Elsevier

The Journal of Hand Surgery

Volume 32, Issue 10, December 2007, Pages 1605-1623
The Journal of Hand Surgery

Review article
The Posttraumatic Stiff Elbow: A Review of the Literature

https://doi.org/10.1016/j.jhsa.2007.09.015Get rights and content

Loss of motion is a common complication of elbow trauma. Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. In this review of the literature, the biologic response to trauma and the possible etiologic events that may lead to fibrosis of the capsules and heterotopic ossification will be discussed, as well as nonsurgical and surgical management of stiffness and expected outcomes of treatment.

Section snippets

Etiology

Loss of motion of the elbow is commonplace after elbow trauma.1, 5, 6, 7, 8 The etiology of posttraumatic stiffness can be multifactorial and can include arthrosis,9, 10 heterotopic bone,11, 12, 13 or failure of fracture healing14, 15, 16 along with contracture of the soft tissues around the elbow.7 Why the elbow is so prone to contracture has been open to debate and deserves further investigation. Regan and Reilly17 postulated 3 potential factors: (1) the complex articular congruity and

Assessment

A functional arc needed to perform most basic daily activities is defined as an arc of flexion from 30° to 130° and an arc of forearm rotation from 50° of pronation to 50° of supination.105 However, the functional impairment depends on the individual requirements of each patient.106

It is important to understand the original injury and initial treatment as well as other associated conditions such as neurologic dysfunction, infection, and ipsilateral limb injury.106, 107 In most cases,

Nonsurgical Treatment

If posttraumatic stiffness develops in spite of precautionary measures such as early active motion, it has the potential for succesful nonsurgical treatment. Regaining joint motion in the most time-efficient manner is critical for return to function, control of rehabilitation costs, and to prevent the need for additional surgery.

The use of turnbuckle-like splints to restore motion of the posttraumatic stiff elbow was described in the Medieval era by the German surgeon Hans von Gersdorff

Surgical Treatment

If nonsurgical treatment fails to restore a functional arc of motion, surgical treatment may be considered.8, 19, 106, 125, 126 Traditionally, surgery has been offered to patients with flexion contractures or extension contractures of at least 30°. However, the justification of surgical intervention is highly individualized, and the patient’s needs and the ability of the surgeon to realize these expectations should be considered, with a mutual assessment of risks and benefits of the

Postoperative Management and Rehabilitation

Although the rehabilitation program for each of the surgical procedures has its unique features, the postoperative management should be aimed at (1) restoring a functional arc of motion, (2) regaining muscle power, and (3) reincorporating the limb into functional activities.177

Most authors start mobilization of the elbow within 2 days after an open contracture release,8, 51, 52, 64, 65, 125, 126, 128, 133, 134, 137, 202 which may be enhanced by sufficient pain control.8, 125, 127, 132, 202, 203

References (206)

  • P.D. Wilson

    Capsulectomy for the relief of flexion contractures of the elbow following trauma

    J Bone Joint Surg

    (1944)
  • J.N. Doornberg et al.

    The posttraumatic stiff elbow: a historical perspective of treatment

  • H. Von Gersdorff

    Feldtbuch der Wundarztney

    (1517)
  • G.E. Smith et al.

    Report on the Human Remains

    (1910)
  • S. Heirweg et al.

    Operative treatment of elbow stiffness: evaluation and outcome

    Acta Orthop Belg

    (2003)
  • M.P. Figgie et al.

    Total elbow arthroplasty for complete ankylosis of the elbow

    J Bone Joint Surg

    (1989)
  • J.B. Jupiter

    Assessment and management of the stiff elbow

    J Musculoskel Med

    (2005)
  • P. Mansat et al.

    The column procedure: a limited lateral approach for extrinsic contracture of the elbow

    J Bone Joint Surg

    (1998)
  • B.F. Morrey

    Post-traumatic contracture of the elbowOperative treatment, including distraction arthroplasty

    J Bone Joint Surg

    (1990)
  • A.G. Schneeberger et al.

    Semiconstrained total elbow replacement for the treatment of post-traumatic osteoarthrosis

    J Bone Joint Surg

    (1997)
  • A.M. Casavant et al.

    Heterotopic ossification about the elbow: a therapist’s guide to evaluation and management

    J Hand Ther

    (2006)
  • D. Ring et al.

    Operative release of complete ankylosis of the elbow due to heterotopic bone in patients without severe injury of the central nervous system

    J Bone Joint Surg

    (2003)
  • S.C. Yang et al.

    Early surgical management for heterotopic ossification about the elbow presenting as limited range of motion associated with ulnar neuropathy

    Chang Gung Med J

    (2002)
  • M. McKee et al.

    Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerusMethods and results in 13 adults

    J Bone Joint Surg

    (1994)
  • D. Ring et al.

    Operative treatment of osteochondral nonunion of the distal humerus

    J Orthop Trauma

    (2006)
  • D.L. Helfet et al.

    Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus

    J Bone Joint Surg

    (2003)
  • N.R. Kay

    Arthrolysis of the post-traumatic stiff elbow

  • J.R. Urbaniak et al.

    Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy

    J Bone Joint Surg

    (1985)
  • R.W. Viola et al.

    Treatment of ectopic ossification about the elbow

    Clin Orthop Relat Res

    (2000)
  • Y. Itoh et al.

    Operation for the stiff elbow

    Int Orthop

    (1989)
  • S.L. Stover et al.

    Heterotopic ossification in spinal cord-injured patients

    Arch Phys Med Rehabil

    (1975)
  • G.W. Wharton et al.

    Ankylosis in the paralyzed patient

    J Bone Joint Surg

    (1970)
  • D.E. Garland et al.

    Forceful joint manipulation in head-injured adults with heterotopic ossification

    Clin Orthop Relat Res

    (1982)
  • H.C. Thompson et al.

    Myositis ossificans: aftermath of elbow injuries

    Clin Orthop Relat Res

    (1967)
  • J.E. Michelsson et al.

    Pathogenesis of experimental heterotopic bone formation following temporary forcible exercising of immobilized limbs

    Clin Orthop Relat Res

    (1983)
  • M.M. Hoffer et al.

    Excision of heterotopic ossification about elbows in patients with thermal injury

    J Trauma

    (1978)
  • J.L. Hunt et al.

    Heterotopic ossification revisited: a 21-year surgical experience

    J Burn Care Res

    (2006)
  • D.E. Garland et al.

    Fractures and dislocations about the elbow in the head-injured adult

    Clin Orthop Relat Res

    (1982)
  • K.A. Hildebrand et al.

    Myofibroblast numbers are elevated in human elbow capsules after trauma

    Clin Orthop Relat Res

    (2004)
  • F.N. Unterhauser et al.

    Alpha-smooth muscle actin containing contractile fibroblastic cells in human knee arthrofibrosis tissueWinner of the AGA-DonJoy Award 2003

    Arch Orthop Trauma Surg

    (2004)
  • K.A. Hildebrand et al.

    High rate of joint capsule matrix turnover in chronic human elbow contractures

    Clin Orthop Relat Res

    (2005)
  • W.H. Akeson et al.

    Effects of immobilization on joints

    Clin Orthop Relat Res

    (1987)
  • K.A. Hildebrand et al.

    Myofibroblast upregulators are elevated in joint capsules in post traumatic contractures

    Clin Orthop Relat Res

    (2007)
  • F. Matsumoto et al.

    High collagen type I and low collagen type III levels in knee joint contracture: an immunohistochemical study with histological correlate

    Acta Orthop Scand

    (2002)
  • M.S. Cohen

    Heterotopic ossification of the elbow

  • A.J. Friedenstein et al.

    Bone marrow osteogenic stem cells: in vitro cultivation and transplantation in diffusion chambers

    Cell Tissue Kinet

    (1987)
  • R. Fijn et al.

    Prevention of heterotopic ossification after total hip replacement with NSAIDs

    Pharm World Sci

    (2003)
  • F.S. Kaplan et al.

    Heterotopic ossification

    J Am Acad Orthop Surg

    (2004)
  • K.H. Wlodarski

    Bone histogenesis mediated by nonosteogenic cells

    Clin Orthop Relat Res

    (1991)
  • P.E. DiCesare et al.

    Effects of indomethacin on demineralized bone-induced heterotopic ossification in the rat

    J Orthop Res

    (1991)
  • Cited by (110)

    • Management of Post-traumatic Elbow Stiffness

      2023, Operative Techniques in Orthopaedics
    • The post-traumatic stiff elbow: A review

      2021, Journal of Clinical Orthopaedics and Trauma
    • Mobilizing orthoses in the management of post-traumatic elbow contractures: A survey of Australian hand therapy practice

      2021, Journal of Hand Therapy
      Citation Excerpt :

      Most of the evidence on stretching, joint mobilizations, and heat in post-traumatic elbow contractures is based on expert opinions or in healthy populations.19-22 A consensus among clinicians is that therapy should never be too aggressive and the use of strong passive stretching should be discouraged.23 Placing excessive loads on tissues beyond their normal elastic range can cause tissue microtears and ruptures.24

    View all citing articles on Scopus

    No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    Supported by Annafonds, Leiden, The Netherlands; Stichting Prof. Michael van Vloten Fonds, Rotterdam, The Netherlands; Stichting Wetenschappelijk Onderzoek Orthopaedische Chirugie, Bussum, The Netherlands. Dr. Jupiter is supported by Wyeth Co., Madison, NJ; Amgen Co., Thousand Oaks, CA; and Small Bone Innovations, New York, NY.

    View full text