic elbow stiffness., Cefo I,Eygendaal D,, Journal of shoulder and elbow surgery, 2011 Apr     [PubMed]
Health status after open elbow contracture release., Lindenhovius AL,Doornberg JN,Ring D,Jupiter JB,, The Journal of bone and joint surgery. American volume, 2010 Sep 15     [PubMed]
The posttraumatic stiff elbow., Morrey BF,, Clinical orthopaedics and related research, 2005 Feb     [PubMed]
Arthroscopic management of the post-traumatic stiff elbow., Tucker SA,Savoie FH 3rd,O'Brien MJ,, Journal of shoulder and elbow surgery, 2011 Mar     [PubMed]
Fracture, Radius (Radial), Head, Patiño JM,Saenz VP,,, 2017 Jun     [PubMed]
Adolfsson L, Post-traumatic stiff elbow. EFORT open reviews. 2018 May;     [PubMed]
Lovy AJ,Hausman MR,Kim JM, Stiff Elbow. American journal of orthopedics (Belle Mead, N.J.). 2017 Sep/Oct;     [PubMed]
Viveen J,Doornberg JN,Kodde IF,Goossens P,Koenraadt KLM,The B,Eygendaal D, Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial. BMC musculoskeletal disorders. 2017 Nov 22;     [PubMed]
Cancio JM,Rhee P, Therapeutic Management of the Posttraumatic Stiff Elbow After Open Osteocapsular Release. Techniques in hand     [PubMed]
Mellema JJ,Lindenhovius AL,Jupiter JB, The posttraumatic stiff elbow: an update. Current reviews in musculoskeletal medicine. 2016 Jun;     [PubMed]
Wu X,Wang H,Meng C,Yang S,Duan D,Xu W,Liu X,Tang M,Zhao J, Outcomes of arthroscopic arthrolysis for the post-traumatic elbow stiffness. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2015 Sep;     [PubMed]
Schwartz DA, Static progressive orthoses for the upper extremity: a comprehensive literature review. Hand (New York, N.Y.). 2012 Mar;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Rheumatology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Rheumatology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Rheumatology, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Rheumatology. When it is time for the Rheumatology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Rheumatology.