Elbow Stiffness in Children and Adolescents

Introduction

Elbow trauma is one of the most common types of injury in the pediatric and adolescent population. While treating elbow injuries, the orthopedist may also be faced with managing a posttraumatic elbow contracture. Elbow stiffness after injury is less common in patients under 18 years of age. However, it is not uncommon after certain injuries. Elbow contractures develop in 3% to 6% of children following a supracondylar fracture of the distal humerus and 33% to 100% of children following a fracture of the neck of the radius. Other causes of elbow stiffness include infection, burns, arthritis, cerebral palsy, brachial plexus palsy, and hemophilia. While there are some similarities in treatment principles, this chapter will focus on posttraumatic stiffness.

Elbow injury may lead to restricted motion not only in the flexion–extension arc, but also in the forearm supination–pronation arc. Loss of elbow and forearm range of motion can significantly inhibit function; therefore, appropriate treatment of posttraumatic stiffness is critical. A 100-degree arc of flexion and extension is generally accepted as the minimum arc needed to maintain function in activities of daily living in adults. Loss of supination and pronation, or a contracture in the extreme of one of these positions, can be equally debilitating. In the adult, the functional arc of pronation and supination is generally quoted to be 45 degrees in each direction. The functional range of motion of the elbow and forearm in a child has not been formally defined, but it is likely different from that of an adult. Children often participate in activities that require a different range and total arc of motion. For example, a gymnast will require full terminal extension in order to safely return to sport and will not be satisfied by a 100-degree arc of motion that excludes full extension. Similarly, a baseball pitcher will demand full extension to throw accurately. Each pediatric patient must be evaluated individually, and treatment must be directed toward maximizing the patient's ability to return to his or her desired activities.

Treatment protocols generally begin with therapy for range of motion as well as static and static progressive splinting until a plateau is reached or normal motion returns. If therapy fails to improve the contracture sufficiently, surgical release is indicated.

While abundant literature exists describing the adult posttraumatic elbow contracture and its treatment, there is limited literature describing posttraumatic stiffness in the pediatric and adolescent elbow. Contracture tends to be less common in children, but when it occurs, it can be equally challenging to treat.

Etiology

The unique bony and ligamentous anatomy of the elbow provides a high degree of congruency and stability. Injury that disrupts this anatomy can lead to instability, limited motion, pain, and altered function. The etiologies of elbow contracture are divided into two categories: intraarticular (intrinsic) causes and extraarticular (extrinsic) causes. Intrinsic causes include articular bony or chondral deformity, intraarticular osteophytes or callus, loose bodies, scarring in the coronoid or olecranon fossa, and arthritic changes. Extrinsic causes include contracture of the joint capsule, ligaments, tendons, and muscles surrounding the elbow joint, as well as heterotopic ossification, extraarticular fractures that change the overall joint biomechanics, and scarring of the skin that limits motion.

Children tend to recover motion remarkably well after a period of immobilization, suggesting they are less susceptible to extrinsic etiologies of stiffness. While the elbow should still be evaluated for all causes of contracture, suspicion should be high for intrinsic causes. In children and adolescents, studies have shown that an intraarticular injury resulting in articular incongruency or malalignment has a higher risk of leading to a contracture. Elbow dislocation, even if simple, is another common culprit in the development of stiffness. Prolonged pain or instability can lead to guarding, which in turn may cause contracture of the capsule and brachialis. Lattanza et al. previously showed that posterolateral rotatory instability (PLRI) can be masked by an elbow contracture and may in fact have been the initial cause of the elbow stiffness.

Fracture malunion, both extraarticular and intraarticular, is a common cause of limited motion in the pediatric and adolescent posttraumatic elbow contracture. In the pediatric elbow, developing secondary ossification centers can make the diagnosis of subtle intraarticular trauma more challenging. Waters et al. found that a subset of pediatric elbow injuries in which “the radiographic appearance seemed harmless” (TRASH lesions) are often missed but can lead to significant morbidity even with appropriate treatment ( Box 34.1 ).

Ligamentous injuries can lead to instability that may manifest as a contracture due to limited use by the child or a concomitant intraarticular injury. The child with a stiff elbow should be thoroughly evaluated for these diagnoses with physical exam and imaging prior to development of a treatment plan. In children, additional etiologies to consider include an entrapped medial epicondyle, ulnar nerve, or annular ligament.

Natural History and Prevention

Early diagnosis and treatment of elbow injuries is the most effective way to prevent contracture, along with appropriate pain management and rehabilitation. However, even with optimal care, contractures can develop. It is sometimes assumed that children will regain full motion of an injured joint after healing and returning to normal use of the arm. The surgeon should never make this assumption and should follow the child clinically until residual stiffness has either resolved or been adequately treated. If motion remains limited 2 to 3 months after immobilization is discontinued, the child should be referred to physical therapy. Rate of recovery is dependent on several factors including the type of injury, age of the child, and the child's individual ability to recover. Therefore, any decision to proceed to surgery should only be made after a plateau with conservative treatment of therapy and static progressive bracing.