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Loss of Elbow Motion
Acute and chronic disorders of the elbow are frequently observed in both recreational and professional athletes, particularly athletes who participate in sports that involve throwing. Although clinicians most frequently evaluate athletes in throwing-related sports who have elbow pathology related to overuse injuries, including ulnar collateral ligament insufficiency, valgus extension overload syndrome, and epicondylitis, acute elbow trauma may affect athletes in all sports. These acute injuries most commonly include elbow fractures/dislocations after falls onto an outstretched hand. The injuries may occur in sports such as wrestling, as a result of the combination of compression and torque applied to the arm when competitors are driven into the mat, or weightlifting, as a result of spontaneous dislocation from massive exertion. Elbow osteoarthritis is almost uniquely seen in middle-aged muscular men who may have been involved in repetitive, strenuous athletic endeavors, especially boxing and weightlifting.
Loss of mobility is the most common complication after elbow injury. The predisposition of the elbow to the development of posttraumatic contracture has been attributed to several factors, including the intrinsic congruity of the ulnohumeral articulation, the presence of three articulations within a synovium-lined cavity, and the intimate relationship of the joints to the intracapsular ligaments and extracapsular muscles. Several authors have studied the degree of elbow motion necessary to complete daily activities. Their conclusions have yielded a functional arc of 100 degrees (range, 30 to 130 degrees) of flexion and extension of the elbow and 100 degrees of rotation of the forearm (50 degrees each for pronation and supination). The inability of the elbow to achieve this degree of flexibility after trauma may lead to substantial impairment of upper extremity function. For patients whose elbow contracture is refractory to conservative management, surgical débridement and release of the elbow is offered to restore functional motion of the joint. Although open approaches have classically been described for the surgical treatment of the posttraumatic elbow contracture, arthroscopic techniques have recently emerged as a less invasive alternative with similar efficacy for the treatment of elbow stiffness, especially when secondary to intrinsic contracture.
Although several authors have attempted to formulate classification schemes to grade the severity of elbow stiffness, the system devised by Morrey most accurately accounts for both osseous and soft tissue pathology contributing to loss of motion. Morrey divides the etiologies of elbow stiffness into either intrinsic or extrinsic factors. Intrinsic factors include intra-articular adhesions and loose bodies, articular malalignment, and loss of articular cartilage, whereas extrinsic factors include capsular and ligamentous contracture, heterotopic ossification (HO), extra-articular malunion, ulnar neuropathy, and postburn contracture of the superficial soft tissues. All of these potential sources of motion loss should be considered and separately addressed in patients who present with a stiff elbow.
History
Assessing Impairment
It is imperative for the practitioner to determine the extent to which the loss of elbow motion compromises a patient's functional capabilities. The magnitude of functional impairment, rather than absolute loss of motion, ultimately directs management decisions when treating the patient with posttraumatic contracture of the elbow. In this regard, the chief complaint is often related to functional loss rather than pain, swelling, deformity, or another manifestation of previous trauma. From the standpoint of activities of daily living, loss of flexion can restrict the ability to bring the hand to the face and head, which makes it challenging to button clothing, eat, and wash the face and hair. A loss of extension is less functionally significant with regard to activities of daily living because most patients can make accommodations for this deficit by moving closer to an object, but it can cause problems with overhead reaching. In modern society, loss of pronation is often reported because it causes difficulties with writing and typing; however, further abducting the shoulder as necessary can help to compensate for this deficit. Loss of supination is less commonly a problem, although it may present difficulties with activities such as carrying an item with two hands, holding a bowl/plate, or using a drive-through window, especially because no effective compensatory motions exist for a lack of supination.
When participating in a sport, lack of extension even to a mild degree often has greater consequences than interfering with activities of daily living alone. Two-handed weight training for which symmetry is important (e.g., bench press and military press) are affected for all athletes, and basketball players and throwing athletes especially struggle as they lose follow-through. Gymnasts’ mechanics and ability to propel themselves are affected by loss of extension as well. With the possible exception of quarterbacks, football, hockey, and lacrosse players tend to accommodate very well to mild or even moderate elbow flexion contractures.
Intrinsic Causes
Several elements of the history can help the practitioner to determine if elbow stiffness is related to intrinsic pathology. When the patient has a history of an intra-articular fracture, radiographs and preferentially a computed tomography (CT) scan should be closely reviewed for evidence of intra-articular malunion or resultant osteoarthritis, especially when the trauma is remote. An inability to achieve full range of motion (ROM) in the setting of malunion may suggest a true bony impingement, whereas a gradual decline over several years is more suggestive of posttraumatic arthritis as the cause of stiffness. The history should determine if the patient has mechanical symptoms such as locking or catching that would be suggestive of intra-articular loose bodies, which can be confirmed by a CT scan, magnetic resonance imaging, or preferably CT combined with an arthrogram.
Stiffness from elbow osteoarthritis presents with months to years of gradually progressive loss of motion and pain at terminal flexion and extension, usually with less pain within the mid arc of motion until the process is very advanced. These patients usually identify pain with triceps- and biceps-strengthening exercises from the forced terminal motion, and fluctuations of pain and swelling often occur that increase in severity the more the elbow is used.
Extrinsic Causes
When evaluating a patient for extrinsic causes of elbow stiffness, it is important to elicit the length of the immobilization period after an acute injury, because immobilization for longer than 7 to 14 days after elbow trauma predisposes the joint to capsular contracture. Except in rare circumstances of persistent instability despite surgical intervention, acute elbow fractures and dislocations should either be inherently stable enough to allow ROM to begin within 7 to 14 days, or the elbow should be surgically stabilized from a bony and/or soft tissue standpoint to allow ROM within that time frame. HO, if it occurs, typically starts to appear within a few weeks of injury and can continue to progress and mature for months. Patients with symptomatic HO initially demonstrate appropriate progress with ROM and then their condition deteriorates as the HO progresses. Surgical intervention for posttraumatic HO should be delayed until it appears to be mature radiographically, typically 3 to 6 months later.
The practitioner should specifically inquire about any associated symptoms of ulnar neuropathy because, in addition to accompanying a loss of flexion, ulnar neuropathy may also cause a loss of flexion after a relatively innocuous elbow trauma. A history of a burn, a degloving injury, or infection of the skin and soft tissues should raise suspicion that the soft tissues are contributing to the contracture, although this situation is uncommon.
Forearm Contracture
Stiffness specific to loss of forearm rotation has several causes. Although one must consider causes intrinsic to the elbow, such as radial head fracture malunion and HO affecting the ulnohumeral and proximal radioulnar joints, other injuries such as a Monteggia fracture, a Galeazzi fracture, and fractures of both bones of the forearm are more common scenarios for isolated forearm contracture. Even with appropriate treatment, a loss of 10 to 20 degrees of forearm rotation is not uncommon after these injuries. Performing a corrective osteotomy in this setting is technically challenging with somewhat poorly reproducible results, and thus the corrective osteotomy is reserved for persons with more severe contractures.
A unique complication of distal biceps tendon reattachment, especially two-incision techniques, is HO at the level of the radial tuberosity that limits forearm rotation. This condition can be treated very successfully through resection of the HO, with excellent return of ROM and biceps strength and improved outcomes compared with HO resection associated with other forearm trauma.
Prior Treatment
If prior operative treatment was performed, it is especially important to obtain and review any operative documentation and arthroscopic images where applicable, especially when further surgical treatment is being considered. Complications related to initial treatments, including infection or neurologic deficits, can potentially account for posttraumatic stiffness and should be investigated. The physician should also ascertain the duration of physical therapy that has already been undertaken, the types of splinting that have been used (e.g., static progressive or dynamic), and to what degree progress has plateaued.
Physical Examination
Physical examination begins with inspection of the entire upper extremity, specifically evaluating for soft tissue contracture, deformity, swelling, and muscle atrophy, while noting the location of any previous arthroscopic portal sites or surgical incisions that would influence further surgical planning.
ROM evaluation should include the hand, wrist, forearm, and elbow and be compared with the contralateral, unaffected extremity. Crepitus, locking, and mechanical symptoms may occur as a result of loose bodies or osteochondral injuries. Pain at the extremes of motion with mechanical blocks may be the result of osteophyte formation and impingement in the coronoid fossa at terminal flexion or within the olecranon fossa at terminal extension. Pain during the mid arc of motion in a young athlete is frequently due to osteochondral lesions. The examiner should test both active and passive motion and characterize the type of end point at the extremes of motion. A gradual passive stretch obtained after the initial limitation in active ROM is suggestive of a residual myostatic contracture that usually would be expected to resolve with time. Varus and valgus stress testing, especially posterolateral drawer testing, is imperative, particularly in the setting of previous trauma, because posttraumatic posterolateral rotatory instability can often present with stiffness as the chief complaint rather than subtle instability.
Performing a careful neurologic examination is essential. As it traverses the cubital tunnel adjacent to the medial joint capsule, the ulnar nerve may become entrapped in scar tissue along the medial elbow after trauma, resulting in posttraumatic ulnar neuropathy. Traction ulnar neuritis of the elbow may manifest as medial elbow tenderness and subjective paresthesias in an ulnar nerve distribution (medial forearm into the small finger and ulnar border of the ring finger), particularly with elbow flexion. Patients with posttraumatic ulnar neuropathy may present simply with loss of flexion and medial elbow pain in the absence of overt symptoms of ulnar neuropathy. Two-point discrimination, grip-and-pinch strength, and intrinsic muscle function should be documented.
Imaging
Standard plain radiographs of the elbow are obtained and include anteroposterior, lateral, and oblique projections. Radiographs may demonstrate evidence of malunion of distal humerus, radial head/neck, or proximal ulna fractures, as well as bony loose bodies and degenerative changes in the ulnohumeral or radiocapitellar joints. HO is readily identifiable on radiographs and gradually progresses from a more poorly defined “fluffy” appearance when immature to a well-defined morphology with clearly visible borders when mature ( Fig. 65.1 ).
A CT scan can help to localize HO, intra-articular loose bodies, and degenerative joint disease within the elbow when surgical intervention is being considered ( Fig. 65.2 ). Although plain radiographs are typically sufficient for establishing a diagnosis for these conditions, they often underestimate the pathology. Accordingly, two- and three-dimensional CT reconstructions are helpful in further delineating bony and articular anatomy. CT arthrography demonstrates filling defects around osseous and nonosseous loose bodies, as well as areas of osseous impingement resulting from overgrowth in the olecranon or coronoid fossae and at the tips of the coronoid and olecranon processes.
For posttraumatic HO, we favor standard CT imaging without arthrography because loose bodies are less often present and the HO is better appreciated without intra-articular contrast obscuring its borders. The use of CT is less common but also beneficial when evaluating intra-articular malunion if corrective osteotomy is being considered. We have found that magnetic resonance imaging has a limited role for the evaluation of stiff elbows.
Decision-Making Principles and Treatment Options
Nonoperative management remains the initial means of treatment and prevention of elbow contracture after acute injuries and typically includes early ROM and supervised therapy as long as the elbow joint and any internal fixation are deemed stable enough to withstand it. Motion is typically initiated no later than 2 to 3 weeks after elbow trauma as long as the injury is stabilized by operative or nonoperative means. In most cases, active or active assisted motion commences prior to passive motion. When posttraumatic HO is identified, patients usually continue to undergo supervised therapy until their ROM plateaus and the HO is mature radiographically.
For cases of elbow stiffness due to osteoarthritis and loose bodies, physical therapy typically does not have a role given the mechanical nature of the disease process, although cortisone injection can be safe and effective in the short term for athletes trying to complete their season.
Static progressive or dynamic splinting for passive stretch of the soft tissues is an effective adjunct to physical therapy once sufficient bony and/or ligamentous healing is present at 6 to 8 weeks after an acute injury. These types of splints should also be used for patients who present with an established contracture after prolonged immobilization and can be used for contractures in either forearm rotation or elbow flexion/extension. Static progressive splints are adjusted by the patient and apply a constant tension to the soft tissues; these splints are generally locked in a given position and do not allow motion of the elbow while the splint is applied. Dynamic splints work by applying a constant tension through an elastic-based mechanism but do permit motion; they usually require a longer continuous period of use, typically 4 to 6 hours. We tend to favor static splints in our practice because patient compliance has been better than with dynamic splints because static splints are generally worn for only approximately 30 minutes per day ( Fig. 65.3 ).
Splinting, either flexion or extension depending on the primary deficit, is most useful during the first 3 to 6 months after an injury, particularly for patients whose stiffness is due to extrinsic soft tissue contracture and who do not show radiographic evidence of bony deformity, arthrosis, or osteophyte impingement. Recent level I evidence has demonstrated that static progressive and dynamic splinting have equivalent results with benefits still observed as long as 12 months after injury. These results have been demonstrated regardless of the cause of the contracture. We typically reexamine patients at monthly intervals to document continued improvements with their splinting regimen and discontinue use of the splints when no improvement is demonstrated at successive visits, especially given their cost and time investment.
Surgical management is indicated for patients who continue to experience significant loss of mobility with resultant impairment of upper extremity function and limitation with daily activities or sport. Although a flexion contracture of at least 25 to 30 degrees and/or less than 110 to 115 degrees of active flexion was historically reported as an indication for elbow contracture release, operative management may also be offered to persons with greater motion requirements for specific lifestyle, occupational, or athletic demands. Most importantly, patients must be willing to comply with extensive postoperative therapy, because operative outcomes depend on diligent participation in a structured rehabilitation program. Compliance with extensive postoperative therapy is especially important for adolescents, who may be less dedicated to improving their elbow motion than other patients whose livelihood depends on maximal functional recovery.
In the setting of acute stiffness after elbow trauma, 4 to 6 months are typically required for swelling and inflammation to decrease sufficiently for “tissue equilibrium” to be achieved, after which surgery is advisable for patients who fail to progress with use of the aforementioned nonoperative methods.
Although patients with degenerative disease that results from anterior or posterior impinging osteophytes are good candidates for débridement, persons with diffuse joint space narrowing and pain throughout the arc of motion are better candidates for salvage-type procedures such as interposition arthroplasty or total elbow arthroplasty.
The timing of operative débridement for osteoarthritis is flexible, and many athletes elect to manage the condition with intra-articular steroid injections during the playing season and then have surgery during the off-season, with an expectation that 4 to 6 months will pass before they are capable of returning to their sport.
Treatment of a stiff yet unstable elbow is particularly challenging. Subtle elbow instability may exist concurrently with loss of motion after elbow fracture-dislocation. Accordingly, special attention should be devoted to evaluating elbow stability either with stability testing or stress radiographs. If instability is present, ligament reconstruction may be combined with capsular release in certain patients, although most cases should be treated with a staged procedure. The priority should be to achieve stability first and restore motion later with an elbow release procedure if necessary.
Surgical Techniques
Open and arthroscopic techniques are well described for the treatment of elbow contracture. Although success has been reported with use of open release via posterior, lateral, medial, and combined approaches, isolated releases from the medial or lateral side are now most commonly used. The choice of approach may be contingent on previous surgery, the location of the primary offending pathology, or simply the surgeon's preference based on his or her comfort level and experience with the approach. The anterior and posterior ulnohumeral joint articular surfaces and capsular tissues can be adequately exposed for débridement from either the medial or lateral side. However, significant involvement of the radiocapitellar joint requires a lateral exposure, whereas posteromedial osteophytes and associated ulnar neuropathy require a medial approach. Although a combined approach can be performed through a universal posterior incision, evidence suggests that ROM gains are less impressive with this technique. For this reason, we recommend the use of separate medial and/or lateral incisions.
Arthroscopy has emerged as a less invasive method of restoring motion, particularly for intrinsic contractures. Although this technique is technically demanding, advances in instrumentation and arthroscopic equipment have resulted in expanding indications for arthroscopic elbow release. Although arthroscopic release has the theoretical benefit of less morbidity and a more rapid return to function, these benefits have yet to be convincingly demonstrated in the literature.
In a systematic review of the literature in 2013, a total of three comparative series of different treatment options for elbow stiffness were included. Also included were 27 retrospective case series. The authors observed that arthroscopic release is associated with the lowest overall complications rates, at an aggregate of 5% from the included studies. In general, they recommended performing the most minimally invasive approach possible to minimize complication rates. Cohen et al. reported on a prospective, nonrandomized study comparing outcomes after the Outerbridge-Kashiwagi (O-K) procedure with an arthroscopic débridement of the olecranon fossa for mild osteoarthritis of the elbow. The authors found that the O-K procedure resulted in significantly better motion, whereas the arthroscopic procedure provided suitable pain relief.
Relative contraindications to arthroscopic elbow release include the most severe elbow contractures, prior ulnar nerve transposition surgery, the presence of significant HO, and previous surgery involving the radial head, which may render the radial nerve susceptible to iatrogenic injury. Patients with these conditions are more reliably treated with open release with direct visualization and protection of neurovascular structures. Surgeons considering arthroscopic elbow release should inquire about previous ulnar nerve transposition and acquire records to confirm the exact nerve location.
Until comparative studies with matched treatment groups have been performed, no definitive conclusions can be made about the superiority of open or arthroscopic elbow release. Given the risks of nerve injury with complex elbow arthroscopy, the surgeon must still choose the procedure that is safest and most effective in his or her hands. Although some surgeons can perform arthroscopic release in nearly all cases, the most reproducible arthroscopic releases to perform are those in cases of stiffness secondary to mild or moderate elbow osteoarthritis where the borders of osteophytes and normal bony contours can be easily appreciated. Posttraumatic contractures without a history of previous surgery and with mild HO are also typically less challenging releases. Cases become increasingly complex in the face of previous surgery and more widespread HO that either approaches neurovascular structures or obliterates the normal bony anatomy.
Arthroscopic Release
Arthroscopic elbow release is a demanding procedure that requires intimate knowledge of intra-articular elbow anatomy and advanced skills in elbow arthroscopy. Multiple portals are required and diligent fluid management is essential, especially because capsulectomy consequently creates unreliable joint distention. The use of joint retractors improves visualization and facilitates appropriate surgical débridement of contracted or impinging structures.
From a mechanical standpoint, posterior débridement improves elbow extension and anterior débridement improves elbow flexion. However, optimal results are possible when the entire joint is considered regardless of the major motion deficiency and primary pathology. To increase extension, any cause of posterior impingement must be removed between the olecranon tip and the olecranon fossa. The fossa may require deepening to achieve terminal elbow extension. The anterior joint capsule and adhesions between the brachialis muscle and distal humerus must also be released. To increase flexion, any cause of anterior impingement must be eliminated in the region of the coronoid and radial fossae. For full flexion to occur, deep concavities must be restored at the fossae to accept the coronoid process centrally and the radial head laterally ( Fig. 65.4 ). The posterior and posteromedial joint capsules and adhesions between the triceps muscle and distal humerus must be released.
Anesthesia and Positioning
We favor use of a regional block rather than general anesthesia when feasible. We position the patient in the lateral decubitus position with the affected extremity over a cradle and all bony prominences well padded. It is helpful to position the patient slightly overrotated toward the surgeon to prevent the arm from “sliding away” during the procedure. The shoulder is positioned at 90 degrees of abduction and adequate extension to keep the elbow elevated higher and allow enough clearance for maximal freedom of passive motion ( Fig. 65.5A ). After the extremity is sterilely prepared and draped up to the axilla, the hand and forearm are wrapped with an elastic bandage to limit fluid extravasation and a sterile pneumatic tourniquet is placed as proximally as possible around the arm.
The major external landmarks and portal sites are then marked, including the olecranon tip, the medial and lateral epicondyles, and the course of the ulnar nerve (see Fig. 65.5B ). The extremity is exsanguinated with a compressive elastic bandage, and the tourniquet is inflated.
Surgical Landmarks, Incisions, and Portals
The elbow joint is first insufflated with 30 mL of normal sterile saline solution through the soft spot outlined by the lateral epicondyle, radial head, and olecranon tip to facilitate joint entry with the arthroscope ( Fig. 65.6 ).
Anteromedial portal.
The proximal anteromedial portal is created through a stab skin-only incision, 2 cm proximal and 2 cm anterior to the medial epicondyle, just anterior to the medial intermuscular septum. Subcutaneous tissue is spread with a hemostat clamp ( Fig. 65.7A ), and the blunt trocar for the arthroscope is inserted, aiming straight medial to lateral. The surgeon should be able to sense the trocar flipping back and forth from posterior to anterior along the septum, ensuring that the trajectory is anterior to the septum to protect an anatomically positioned ulnar nerve. It should be noted that entry into the joint might be difficult, particularly in cases involving posttraumatic stiffness with a contracted capsule. Care must be taken to pass directly along the anterior humeral cortex because the capsule may be quite adherent, pushing the instrument into an extraarticular plane.
The anterior joint compartment is then penetrated with the tip of the trocar directed laterally toward the radial head (see Fig. 65.7B ). The trocar is then advanced gently through the capsule and exchanged for a long standard 4.0-mm 30-degree arthroscope (or occasionally a 2.7-mm 30-degree arthroscope for small elbows). Gravity inflow of sterile saline solution is established to allow for distention of the elbow capsule. Specialized cannulas that do not have any holes near the tip ( Fig. 65.8 ) may be helpful because standard cannulas can lead to the inadvertent entry of fluid into the soft tissues during visualization of the joint.
This medial portal allows excellent inspection of the lateral joint including the radial head, capitellum, and lateral capsule. An examination of the anterior elbow joint compartment is performed to evaluate for loose bodies, synovitis, and cartilage injury. The arthroscope is then directed laterally, and the camera is rotated to visualize the radiocapitellar joint in the horizontal plane. If visualization is difficult, a retractor or freer elevator can be introduced through a proximal anterolateral portal (described in the next section). Improved visualization of the lateral capsule and soft tissues is achieved by providing tension to the capsule anteriorly.
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