➢ Open and arthroscopic release are both effective surgical treatments for posttraumatic elbow stiffness.
➢ Both static and dynamic bracing are effective for increasing elbow range of motion when heterotopic ossification is not present.
➢ Some loss of immediate postoperative range of motion is expected.
➢ Recurrence of heterotopic ossification around the elbow is rare.
➢ The occurrence of ulnar nerve palsy is rare and often requires transposition.
Elbow stiffness is a well-known complication of elbow trauma that is commonly associated with morbidity1,2. It has been theorized that a 50% reduction of elbow range of motion can reduce upper extremity function by as much as 80%3. Injuries are the most common cause of elbow stiffness requiring operative release1,2. Posttraumatic contracture of the elbow occurs in any age group, but high-energy injuries in young, active patients with functional needs involving repetitive strength are often involved4. Stiffness of the elbow is defined as flexion of <120°, loss of extension of >30°, or forearm rotation of <45° in either direction5.
The propensity of the elbow to stiffness is due to the congruent nature of the joint, the presence of 3 articulations within the same synovial cavity, and the close relationship of the joint capsule to the ligaments as well as the surrounding musculature.
The main biological reason that the elbow is prone to contracture is the propensity of the capsule to undergo an inflammatory process even in the event of minor trauma2.
The etiology of posttraumatic stiffness can be multifactorial and includes arthrosis, heterotopic bone formation, failure of fracture-healing, and contracture of the soft tissues around the elbow1.
Intra-articular effusion causes the joint to move into the flexed position as this position maximizes the elbow’s capacity while minimizing joint pressure2.
Loss of flexion is a greater functional problem than loss of extension is6. Although a functional range of motion is between 30° and 130°, many occupations and sports require a greater range of motion. For these individuals, even the smallest decrease in range of motion can be a problem7.
Loss of range of motion past the functional range causes a serious problem functionally and cosmetically because of the elbow’s function as a link between the shoulder and the hand. The elbow also provides power for lifting objects and provides stability for precision-based tasks8. Although loss of flexion and extension is very common, loss of rotation is another common problem that needs to be addressed.
Use of Levels of Evidence in the Assessment of Scientific Information
The levels of evidence guideline for this journal were established in January 20039. This guideline provides levels of evidence that are based on a hierarchal rating system for the classification of study quality. A 5-level rating system was developed for 4 different types of studies: therapeutic, prognostic, diagnostic, and economic or decision-modeling. In the present study, recommendations for or against different aspects of treatment of posttraumatic elbow stiffness were graded with the use of these guidelines. The reasoning pertaining to each of the treatments is explained in each section below. A summarized review of this information and details on grades of recommendation are shown in Table I.
The elbow joint is a highly constrained synovial joint with 3 main articulations. The ulnohumeral joint is the major force-bearing articulation for flexion and extension. This joint is composed of the humeral trochlea and the trochlear notch of the proximal aspect of the ulna. The second articulation is the radiocapitellar joint between the capitellum of the humerus and the radial head. This joint is involved in flexion and extension along with forearm rotation. The third articulation is the proximal radioulnar joint, which is mainly involved in rotation. Anteriorly, the coronoid process of the proximal aspect of the ulna articulates with the capitellum of the distal aspect of the humerus. Posteriorly, the olecranon articulates with the olecranon fossa of the distal aspect of the humerus. In the lateral plane, the articular surface of the humerus is rotated about 30°. Anteriorly in the axial plane, the articular surface of the distal aspect of the humerus is internally rotated approximately 3° to 8°. In the frontal plane, the articular surface is tilted in approximately 6° of valgus. Of the soft-tissue boundaries of the elbow, the anterior and posterior portions of the capsule are the weakest. The annular ligament functions as a stabilizer of the proximal radioulnar joint5.
The elbow also includes well-defined medial and lateral ligaments. The ulnar collateral ligament (UCL) is located on the medial aspect of the elbow. This ligament consists of 3 bands. The posterior band is an extension of the posterior capsule, and the anterior band is cord or fan-shaped. The anterior band is the strongest valgus stabilizer and is tight in extension. The posterior band is tighter in flexion, with the greatest change in tension from flexion to extension. The transverse band has minimal function. The lateral collateral ligament (LCL) is found radially and is composed of the radial collateral ligament, the accessory ligament, and the annular ligament. Together, these structures function to serve as a fulcrum for the forearm and to orient the hand in space10.
Two main classification systems are used to describe stiffness of the elbow. In the Kay classification system, which is based on the specific mechanisms involved, stiffness is classified as type I (soft-tissue contracture), type II (soft-tissue contracture with ossification), type III (nondisplaced intra-articular fracture with soft-tissue contracture), type IV (displaced intra-articular fracture with soft-tissue contracture), or type V (posttraumatic osseous bars)11.
The Morrey classification system is based on the anatomic location and the cause of the abnormality (extrinsic, intrinsic, or mixed)12. This system seems to be more useful because contractures typically involve more than one anatomic location1. Intrinsic causes involve intra-articular adhesions, articular malalignment, and loss of cartilage. Extrinsic (extra-articular) causes are contracture of the soft tissues (joint capsule) or collateral ligaments, heterotopic ossification, and extra-articular malunion. Stiffness can also be a result of both intrinsic and extrinsic mechanisms1,2.
Intrinsic contracture involves intra-articular adhesions, loss of cartilage due to avascular changes that occur in the comminuted segments, and gross joint distortion due to the initial trauma, inadequate reduction, or failed reduction8. Extrinsic causes include soft-tissue contracture and heterotopic ossification. One of the associated physiological reactions associated with soft-tissue contracture around the elbow is an increase in myofibroblast production. Animal models have shown that, in soft-tissue contracture, there are increased numbers of highly contractile myofibroblasts13,14. Histologically, this contracted tissue differs from normal tissue. The abnormal characteristics are due to the increased formation of collagen crosslinks, decreased proteoglycan content, and decreased water content15.
Another physiological mechanism that occurs is the increased expression of transforming growth factor-beta (TGF-β). These processes combined could possibly result in scarring of the capsules by causing fibrosis1. Clinically, contraction of the collateral ligaments often occurs when ossification of the ligaments has occurred or when the elbow has undergone prolonged immobilization4.
Heterotopic ossification is due to the inappropriate formation of lamellar bone in soft tissues. Specifically, heterotopic bone is formed when pluripotent mesenchymal cells differentiate into osteoblasts, which produce osteoid that mineralizes to form bone16. Histologically, this heterotopic bone is identical to native bone17.
Rotational Elbow Stiffness
Rotational elbow stiffness is another cause of functional impairment that improves with treatment. Loss of forearm rotation can be disabling, with loss of supination being more devastating than loss of pronation. Pronation loss is more manageable because of the compensatory motion of shoulder abduction.
Ling et al., in a retrospective study of 14 patients, found that both sagittal and rotational range of motion directly influenced upper limb function18. The relationship between these 2 variables was weak, signifying that both impairments must be addressed separately. In that study, after open capsular release, the mean arc range of motion increased from 74° preoperatively to 135° postoperatively. At the time of long-term follow-up, some of the gained range of motion was lost, with a mean range of motion of 104°. The mean rotational range of motion was 135° postoperatively but decreased to 124° at the time of long-term follow-up. Although there was a substantial overall increase in range of motion with some loss of postoperative motion, the overall increase in range of motion from the preoperative baseline correlated with a mean increase of 52.7 points in the QuickDASH score (range, 0 to 100).
Elbow Bracing for Postoperative and Nonoperative Management
Elbow bracing is an integral part of treatment of posttraumatic elbow stiffness. In some instances, bracing is the mainstay of treatment. In other instances, bracing is part of the postoperative protocol. Bracing focuses on the physiological properties of soft tissues. The viscoelastic properties of soft tissue allow the elbow brace to stretch retracted tissue by the induction of biological lengthening of collagen fibers. This mode of treatment has been shown to be effective. Marinelli et al. found that bracing for the treatment of elbow stiffness was very effective for increasing functional range of motion3. When used after surgical release, bracing was associated with a mean increase in range of motion of 46.8°. When used for the treatment for elbow contracture after articular fixation, bracing was associated with an overall increase of 38°. Finally, when used as the primary treatment modality, bracing was associated with a mean increase of 34°.
Deciding on which brace to use is another aspect of the treatment plan. The 2 main brace types are static and dynamic. Static splinting works by utilizing a stepwise increase in joint angles that applies force to contracted tissue. This force then dissipates as the tissue stretches. Dynamic splinting applies a constant force to the tissues, which is maintained as the tissues stretch. Lindenhovius et al. found that both brace types were equally effective19. At 3 months, the mean improvement in the arc of flexion was 29° in the dynamic progressive splinting group and 28° in the static group; at 6 months, the mean improvement was 40° in the dynamic group and 39° in the static group; and at 12 months, the mean improvement was 47° in the dynamic group and 49° in the static group. Another postoperative protocol, not uniformly used, is the use of continuous passive motion (CPM). In another study, Lindenhovius et al. concluded that range of motion was not significantly greater when CPM was used postoperatively as compared with when it was not20.
When addressing intrinsic contractures, treatment is complicated by identifying and treating the intra-articular cause. Periarticular soft-tissue contractures, heterotopic ossification, and incongruities of the joint due to malunion or nonunion all commonly are associated with periarticular soft-tissue contracture. When elbow stiffness is partially attributed to posttraumatic osteoarthritis, treatment often involves distraction of the joint. This added step is often needed to achieve a favorable outcome. The advantage of this procedure is that, through the use of external fixation, the joint space can be distracted without an open procedure. External fixation provides the advantage of static fixation with the benefits of continued range of motion through the joint21,22. Kulkarni et al., in a retrospective review of the records for 26 patients who underwent open arthrolysis and external fixation, reported an average increase of 55° of flexion and 35.3° of extension22. Cheng and Morrey, in a study of 13 patients who were managed with interposition arthroplasty, reported favorable results after a mean duration of follow-up of 63 months, with 9 patients (69%) having satisfactory pain relief and 8 patients (62%) having a good or excellent result according to the Mayo Elbow Performance Score23,24. Four patients (31%) underwent total elbow arthroplasty at a mean of 30 months, with good results. Instability before and after surgery was found to be associated with poorer results.
Arthroscopy is an effective method for the treatment of posttraumatic elbow stiffness. The potential advantages of arthroscopy are minimal incisions, decreased blood loss, decreased postoperative pain, and easier rehabilitation. The potential disadvantages are the increased risk of nerve injury and the increased technical demands in terms of arthroscopic skill.
The primary indications for arthroscopic treatment of elbow stiffness are pain, functional impairment, and loss of the functional arc of flexion and extension of the elbow joint that is resistant to nonoperative treatment. Often, a trial of nonoperative treatment is attempted for 3 to 4 months before surgery is indicated, except in the presence of an intra-articular abnormality19,25. In order for treatment to be effective, the patients must be willing to work toward maintaining the range of motion obtained in the operating room through home exercises and therapy. The contraindications for arthroscopic treatment are extensive heterotopic ossification requiring open treatment, severe elbow contractures associated with notable extra-articular soft-tissue adhesions, loss of forearm pronation and supination, severe cartilage damage, and intra-articular incongruity secondary to fracture or arthritis25.
Arthroscopic treatment has been shown to be effective, although the reported increase in range of motion has varied in the literature. Pederzini et al., in a review of the records for 243 patients, suggested that the outcome of treatment was partially attributed to the etiology of the elbow stiffness26. In that study, the mean increase in range of motion was 33° when the cause was traumatic compared with 13° when the etiology was osteoarthritis. Wu et al., in a study of 34 patients, reported an average increase in elbow range of motion (and standard deviation) from 48.6° ± 19.3° preoperatively to 114.5° ± 25.7° postoperatively27. Overall, the mean improvement was 65.9°. The Mayo elbow performance index (MEPI) increased from 68.2 ± 16.4 preoperatively to 92.4 ± 21.6 postoperatively (with 0 to 59 indicating a poor result, 60 to 74 indicating a fair result, 75 to 89 indicating a good result, and 90 to 100 indicating an excellent result). Good to excellent results were reported for 29 patients. Salini et al. found that arthroscopic treatment was effective for increasing range of motion to functional levels in 84% of cases, with a total average range of motion of 13° to 137° postoperatively10.
Postoperative range motion can be maintained over time. Kim and Shin, in a study of 63 patients, reported an average increase in range of motion of 43° after one year28. In that study, range of motion increased for one year, with no significant increase after that time. The average duration of follow-up in that study was 42.5 months. Preoperative range of motion can affect surgical outcomes as well. Ball et al., in a retrospective study of 14 patients, concluded that the mean increase in range of motion was 50° for patients with a preoperative range of motion of <100°, compared with 41.6° in those with a preoperative range of motion of ≥100°29.
A cumulative review of studies focusing on arthroscopic treatment demonstrated a mean increase of 40.5° in the arc of motion (Table II).
The category of open treatment includes a wide variety of procedures with specific indications that are based on the etiology of the abnormality. Historically, open procedures have been effective. Yang et al., in a study of 17 elbows that were treated with open arthrolysis, reported that the mean Mayo score increased from 65 preoperatively to 87.5 postoperatively30. Nine elbows had an excellent result and 6 had a good result; thus, the total rate of excellent or good results was 88.2%. Two patients had a fair or poor outcome. Two complications were reported, including chronic infection (1 patient) and new-onset ulnar neuropathy (1 patient).
Capsulotomy is another method of treatment that is effective for increasing ulnohumeral motion. Ring et al., in a review of 46 patients with posttraumatic elbow stiffness, reported an average ulnohumeral motion of 53° at an average of 48 months after open capsular excision31. In that study, 29% of the patients underwent a second procedure because of recurrence and gained an additional 24° of ulnohumeral motion, with an overall flexion arc of 103°. The American Shoulder and Elbow Surgeons (ASES) pain score, persistent ulnar neuropathy, and the duration of follow-up after the initial capsular release were found to be independent predictors of a higher (better) Disabilities of the Arm, Shoulder and Hand (DASH) score.
The outcomes of open arthrolysis have been shown to be maintained over the long term. Rhee et al. reported on 18 patients who were managed with debridement arthroplasty (which entails the removal of olecranon osteophytes and any present loose bodies) through the posterior approach32. After an average duration of follow-up of 59 months, 16 elbows had painless motion and 2 had mild intermittent pain. Postoperatively, flexion improved to 120° and extension improved to 10°, corresponding to increases of 34° (p < 0.001) and 25° (p < 0.001), respectively, compared with the preoperative values. At the time of the latest follow-up, 58% of the patients reported no pain. Sharma and Rymaszewski, in a retrospective review of 25 patients, reported an increase in range of motion from 55° to 105° at one year33. At an average of 7.8 years, this improvement in range of motion was maintained, proving that open arthrolysis provides sustainable increases in range of motion.
When the radial head is involved in the abnormality, the surgeon must decide whether to resect the radial head or to perform a radial head arthroplasty. Yu et al., in a comparative study analyzing the outcomes at a mean of 22 months after radial head replacement (19 patients) or radial head resection (15 patients), reported that the mean improvement in flexion was 79° and 82° in the resection and replacement groups, respectively, and that the mean improvement in rotation was 96° and 102°, respectively34. The authors concluded that, after complete release of the tissues has been performed and the joint is stable, resection is favored over radial head replacement because of the technical demands of radial head replacement.
Surgical release has been shown to yield more favorable outcomes when the abnormality is heterotopic ossification. Lindenhovius et al., in a study of elbow contracture release in elbows with and without heterotopic ossification, reported an increase in flexion of 54° (to a mean arc of 113° [range, 60° to 145°]) in the group with heterotopic ossification and of 35° (to a mean arc of 87° [range, 0° to 125°]) in the group without heterotopic ossification35. After all subsequent procedures, the final range of motion was 116° in the group with heterotopic ossification, compared with 98° in the group without heterotopic ossification.
Koh et al., in a retrospective review of the records for 77 patients who were managed surgically for heterotopic ossification, reported an average increase in range of motion from 45° preoperatively to 112° postoperatively36. At the time of the latest evaluation, 65 patients had an overall arc range of motion of >100°. Recurrence of heterotopic ossification was observed in 16 patients. Recurrence of stiffness was thought to occur as a result of the genetically driven fibrotic scar formation (similar to keloid scarring) and, in some instances, to the inability to remove all of the diseased tissue without compromising joint stability. That study suggested that operative intervention should be performed within 19 months after the initial injury as the time to surgery was the only independent risk factor that affected the final range of motion.
Morrey reported similar findings in a retrospective review of 38 patients4. After an average duration of follow-up of 16 months, the mean increase in total range of motion was 40°, the mean increase in flexion was 14°, and the mean increase in extension was 26°. The cause of the trauma did not affect outcome, but patients with severe stiffness and those who were managed <1 year after the injury had better outcomes (p < 0.001).
Elbow release through a limited lateral approach is an effective method of treatment when release of both the ulnohumeral and radiocapitellar joints is necessary. This operation is called the “lateral column procedure” because the anterior and posterior aspects of the lateral supracondylar osseous ridge are elevated. This procedure, which consists of an arthrotomy, capsular release, and excision of osteophytes through a limited lateral approach, safely releases the anterior aspect of the capsule and exposes the posterior capsule if release is needed37. Gundlach and Eygendaal, in a study of 21 patients who were managed with the lateral column procedure, reported a mean increase in range of motion of 35° that did not decrease by the time of the 2-year follow-up38. Mansat and Morrey, in a review of 38 elbows, reported a mean gain in range of motion of 45° at a mean of 43 months after the lateral column procedure37. At the time of the latest follow-up, 34 elbows (89%) had improved range of motion and 31 (82%) had a satisfactory result. Four complications occurred, including hematoma formation in 2 patients (5%) and transient ulnar nerve palsy in 2 patients (5%). Ten patients (26%) had recurrence, with a 24° decrease in range of motion compared with the immediate postoperative range. An overall increase of 52.7° was seen after open treatment when the various studies were combined (Table III).
All methods of treatment are associated with complications. The most common complication associated with all treatment methods is recurrence. Morrey found that 10 (26%) of 38 patients had loss of motion postoperatively that required repeat release4, Ring et al. reported that 9 (20%) of 46 patients had a recurrence that required release31, Lindenhovius et al. reported that 2 (12.5%) of 16 patients underwent additional procedures because of recurrence35, and Marti et al. reported that 4 (8.5%) of 47 elbows had recurrent stiffness39.
Operative treatment and severe flexion contractures increase the risk of other complications such as neuropathy and nerve palsy, which are thought to be due to compression of the ulnar nerve at the location of the cubital tunnel. With flexion of the elbow to >90°, the dimensions of the tunnel decrease whereas the pressure on the ulnar nerve increases25. Park et al., in a study of 27 patients, reported that 1 patient (3.7%) had a complete ulnar nerve palsy that required release because of entrapment of the nerve in the cubital tunnel, which was narrowed because of fibrous thickening of the surrounding tissues40. This complication was treated with anterior transposition of the ulnar nerve. The ulnar nerve is not the only nerve that can be affected. Pederzini et al. reported that 5 (2.4%) of 212 patients had some symptoms in the distributions of the ulnar, median, and posterior interosseous nerves postoperatively26. Kim and Shin reported that 2 (3%) of 63 patients had transient median nerve symptoms that resolved with observation28. Aldridge et al. reported that 8 (10%) of 77 patients had nerve complications41. These complications included ulnar neuropathy (4 patients), transient radial nerve palsy (2), paresthesia in the superficial radial nerve (1), and posterior interosseous nerve palsy (1). Wu et al. reported that 3 (10%) of 31 patients had symptoms in the ulnar nerve distribution, all of which resolved in 6 months27. Marti et al. reported that 7 (15%) of 47 patients had transient ulnar paresthesias39.
Another complication that is more specific to elbow arthroscopy is synovial fistula at the arthroscopic portal site. Pederzini et al. reported this complication in 13 (6.1%) of 212 patients; in all cases, it resolved with observation26.
Postoperative elbow stiffness is a common complication after even minor injury. Function of the elbow is essential for the activities of daily living. The outcomes of treatment are favorable when the etiology is considered in the decision-making process. Nonoperative management should be attempted in all cases of posttraumatic stiffness of the elbow, except when the stiffness is due to heterotopic ossification or intrinsic causes. Operative intervention should be considered after nonoperative treatment has failed and should be performed within the first year to 19 months after the injury.
Investigation performed at the Vanderbilt University Medical Center, Nashville, Tennessee
Disclosure: No source of funding was used in the production of this manuscript. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.
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