- Discussion:
- generally the functional range of motion for the elbow is between 30 to 130 deg;
- flexion contractures greater than 45 deg will significantly limit ADL's;
-
hetertopic ossfication:
- may occur after isolated
spinal cord injury (3-5%), but will tend to occur in the majority of patients w/ spinal cord injuries and elbow trauma;
-
diff dx of elbow stiffness:
- loss of the normal 30° anterior tilt of the distal humeral articular surface;
- narrowing or distortion of the trochlear articular surface;
- obstruction of the coronoid and olecranon fossae;
- ulnohumeral arthrosis;
- PreOp Planning:
- it is necessary to determine whether these patients have loss of motion due to soft tissue contracture or due to osseous impingment;
-
need to determine whether the loss of motion is flexion, extension, or flexion and extension and whether osteophytes or heterotopic bone contributes;
- if
hetertopic ossfication has caused loss of motion, consider allowing process to mature (sharp cortical and trabecular markings) before operative resection;
- attempt to determine from radiographs, the anatomic location of the ossification, ie, between the brachialis and anterior capsule or
between the triceps and the posterior capsule;
- Non Operative Treatment:
- indicated for patients whose contracture is due to soft tissues rather than bony impingment.
- some patients may expect a 30 deg increase in elbow range of motion with use of a turnbuckle splint over 5 months;
- some authors will not procede with surgery until the patient has undergone 12 weeks of PT and until 5 months have passed since the time of surgery;
- serial casting and/or bracing:
- may expect 30 deg improvement in some patients;
- casts are changed every 3-5 days for 2 months;
- in the study by JJ Gelinas et al JBJS B 2000,
- in study by JJ Gelinas et al (JBJS B 2000): 22 patients treated w/ elbow contracture using a static progressive turnbuckle splint for 4.5 ± 1.8 months;
- mean range of flexion before splintage was from 32 ± 10° to 108 ± 19° and afterwards from 26 ± 10° (p = 0.02) to 127 ± 12° (p = 0.0001);
- total of 11 patients gained a 'functional arc of movement,' defined as at least 30° to 130°
- in eight patients movement improved with turnbuckle splinting, but the functional arc was not achieved;
- 6 of these were satisfied and did not wish to proceed with surgical treatment and two had release of the elbow contracture.
- 3 patients movement did not improve with the use of the turnbuckle splint and one subsequently had surgical treatment;
- references:
- The effectiveness of turnbuckle splinting for elbow contractures. J. J. Gelinas et al JBJS- Br 2000;82-B:74-8.
- Operative Treatment:
-
postero-lateral release of anterior capsule;
- allows both anterior and posterior access to the elbow, and therefore, can address both flexion and extension contractures;
- w/ callus impinging into the olecranon, this approach allows the tip of the olecranon to be removed;
- medial release:
- patients that lack flexion (past 90 deg) will have a contracture of the posterior band of the MCL, and this structure will require surgical release;
- posterior band of the MCL lies on the floor of the cubital tunnel, and excessive scarring can also lead to ulnar nerve compression;
- Wada et al (JBJS B 2000) treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows);
- single medial approach, posterior oblique bundle of medial collateral ligament was resected, followed by posterior and anterior capsulectomies;
- all 14 elbows showed scarring of the posterior oblique bundle of the
medial collateral ligament;
- additional lateral release through a separate incision was required in only four elbows;
- at a mean interval of 57 months after operation, active extension improved from 43° to 17° and active flexion improved from 89° to 127 deg;
- references:
- The medial approach for operative release of post-traumatic contracture of the elbow. T. Wada, J Bone Joint Surg [Br] 2000;82-B:68-73.
-
Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness
-
anterior approach (Urbaniak):
- allows direct release of the capsule;
-
ulna-humeral arthroplasty:
-
olecranon osteotomy:
- allows release of posterior capsule and will allow concomitant release of the anterior capsule if a non union is present;
- Post Operative Care:
- continuous passive motion: traditionally this has been associated w/
RSD, but there is little evidence to support this;
- forced passive manipulation: may be associated w/
hetertopic ossfication (again little evidence to support this);
Manipulation of the stiff elbow with patient under anesthesia.
Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy.
Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study.
Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty.
Flexorplasty of the elbow.
Elbow flexorplasty. An analysis of long-term results.
The surgical treatment of heterotopic ossification at the elbow following long-term coma.
Turnbuckle orthotic correction of elbow flexion contractures after acute injuries. DP Green and H McCoy. JBJS. Vol 61-A. 1979. p 1092-1095.
Radial nerve palsy after arthroscopic anterior capsular release for degenerative elbow contracture.
Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture.
