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related talks: broken elbow; elbow dislocation; broken arm; swollen elbow; ulnar fracture (broken forearm); children's broken forearm (both bone forearm fracture); radial head fracture (type of broken elbow); broken wrist; elbow arthritis
What Causes Elbow Stiffness?
Elbow stiffness occurs after an injury to the elbow, such as a broken elbow or an elbow dislocation. These injuries cause a few changes within the elbow that may lead to stiffness:
1) Scar tissue formation,
2) Thickening of the joint capsule. Our elbow joint (and every other joint in our body) is surrounded by a capsule that protects the cartilage and maintains the joint fluid in place. If the capsule becomes to thick it blocks motion.
3) Heterotopic bone formation. Calcium is the main product of bone and for reasons not well understood, sometimes calcium can become deposited into the muscle, ligaments, and other soft tissue around the elbow. A new bone is forming inside muscle, its like turning an elbow into stone (think the Greek myth of Medusa).
Elbow stiffness is a big problem in orthopedics. Its a problem because 1) its very common after injury, 2) it causes a lot of disability in people because elbow motion is critical for allowing people to position their hand to perform every day tasks; and 3) it can be hard to treat.
So what is normal elbow motion, what is an acceptable amount of stiffness and what is too much stiffness? Does the elbow need to be perfect? The answer really depends on who you ask, different people have different needs. But there are some basic guidelines. A normal range of motion is about 0 - 150 degrees. Most doctors believe that 30 to 130 degrees is required for most tasks of daily living.
Lost flexion (bending the elbow) is worse than lost extension (straightening the elbow). Lost flexion limits the use of eating utensils, shaving, buttoning a shirt, and maintaining hygiene. It prevents you from bringing your hand close to your body. Limits in extension are easier to adapt to because extension puts your hand outward, toward to world, and its easier to find ways to compensate (like taking a step forward).
Its important for people to realize that most cases of stiffness are caused by the initial injury. Stiffness is rarely related to the screws or plates used in surgery to fix the injury. Stiffness is rarely related to a bad physical therapist. And most importantly, its critical for people to known that elbow stiffness is not their fault either. It does not occur if you "havent been working hard enough," rather it occurs because elbows like to stiffen after traumatic injury. Some worse than others.
How is Elbow Stiffness diagnosed?
A stiff elbow is easy to identify, so identifying the underlying cause is the main focus of diagnosing elbow stiffness.
Doctors will obtain x-rays to look for heterotopic ossification and to evaluate the presence of post-traumatic arthritis (cartilage injury) in the main elbow joint (the trochlear notch).
Categorizing the severity of stiffness is also critical for guiding treatment: is the elbow mild, moderate, or severely stiff?
A Mildly Stiff elbow is less than 30 degrees of lost motion, which is almost always lost in extension (cannot fully straighten elbow).
Moderate Stiffness is limited elbow flexion (bending) and extension (straightening). Moderate stiffness is about 40 - 100 degrees of total motion.
Severe stiffness is significantly reduced elbow motion with less than 30 degrees total. This is typically seen in cases with significant heterotopic ossificant (the elbow has turned to stone!) and scarring after a severe injury.
How is Elbow Stiffness treated?
The best way to treat elbow stiffness is to prevent stiffness from the beginning. This means starting elbow motion as soon as possible (when its safe) after an injury. Early motion (especially before 2 weeks) is definitely effective at reducing stiffness, but its not always possible to begin early motion (especially if the elbow is very unstable after the injury), and many times stiffness develops no matter what is tried.
So, now the elbow is stiff, how is it treated. Physical therapy is helpful. Improvements with formal therapy are typically seen up to 6 months after an injury. The question is when to decide that the benefit of therapy has been max'd out and come to terms with the fact that further gains can only be expected with surgical intervention.
After 6 months, if more than 40 degrees of extension is lost, or there is less than 105 degrees of flexion, most people will benefit from surgery. However, some people that require better dexterity, such as athletes, will want surgery with even less stiffness.
Surgery is called a "Contracture Release" meaning removal of scar tissue, thickened capsule, and any heterotopic bone that is limiting motion.
Surgery is done arthroscopically (with a small camera and instruments placed in portals), or with a larger incision.
In Mild Contractures, an arthroscopic removal of the thickened capsule can be a successful treatment. In more severe cases, a full incision (or two incisions) are required to visualize all sides of the elbow and remove scar tissue. Sometimes after surgery the elbow is actually unstable initially and requires a Hinged External Fixation to allow for motion while providing some stability.
The best timing for surgery in cases of hetertopic ossification (HO) is debated. Surgeons want to wait until all of this abnormal bone has formed, and for the elbow to "cool down" meaning its no longer producing HO. Although some doctors use a test called a Technetium Bone Scan to identify activity of your elbow (if its active its still making abnormal bone), studies have shown that these scans can show activity years after an injury, when there is no real evidence that new bone is actually being formed. Therefore, most doctors use 6 months as the time when the vast majority of elbows "cool down" and its safe to remove HO without a high risk for recurrence.
What is the long term outcome?
Elbow stiffness is difficult to treat even with new advances in surgical approaches. The goal is usually to obtain a functional elbow so you can perform everyday tasks, yet a completely normal elbow is usually difficult to achieve after a traumatic injury.
The best predictor of long-term outcome, is the stiffness severity before treatment began (that is why its so critical to start moving the elbow early in treatment, to prevent stiffness from ever forming).
In people with mild stiffness the expectation is to obtain near complete recovery of motion.
In people with moderate stiffness its uncommon to regain full extension, but typically very good functional motion is achieved.
In cases of severe stiffness, there is a lot of variability between patients, but there is a very low chance of fully regaining elbow motion, there is a real possibility of some limitations in daily functioning, and a high chance that rehabilitation of the elbow will take months and strength in the elbow will be decreased.
Treatments can improve all degrees of elbow stiffness, but the final endpoint is variable and mostly based on where you start out.
Surgical release of scar tissue that has caused an elbow contracture can be a very technically challenging operation because the scar tissue can encircle your artery and nerves as they travel past the elbow. Therefore there are certainly risks of injury tissue arteries or nerves during a release. Studies suggest that about 10% of patients experience numbness or weakness in their Ulnar Nerve after surgery, however most improve over the following days,weeks, months.
Reference
1. Bruno RJ et al. Posttraumatic elbow stiffness: evaluation and management. JAAOS 2002; 10: 106-116. full article. review
2. Morrey BF et al. A biomechanical study of normal functional elbow motion. JBJS 1981;63:872–877. full article. classic paper describing functional ROM: 30-130, pro-sup: 50-50.
3. Savoie FH III et al. Arthroscopic management of the arthritic elbow: Indications, technique, and results. JSES 1999;8:214–219. full article. arthroscopic mod of Outerbridge-Kashiwagi procedure in 37 pts. w. severe limited ROM (<50) resect radial head and debride olecranon/coronoid: intermediate step to elbow arthroplasty.
4. Husband JB, Hastings H II. The lateral approach for operative release of posttraumatic contracture of the elbow. JBJS 1990;72:1353–1358. full article. classic lateral approach to contracture release: 7 pts, inc 50 deg on avg.
5. Ring D et al. Elbow capsulectomy for posttraumatic elbow stiffness. J Hand Surg 2006; 31: 1264-71. full article. 47 pts, also avg 50 deg improvement to achieve 103 avg full arc ROM at 48 months.
6. Keener JD, Galatz LM. Arthroscopic management of the stiff elbow. JAAOS 2011; 19: 265-74. full article. review.
7. Hastings H II, Graham TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clin 1994;10:417–437. full article. incidence HO depends on trauma, pt factors. classification system.
8. Poggi MM, Thomas BE, Johnstone PA: Excision and radiotherapy for heterotopic ossification of the elbow. Orthopedics 1999;22:1059–1061. full article. radiation postop may dec HO.