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Open elbow contracture release


OVERVIEW

Chapter synopsis

  • Elbow stiffness is common after injury.

  • A stiff capsule can usually be stretched with confident exercises; patience is warranted because intentionally hurting one’s elbow after injury or surgery can be counterintuitive.

  • Operative treatment is more appealing when heterotopic ossification, implants, malunion, nonunion, or articular damage hinders motion and when there is compression of the ulnar nerve.

  • Knowledge of both the medial and the lateral approaches to elbow contracture release allows the surgeon to address all forms of posttraumatic elbow stiffness.

Important points

  • Be patient with pure capsular contracture.

  • Examine closely for signs of ulnar nerve compression.

  • Heterotopic ossification has a better prognosis than pure capsular contracture. It is probably best to plan surgery for 3–4 months after injury to allow the bone to mature and the soft tissues to become more mobile.

Clinical and surgical pearls

  • A single posterior skin incision gives access to the entire elbow.

  • Good anterior exposure is possible through either lateral or medial muscle intervals.

  • The anterior interval on the lateral side is roughly between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC) (it is difficult to be precise). On the medial side, the anterior interval is a 50:50 split of the flexor-pronator mass anterior to the ulnar nerve.

Clinical and surgical pitfalls

  • For the release of capsular contracture, remove the implants after having achieved the best flexion and extension possible with release and manipulation.

  • It is advisable to keep the implants used to repair the fracture in place when the heterotopic bone is removed. The combined removal of bone and implants creates a notable risk of fracture.

  • Three-dimensional computed tomography identifies the precise location of the heterotopic bone that is blocking motion, which helps plan the surgery.

Elbow motion can be restricted by contracture of the skin, capsule, and muscles; heterotopic ossification, osteophytes, or implants; articular incongruity or damage; and malunion or nonunion. Ulnar neuropathy is commonly associated with elbow contracture and can become more symptomatic after surgery that increases mobility. , The best candidate for an arthroscopic elbow contracture release is a patient with capsular contracture with or without osteophytes. Most patients with pure capsular contractures after trauma can achieve functional motion with time and stretching exercises, perhaps assisted by splints. , Given that elbow flexion increases tension and pressure on the ulnar nerve in the cubital tunnel, ulnar nerve decompression and/or transposition is worth considering in patients with less than 100 degrees of flexion even when there are no signs or symptoms of ulnar neuropathy. Once the ulnar nerve is released, capsular excision from the medial side is straightforward. Arthroscopic elbow contracture release causes less surgical trauma, but it is only suited to pure capsular contracture, which uncommonly benefits from surgery, and primary osteoarthritis. Operative treatment of elbow stiffness is most useful in patients with heterotopic bone, malunion, errant implants, or ulnar neuropathy—situations in which an open procedure is preferable.

Preoperative considerations

History

Etiology (trauma, burn, or central nervous system injury) and prior surgeries influence treatment. In patients with central nervous system injury, confirm that the patient can do stretching exercises before considering surgery. Pure capsular contracture can be stretched for more than a year after injury. If you notice the verbal or nonverbal signs of catastrophic thinking (or you identify substantial misconceptions on questionnaires), it’s best to be patient and guide patients to a healthier understanding of the recovery process. Numbness (particularly with flexion stretches) and dexterity problems suggest ulnar neuropathy.

Physical examination

The status of the skin with respect to prior injury and operative treatment will influence the operative tactics. For instance, a midline medial incision is usually favored in people with ankyloses from the heterotopic bone after a severe burn because the bone is typically posteromedial, and a midline incision will heal well even if it separates, which often happens with less compliant skin after grafting. When planning operative treatment to manage stiffness after trauma, we prefer to wait until the skin and scars are mobile and soft and no longer edematous or adherent. Motor and sensory examinations of the ulnar nerve are performed, along with evaluation for a Tinel sign.

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