Summary Elbow Stiffness and Contractures of the elbow result in loss of motion and difficulty performing activities of daily living and may occur as a result of trauma, osteoarthritis, elbow surgery, or a congenital condition. Diagnosis is made clinically with assessment of active and passive elbow range of motion with a comparison to the contralateral side. Treatment is a trial of aggressive physical therapy to achieve functional range of motion. Operative management is indicated in the event of bony block to motion, congenital disease and lack of improvement with physical therapy. Etiology Pathophysiology causes of elbow stiffness and contractures include osteoarthritis trauma (fractures) surgery cerebral palsy traumatic brain injury burns prolonged immobilization congenital conditions arthrogryposis congenital radial head dislocation pathoanatomy intrinsic causes joint incongruity synovitis loose bodies intra-articular fractures malunions osteochondritis dissecans post-traumatic arthritis coronoid osteophytes olecranon tip osteophytes radiocapitellar joint space narrowing 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 ligament mixed (intrinsic + extrinsic) late effects of intrinsic conditions can lead to extrinsic stiffness Anatomy ROM functional motion 30° - 130° (extension-flexion) 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° - 50° (pronation/supination) Elbow ligaments and biomechanics primary ligaments of elbow include medial ulnar collateral ligament anterior bundle is most imporant stabilizer to both valgus and distraction forces posterior bundle posterior oblique portion of medial ulnar collateral ligament radial collateral ligament annular ligament Nerves ulnar nerve proximity to the elbow joint places nerve at risk if joint is contracted Presentation Symptoms pain pain in mid-arc of motion may indicate intra-articular pathology extrinsic soft tissue contractures typically painful at the extremes of flexion and extension where bone impingement and soft tissue stretching may occur 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 if <90-100° of flexion, posterior band of MCL is likely contracted and should be released pronation/supination neurological assess median, radial, and 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° static splinting indications failed trial of physical therapy with elbow flexion contractures greater than 30° OR elbow flexion less than 130° Operative capsular release +/- release of posterior band of MCL indications extrinsic capsular contractures with normal joint surface congruency most predictable beneficial results patients with arthritis less predictable once joint surface is incongruous outcomes compliance with postoperative rehabilitation is critical less predictible outcomes when ankylosis present preoperatively contraindications charcot elbow joint neurologic elbow disorder poor skin relative contraindication, may need plastic surgery (rotational flap) osteophyte excision indications intrinsic contractures with arthritis confined to olecranon fossa perform in conjuction with capsular release of bony block to terminal range of motion bone typically should be removed from coronoid, coronoid fossa, olecranon, 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 musculocutaneous neurectomy indications neurogenic contractures with a flexion deformity of less than 90 degrees Techniques Capsular release +/- release of posterior band of MCL approaches arthroscopic technically demanding, radial nerve most at risk with portal placement, followed by ulnar and median nerves posterior compartment - debridement of olecranon fossa/osteophytes with posterior capsular release caution using suction medially due to proximity of ulnar nerve anterior compartment - debridement of coronoid fossa/osteophytes with anterior capsulotomy or capsulectomy open lateral column approach (Morrey) can be performed thorugh lateral or posterior skin incision elevate ECRL and BR anteriorly, triceps posteriorly mobilize brachialis off of anterior capsule debride/release anteriorly and posterly, including coronoid tip/fossa, olecranon tip/fossa, anterior and posterior capsule, and radiocapitellar joint medial "over the top" column approach (Hotchkiss) best for patients with extrinsic contractures, MCL calcifications, and/or baseline ulnar nerve symptoms perform with decompression or transposition of ulnar nerve release posterior band of MCL to increase flexion working anterior to flexor-pronator mass, debride/release anteriorly, including coronoid tip/fossa and anterior capsule combined medial and lateral approach single posterior incision allows for medial and lateral column approaches if <90-100° of flexion, posterior band of MCL is likely contracted and should be released with consideration of concomitant ulnar nerve decompression or transposition timing of contracture release consider contracture release 4 to 6 months post-injury/surgery if range of motion has plateaued and appropriate splinting/therapy has been performed heterotopic ossification can be resected at maturity determine based on visualization of well-corticalized margins of new bone (with lack of changes on serial radiographs) laboratory studies not necessary to determine heterotopic bone maturity rehabilitation surgery performed under regional block can be helpful for pain control postoperatively continuous passive motion through full range of motion compressive dressing to help with swelling therapy with active, and active-assist range of motion use extension splinting as needed use dynamic or static progressive splinting as needed outcomes improvement in range of motion can be variable Most patients will retain two-thirds of the motion gained at the time of surgical release Complications Post-operative heterotopic ossification may treat prophylactically with low-dose radiation therapy or indomethacin low-dose radiation may be contra-indicated with acute fractures due to risk of nonunion Transient ulnar neuropraxia Ulnar nerve damage ulnar nerve transposition should be considered to reduce risk of ulnar nerve injury if preoperative flexion is less than 100 degrees Recurrent contracture Prognosis Patients are able to perform activities of daily living if elbow ROM of 30° (extension) to 130° (flexion) is achieved most activities require a 100° arc of motion at the elbow to be functional a 30° loss of extension is well tolerated by most patients flexion loss causes more dysfunction than extension loss