The stiff elbow

Abstract

Elbow motion is essential for upper extremity function to position the hand in space. Unfortunately, the elbow joint is prone to stiffness following a multitude of traumatic and atraumatic etiologies. Elbow stiffness can be diagnosed with a complete history and physical exam, supplemented with appropriate imaging studies. The stiff elbow is challenging to treat, and thus, its prevention is of paramount importance. When this approach fails, non-operative followed by operative treatment modalities should be pursued. Upon initial presentation in those who have minimal contractures of 6-month duration or less, static and dynamic splinting, serial casting, continuous passive motion, occupational/physical therapy, and manipulation are non-operative treatment modalities that may be attempted. A stiff elbow that is refractory to non-operative management can be treated surgically, either arthroscopically or open, to eliminate soft tissue or bony blocks to motion. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved. Our purpose was to review the etiologies, classification, evaluation, prevention, operative, and non-operative treatment of the stiff elbow.

Figure 1

Anterior (a) and lateral (b) views of elbow bony anatomy. Anterior (c) and lateral (d) views of elbow ligamentous anatomy.

Figure 2

Plain radiograph, A-P and lateral view, of elbow with heterotopic ossification.

Figure 3

Elbow with soft tissue contracture secondary to burn.

Figure 4

Static progressive elbow splint.

Figure 5

Lateral column approach (a). Skin incision (a-1). Anterior and posterior inter-muscular intervals (a-2). Anterior and posterior intervals carried down to joint capsule (a-3). Anterior interval carried down to capsular incision anterior to lateral radial collateral ligament (a-4). Posterior interval carried down through capsule to posterior joint space (a-5). Medial over-the-top approach (b). Skin incision (b-1). Skin and subcutaneous tissue retracted to expose structures surrounding medial epicondyle (b-2). Common flexor tendon, pronator teres, and brachialis reflected anteriorly from medial epicondyle to reveal joint capsule (b-3). Anterior capsule incised to reveal joint (b-4). Posterior joint space exposed and ulnar nerve transposed (b-5). Release of posterior medial collateral ligament (b-6).

Figure 6

Arthroscopic view of elbow with abundant soft tissue adhesions (a). Arthroscopic lysis of adhesions (b) and debridement (c).

Figure 7

En face view of distal humerus with severe degenerative disease (a). Cutis graft preparation from abdomen (b, c). Distal humerus following cutis soft tissue resurfacing (d).

Figure 8

Plain radiograph, lateral view, of elbow with external fixator.

Figure 9

Plain radiographs, A-P (a) and lateral (b) views, of total elbow arthroplasty.