questions
4

Elbow Stiffness and Contractures

Author:
Topic updated on 06/20/16 6:36pm
Introduction
  • Stiffness and contractures of the elbow result in loss of motion and difficulty performing activities of daily living
  • Pathophysiology
    • causes of elbow stiffness and contractures include
      • trauma
      • surgery
      • arthritis
      • cerebral palsy
      • traumatic brain injury
      • burns
      • congenital conditions
        • arthrogryposis
        • congenital radial head dislocation
    • pathoanatomy
      • intrinsic causes
        • joint incongruity
        • synovitis
        • loose bodies
        • intra-articular fractures
        • osteochondritis dissecans
        • post-traumatic arthritis
      • extrinsic causes
        • formation of eschar following a burn
        • heterotopic ossification
        • adhesions/contraction of the capsule
        • ligament contractures
          • scarring of posterior oblique portion of medial ulnar collateral 
  • Prognosis
    • patients are able to perform activities of daily living if elbow range of motion of 30 degrees to 130 degrees flexion/ extension is achieved
      • most activities require a 100 degree arc of motion at the elbow to be functional
      • a 30 degree loss of extension is well tolerated by most patients 
Anatomy
  • ROM
    • functional motion
      • 30° to 130 flexion/extension
        • most activities require a 100 degree arc of motion at the elbow to be functional
        • a 30 degree loss of extension is well tolerated by most patients 
      • 50° supination
      • 50° pronation
  • Elbow ligaments and biomechanics  
    • primary ligaments of elbow include
      • ulnar collateral ligament
        • anterior bundle is most imporant stabilizer to both valgus and distraction forces
      • radial collateral ligament
      • annular ligament
  • Nerves  
    • ulnar nerve 
      • proximity to the elbow joint places nerve at risk if joint is contracted 
Presentation
  • Symptoms
    • pain
      • may or may not be painful
    • decreased motion
      • often limits activities of daily living
  • Physical exam
    • inspection
      • examine the skin around the elbow
        • look for scars from previous surgeries
        • inflammation
    • range of motion
      • measure elbow flexion/extension, pronation/supination
    • neurological 
      • assess ulnar nerve function
Imaging
  • Radiographs
    • recommended view
      • AP, lateral and oblique views
      • serial radiographs
        • if heterotopic ossification is noted 
    • findings
      • dependent on pathology causing stiffness/contractures
  • CT scan  
    • indications
      • loose bodies in joint
      • non-unions
      • joint incongruity 
      • abnormal bony anatomy  
  • MRI
    • rarely indicated
Treatment
  • Nonoperative
    • NSAIDs, physical therapy with active and passive range of motion exercises
      • indications
        • first line of treatment in most cases
        • contractures <40 degrees
    • static splinting  
      • indications
        • failed trial of physical therapy with 
          • elbow flexion contractures greater than 30 degrees OR
          • elbow flexion less than 130 degrees  
  • Operative
    • osteophyte excision
      • indications
        •  intrinsic contractures with arthritis confined to olecranon fossa
    •  distraction interpositional arthroplasty 
      • indications
        •  intrinsic contractures with diffuse arthritis in high demand younger patients
    • total elbow arthroplasty
      • indications
        •   intrinsic contractures with diffuse arthritis in low demand elderly patients
      • outcomes
        • high failure rate in young, active patients
        • permanent 5-lb lifting restriction 
    • capsular release +/- release of posterior band of MCL 
      • indications
        • extrinsic capsular contractures
        • patients with arthritis
    • musculocutaneous neurectomy
      • indications
        • neurogenic contractures with a flexion deformity of less than 90 degrees
Complications
  • Post-operative heterotopic ossification
    • may treat prophylactically with low-dose radiation therapy or indomethacin
  • Transient ulnar neuropraxia
  • Ulnar nerve damage 
    • transpose nerve anteriorly during procedure
  • Recurrent contracture

 

Please Rate Educational Value!
3.0
Average 3.0 of 24 Ratings

Qbank (4 Questions)

TAG
(OBQ09.213) Static progressive turnbuckle splinting is most appropriate for which of the following patients? Topic Review Topic

1. 3 months after ORIF of a distal humerus fracture with a flexion arc of 45° to 100° with no further improvement with physical therapy
2. 4 weeks after nonoperative treatment of a displaced radial head fracture with block to supination
3. 1 week after simple elbow dislocation with flexion arc of 10° to 140°
4. Presence of extensive heterotopic ossification after a complex elbow dislocation with associated ankylosis of the joint
5. Immediatly after elbow arthroscopy for loose body removal and debridement

PREFERRED RESPONSE ▶
Sorry, this question is available to Virtual Curriculum members only.

Click HERE to learn more and purchase the Virtual Curriculum today!






Evidence



Topic Comments