Stiffness

Functional range

 

30- 130o - Flexion / Extension

50o each - Pronation / Supination

 

Aetiology

 

Extrinsic

- skin / subcutaneous tissue

- capsule (anterior / posterior)

- collateral ligament contracture

- muscle contracture

- HO

 

Intrinsic

- articular deformity / malunion

- articular adhesions

- impinging osteophytes (olecranon / coranoid)

- impinging fibrosis (olecranon / coranoid)

- loose bodies

 

Mixed

 

History

 

Decreased flexion / extension

- ulno-humeral joint

 

Decreased pronation / supination

- radio-capitellar joint

 

Pain

- post-traumatic elbow stiffness is usually not painful

- indicates chondral damage

 

Examination

 

Active v passive ROM

 

Management

 

Non-operative

 

Options

 

Physio

- graduated active assisted stretching 

 

Dynamic hinged elbow splint 

- often poorly tolerated

 

Static progressive 

- turnbuckle splint

 

Operative Treatment

 

Options

 

MUA

- not recommended

- may worsen stiffness

- due to haematoma or articular damage

 

1.  Arthroscopic Release

2.  Open Release

3.  OK Procedure

4.  Interposition arthroplasty

5.  Total Elbow Arthroplasty

 

1.  Arthroscopy 

 

Used increasingly to treat stiffness

 

Relative Contra-indications

- previous ulna nerve transposition

- severe soft tissue contractures

- bridging HO

 

Technique

- remove scar tissue / loose bodies

- remove olecranon / coronoid osteophytes

- radial head resection

- resect bony malunions

- can perform modified O-K procedure

 

Case

 

Post elbow fracture malunion / posterior impingement / FFD 40o

 

Elbow Malunion LateralElbow Malunion MRI

 

Elbow Malunion ImpingementElbow Malunion Impingement

 

Elbow Malunion Partial DebridementElbow Malunion Post Debridement

 

Elbow Malunion PreopElbow Malunion Post Op

 

2.  Open Soft tissue releases 

 

Approach

 

Universal posterior approach

- arm over patient held by assistant

 

Lateral interval

- to distal humeral elevating BR and ECRL

- distally between ECRB and EDC

 

Medial interval

- find and protect ulna nerve

- between triceps and brachialis proximally

- detach pronator teres distally

 

Technique Morrey

 

A.  Muscle releases

- brachialis released from humerus

- triceps released from humerus

 

B.  Capsulotomy / capsulectomy

- anteriorly elevate brachialis off capsule

 

C.  Excision of HO

 

D.  Removal of osteophytes

- coronoid / olecranon 

 

E.  Debridement of osteochondral flaps / loose bodies

 

F.  +/- Release of collateral ligaments

- preserve anterior band of MCL 

- ligament reconstruction & hinged elbow fixator if becomes unstable

 

G.  Radial head debridement / excision 

- especially if blocking supination / pronation

 

Results

 

Increases of 30 - 40o

 

3.  OK procedure

 

Elbow OK Procedure APElbow OK Procedure Lateral

 

Definition

 

Outerbridge - Kashiwagi procedure

- debridement athroplasty

 

Technique

 

Posterior approach 

- triceps split

 

Excision of posterior capsule

 

Excision of tip of olecranon

 

Access to anterior compartment via olecranon fossa

- 1 cm diameter hole

- use burr

- need to minimise bone dust

 

Debridement of coranoid and radial head

 

Removal of loose bodies

 

Results 

 

4.  Interposition Arthroplasty

 

Indication

- stiff elbow joint

- damage to >50% of ulno-humeral articular surface

- failure to achieve good range of motion following soft tissue release

 

Technique

 

Kocher Approach

 

Detach lateral ligament from humerus

 

Refashion ulno-humeral surface

- may be necessary in fracture or extensive malunion 

- create congruent surfaces for flexion / extension

 

Strip of fascia lata 

- fashioned and attached to anterior humerus

- fascia passed around end of humerus to cloth front and back

- then doubled on itself and attached to anterior ulna

- articular surface is fascia on fascia

 

Lateral ligament is then reattached

 

+/- hinged external fixation with distraction

 

5.  Total elbow replacement (arthroplasty)

 

Results

- 70% satisfaction

- less successful than RA

- some improvement in range (20o)