Matthew T. Provencher, Mark S. Cohen, and Anthony A. Romeo
DEFINITION
Elbow stiffness can cause significant impairment in function of the upper extremity, especially in performance of the activities of daily living (ADLs).
A lack of compensatory biomechanical function (ie, the scapula for the shoulder) makes elbow stiffness poorly tolerated.
A functional arc of 100 degrees (30 to 130 degrees) is required for most ADLs.13
Posttraumatic elbow motion loss is most common, but osteoarthritis, inflammatory conditions, systemic conditions (head injury), and neurologic problems may also cause contractures.
Flexion loss is less tolerated than extension loss, but loss of extension is more common.12
The key to treatment is to determine the functional and occupational impairment and not base treatment decisions solely on the absolute loss of motion of the elbow.7
ANATOMY
The elbow has a predilection for stiffness based on its anatomy: the close relationship of the capsule to the surrounding ligaments and muscles and the presence of three joints within a synovial-lined joint cavity—a hinge (ginglymus) ulnohumeral articulation and rotatory joint (trochoid) of both the radiohumeral and radioulnar joints.7
The anterior elbow capsule proximally attaches above the coronoid fossa and distally extends to the coronoid (medial) and the annular ligament (lateral). The posterior capsule starts proximally just above the olecranon fossa and inserts at the articular margin of the sigmoid notch and annular ligament (FIG 1).
The anterior capsule is taut in extension and lax in flexion, with the strength of the capsule provided from the cruciate orientation of the fibers of the anterior capsule.
Greatest capsular capacity is at 80 degrees flexion.5,15 Normal capacity of 25 mL is reduced significantly in a contracture state to 6 mL.5,15
FIG 1 • Anatomic drawing of elbow capsular structures. The anterior (A) and posterior capsular areas (B) are highlighted. The anterior capsule distally extends to the coronoid medially and annular ligament laterally. C. Lateral diagram of the elbow shows the capsular size and fat pad.
FIG 2 • Anatomic location of the ulnar nerve at the elbow (A), which is contained in the cubital tunnel (B).
The joint capsule is innervated by branches from all the major nerves that cross the joint (Hilton's law) and musculocutaneous nerve.10
The cubital tunnel, which houses the ulnar nerve at the elbow, becomes taut in flexion (because the attachment sites of the retinaculum are at maximal distance between the olecranon and medial epicondyle) and lax in extension.
Flexion contractures may adversely compress the ulnar nerve (FIG 2).
PATHOGENESIS
The reasons for altered capsular properties are multifactorial and not completely known.
Hildebrand et al6 have found increased numbers of myofibroblasts in the anterior capsule, a cell line that can lead to collagen cell contraction.
Increased matrix metalloproteinases and collagen disorganization have also been described in the contracted capsular tissue.
From a peripheral injury, such as head trauma, a complex chain of events can lead to elbow contracture and heterotopic ossification.
From a cellular level, there is an increase in the formation of collagen cross-linking, hypertrophy, decreased water content, and decreased proteoglycan content in the contracted elbow tissue.1
Growth factors and other cellular mechanisms may be involved. This is highly variable among individuals.12
There is loss of joint volume (20 mL to 6 mL) and thickened capsular width (from a normal width of approximately 2 mm).5,10,14
Posttraumatic contractures thicken and tighten variable areas of the elbow capsule, especially the anterior aspect.
NATURAL HISTORY
Elbow contracture is frequently posttraumatic. Heterotopic ossification may occur in conjunction with capsular thickening. Patients most at risk are those with combined head and elbow trauma, burn patients, and those who have undergone surgical approaches to the elbow.4
Classification of the cause of elbow stiffness is important in making treatment decisions (Table 1).7
Most contractures have mixed elements (both intrinsic and extrinsic factors).8
Morrey12 characterized elbow stiffness as static or dynamic, based on tissue involvement (Table 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
It is critical to determine the degree of functional impairment for each patient. Management decisions should be based on subjective impairment, not necessarily the amount of motion loss.7
The surgeon should obtain a history of associated conditions because neurologic, peripheral nerve, or brain injury may influence management decisions.
The surgeon should assess the function of the entire ipsilateral and contralateral upper extremity.
The surgeon should determine hand dominance, the patient's occupation, and the extent of prior therapy, including bracing (both static and dynamic).
Physical examination should start with the head, including the cranial and cervical nerves.
The surgeon palpates the cervical spine and checks the spine range of motion.
The surgeon evaluates the shoulder joint to ensure good strength and range of motion.
Careful assessment of the ulnar nerv.
Two-point discrimination: A normal amount of discrimination is less than 6 mm.
Froment sign and intrinsic hand muscle function: The patient is asked to grasp a piece of paper between the adducted thumb and index finger. The patient must keep his or her thumb flat against the index finger. If the patient cannot do so, the flexor pollicis longus contributes more to hold paper and indicates weakness of the adductor pollicis and ulnar nerve injury.
Decreased grip strength may signify an ulnar nerve problem.
Elbow range of motion: Flexion and extension with the humerus flexed to 90 degrees, pronation, and supination can be objectively evaluated with a linear object (pencil) held in a clenched fist and the elbow at the side of the body.
Elbow instability examination: The surgeon should check the ligamentous restraints to varus and valgus stress.
Ligaments are assessed with varus and valgus stress at 0 and 30 degrees of flexion if amenable.
The cubital tunnel is palpated to assess for tenderness or a positive Tinel's sign.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs (anteroposterior [AP] and lateral) are usually adequate.
The AP provides joint line and subchondral bone visualization.
If an elbow is contracted more than 45 degrees, the AP view of the joint line is usually distorted,12 but advanced imaging is rarely necessary unless a fracture or malunion is present.
The lateral view may show osteophytes on the olecranon or coronoid (FIG 3A,B).
If there is articular incongruity or other joint abnormalities, the surgeon should consider obtaining a computed tomography scan with reformatted images in the coronal and sagittal planes.
Radiographs can be used to follow the maturation process of heterotopic ossification.
Arthroscopic treatment is usually not recommended in the presence of heterotopic ossification, which usually signifies multiple extrinsic causes of elbow contracture, not amenable to arthroscopic treatment (FIG 3C).
DIFFERENTIAL DIAGNOSIS
Heterotopic ossification
Closed head injury
Burns
Elbow fracture–dislocation
Dysplastic radial head (congenital)
Muscular hypotonia
Stroke
NONOPERATIVE MANAGEMENT
Nonoperative management should be considered up to 6 months after contracture onset.8
Response is better if there is a soft “spongy” endpoint during range of motion.8,14
The goal is to gain motion gradually without causing additional trauma to the capsule and subsequently development of additional capsular contracture (more pain, inflammation, and swelling leads to more contracture).
FIG 3 • A. Preoperative lateral radiograph of an elbow before arthroscopic resection of osteophytes at the olecranon and coronoid, with associated anterior capsular contracture. Heterotopic ossification is absent. B. Postoperative radiograph after resection of osteophytes. C. Lateral radiograph of an elbow with heterotopic ossification. Arthroscopic resection is not recommended in this type of patient.
Edema control is critical, and therapy should focus on this, not exercises that induce inflammation around the elbow.
Static and preferably patient-adjusted static progressive splints (turnbuckle splints) have proven valuable and should be used between therapy sessions.7
Dynamic splinting may be helpful, but care should be taken not to incite an inflammatory process because these provide a constant tension over time. Static progressive splints that allow for stress relaxation of the soft tissues are more effective and better tolerated.
Nonoperative improvements in range of motion vary widely but have been reported anywhere from 10 to 50 degrees or more.8,10,14
O'Driscoll14 described four stages of elbow stiffness.
Bleeding: minutes to hours
Edema: hours to days. Both bleeding and edema cause swelling within the joint and surrounding tissues, and the tissues become biomechanically less compliant. Early elbow range of motion through an entire range during stages 1 and 2 can prevent stiffness.
Granulation tissue: days to weeks. Splints can be used to regain range of motion.
Fibrosis: Maturation of the granulation tissue further decreases compliance. More aggressive splinting is necessary, along with possible surgical management.
SURGICAL MANAGEMENT
The key is to identify the functional disability of the patient—pain, loss of motion, or both—and what would be most beneficial.
The indications include a loss of function to preclude the patient from performing ADLs and occupational or vocational activities.
Arthroscopic treatment of elbow stiffness should be undertaken only if the offending structures can be treated from an arthroscopic approach. Heterotopic ossification is not amenable to arthroscopic treatment.
Appropriate counseling with the patient should cover realistic expectations of range of motion and functional recovery. Will patients be able to get their hand to their mouth, comb their hair, or reach behind their back, or are more extensive demands required?
Preoperative Planning
The surgeon should assess for heterotopic ossification on plain radiographs. Arthroscopic treatment is not indicated if this is causing the contracture.
An examination under anesthesia helps to confirm nonmuscle-related pathology and to assess the static component of contraction, which should mirror the in-office examination.
If the examination documents irritation or neuropathy, the ulnar nerve should be exposed and released.
We recommend that the ulnar nerve be released before the arthroscopic portion for ease of dissection before fluid distention.
In patients with elbow flexion of less than 100 degrees and in those with ulnar nerve tension signs or sensitivity to percussion, the nerve should be prophylactically released to prevent compression once flexion is restored postsurgically.12
The surgeon must ensure that the ulnar nerve cannot be subluxated or transposed.3
Contraindications to arthroscopic release are prior surgery that has altered the neurovascular anatomy, joint deformity that would compromise arthroscopic view, prior ulnar nerve transposition, and malunited elbow fractures.16
Positioning
Either the lateral decubitus or prone position can be used (FIG 4A,B).
Lateral decubitus: well-padded pillow at edge of beanbag underneath elbow antecubital fossa
Prone: adequate chest and arm support, shoulder abducted to 90 degrees
Well-padded sterile tourniquet for either position
FIG 4 • A,B. Setup of patient for elbow arthroscopy in lateral (A) and prone (B) positioning. C. Landmarks of the elbow drawn for operative incisions and to identify at-risk structures, including the ulnar nerve, in the prone position.
The remainder of the arthroscopic setup has been described elsewhere.
The surgeon should clearly mark the course of the ulnar nerve, portal sites, and bony landmarks with surgical marker (FIG 4C).
Approach
As with any arthroscopy, the surgeon must be able to visualize the joint.
O'Driscoll states that the single most important factor to improve visualization is the use of arthroscopic retractors.14
Loss of volume makes this difficult, but it can be facilitated with the use of elbow arthroscopic retractors.
The key is to avoid nerve injury during the approach and during capsular treatment.
The surgeon should plan for intraoperative ulnar nerve release if indicated. Nerve decompression is performed before arthroscopy because fluid extravasation distorts the surgical tissue planes (FIG 5).
FIG 5 • If the ulnar nerve is thought to be involved, it may be released before starting the arthroscopy to facilitate dissection without the soft tissue changes that occur after fluid extravasation from the elbow joint. The ulnar nerve is marked with a vessel loop.
TECHNIQUES
PORTAL ESTABLISHMENT IN CONTRACTED ELBOW
The joint is distended with saline through the “soft spot” portal (up to 20 mL, less depending on contracture).
Portals are established.
The 4.5-mm, 30-degree arthroscope is used through a proximomedial portal (about 2 cm proximal to the medial epicondyle and just anterior to the medial intermuscular septum) (TECH FIG 1A,B).2
The proximolateral portal (1.5 to 2 cm proximal to lateral epicondyle) is identified with either a blunttipped Wissinger rod or a spinal needle using an outside-in technique. Retractors are used to improve distention and visualization (TECH FIG 1C).
Blunt dissection techniques with the Wissinger rod are used to obtain a working space.
A 4.5-mm shaver (oscillate function) removes more material from the working space, but not yet the capsule.
A small radiofrequency device can be used to débride the scar tissue within the joint. Inflow should be increased during the use of thermal energy.
The capsule is not removed until the tissue planes are better defined to minimize nerve injury risk. The capsule is débrided superficially to define it as a structure.
TECH FIG 1 • A. Arthroscopic view of a right elbow joint after first obtaining scope entry into the proximomedial portal, looking laterally. There is synovitis in the joint. B. After the synovitis is gently débrided with an arthroscopic shaver, the bony overgrowth of the coronoid and radial fossa is revealed. There is a lack of concavity in the trochlea and capitellum area. C. Arthroscopic view of elbow joint viewed from the medial portal, showing the increased visualization of the elbow joint that is obtained with the use of intra-articular retractors. C, capitellum; RH, radial head; T, trochlea.
ANTERIOR CAPSULAR RELEASE
Capsulotomy of the anterior capsule is performed with an arthroscopic basket cutter.
The brachialis muscle can be visualized and the plane between the capsule and brachialis developed from the lateral working portal (TECH FIG 2A).
The brachialis protects the median nerve, so the surgeon should avoid penetrating this muscle.
The surgeon continues incising the capsule from lateral to medial.
The capsulotomy should be continued to the level of the collateral ligaments on each side, but the ligaments are not incised.
The lateral side is at risk of injuring the radial nerve behind the capsule (just anterior to the radial head).
Capsulectomy in this area, although it may improve the results, carries a higher risk for radial nerve injury. It may be safest to remove the capsule well proximal to the joint line on the lateral side to avoid this risk.
The posterior interosseous nerve is the most significant nerve at risk during elbow arthroscopy.16 It is adjacent to the anterolateral capsule (distally).
The surgeon should view from the lateral portal to ensure adequate medial release (TECH FIG 2B).
TECH FIG 2 • A. Arthroscopic view of the elbow joint after capsulectomy and deepening of the coronoid and radial fossa. The dissection is carried down to the fibers of the brachialis muscle but does not violate the brachialis (retracted structure). B. View from the lateral portal shows the partially completed release. Bony work and resection are completed before capsulectomy. The concavity in the coronoid and trochlear fossa areas is formed, but anterior capsulectomy is not yet completed. AC, anterior capsule; C, capitellum; RH, radial head; T, trochlea.
POSTERIOR CAPSULAR RELEASE
The surgeon establishes a posterocentral portal for the arthroscope (4 cm proximal to the olecranon tip through the triceps) and a posterolateral working portal (2 cm proximal to the olecranon tip and lateral to the triceps).
A shaver is used to débride and open the space and remove loose bodies and osteophytes. Suction is avoided in and along the medial gutter.
The capsule is elevated from the distal humerus (using a shaver or elevator).
TECH FIG 3 • A. View from the lateral portal after medial release showing completed capsulectomy and bony débridement in the coronoid fossa area. T, trochlea; CF, coronoid fossa. B. Loose bodies are removed during this procedure via a 5-mm smooth cannula.
The posterior capsule is released with a basket cutter or arthroscopic elevator on the medial and lateral sides; the surgeon stops before the medial aspect of the olecranon fossa (to avoid injury to the ulnar nerve).
The posteromedial capsule should be resected in the setting of significant flexion loss (posterior band of the medial collateral lateral) and is the floor of the cubital tunnel.
The surgeon does the release along the olecranon and retracts the area of capsule near the epicondyle.
Final inspection from both portals is done to ensure adequate release (TECH FIG 3).
Loose bodies are removed via a 5-mm-smooth cannula.
ULNAR NERVE RELEASE AND TRANSPOSITION
Subcutaneous transposition or in situ decompression of the ulnar nerve can be performed.
As advocated by O'Driscoll, 14 the ulnar nerve is exposed before performing the arthroscopic release to allow gentle fluid extravasation from the soft tissue posteromedially.
Gentle retraction on the nerve can help protect it while performing arthroscopic releases in this area.
At the end of the case the ulnar nerve can be released using a variety of described techniques.
WOUND CLOSURE AND INTRAOPERATIVE SPLINTING
A drain is placed through the proximal anterolateral portal because accumulation of fluid will compromise range of motion.
Our postoperative dressing is a bulky dressing with Webril, Kerlex, and Ace bandage from wrist to shoulder with material cut out in the antecubital fossa to facilitate immediate continuous passive motion (CPM).
Alternatively, an anterior plaster slab over the elbow is used with the forearm in full extension (TECH FIG 4).
Indwelling catheters or a long-acting regional block may be used to facilitate CPM (from full flexion to extension), which should start in the hospital.
Before starting CPM, the dressing is changed to a soft, noncompressive gauze to prevent skin complications.
TECH FIG 4 • A. Postoperative dressing is applied to the patient after capsular release in the operating room with a drain. B. Flexion obtained after removing splint material from the antecubital fossa. C.Immediate continuous passive motion is instituted.
POSTOPERATIVE CARE
CPM should be continued at home up to 4 weeks and should be used in full range of motion (0 to 145 degrees) with a bolster behind the elbow.16
Daily physical therapy is instituted, with home CPM continued. Immediate postoperative care and rehabilitation are included.
The surgeon should consider prophylaxis of heterotopic ossification with indomethacin.
OUTCOMES
Patients usually regain about 50% of lost motion.7,14
About 80% of patients obtain a functional arc of motion greater than 100 degrees.7
Ball et al3 reported on 14 patients with mean flexion improvement from 117 degrees to 133 degrees and extension from 35 to 9 degrees; mean arc of motion improved from 69 degrees to 119 degrees (in 10 patients who had motion arc of less than 100 degrees).
It is difficult to compare arthroscopic versus open capsular releases.
Compared to open series, Savoie and Field16 reported on 200 patients with capsular release: there was a mean improvement in extension of −46 degrees to −3 degrees and flexion of 96 degrees to 138 degrees, with a decrease in pain scale score from 6.5 to 1.5.
COMPLICATIONS
Radial or posterior interosseous nerve palsy
Iatrogenic injury can be avoided by avoiding suction in high-risk areas.
Retractors of soft tissue are used to improve visualization and distention.
The surgeon should use care when anterior to midline of radiocapitellar articulation in the capsule.
Median nerve
Iatrogenic injury is avoided by not penetrating the brachialis muscle.
The surgeon should place portals carefully, avoiding anterior.
Ulnar nerve
In the medial aspect of joint, the surgeon should use retractors to move the capsule medially.
Transposition before the case may aid in ulnar nerve protection and also allow fluid extravasation.
Ulnar neuritis
If present preoperatively, ulnar nerve release should be ensured.
Postoperatively it may be transient; there is a much lower incidence if it is transposed during initial surgery.
Excessive bone resection, especially of radial head
The surgeon should avoid excessive resection.
REFERENCES
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