Understanding the stages of elbow stiffness can help with prevention

Elbow stiffness following trauma, surgery or due to joint degeneration is a common problem that can significantly impede upper extremity range of motion. Morrey and colleagues found that most individuals can perform their activities of daily living with 100° elbow flexion arc from 30° to 130° flexion and a 100° rotation arc from 50° of supination to 50° pronation.

However, small contractures can affect specific functional tasks in some individuals, such as athletes, Denise M. Eygendaal, MD, PhD, an orthopaedic surgeon at Amphia Hospital Breda, in Teteringen, The Netherlands, told Orthopaedics Today Europe.

A significantly stiff elbow will have a serious impact on function, especially if the dominant arm is affected, Lech A. Rymaszewski, MRCS, an orthopaedic surgeon at the Glasgow Royal Infirmary in Scotland, noted.

“In contrast, flexion contractures up to 30° can be easily tolerated as the loss of extension will only be a few centimeters when reaching out, but beyond that it becomes increasingly irksome, especially as everybody notices that you cannot extend your elbow,” Rymaszewski said.

He also highlighted to role of pain in the management of elbow stiffness.

“If you have impingement pain at full extension or flexion, the patient will complain more about their loss of function because they are apprehensive of doing any activities at the limits of movement,” Rymaszewski said.

Although treatment options are available, which include splinting, physiotherapy, open and arthroscopic surgery, prevention should be paramount, according to sources who spoke with Orthopaedics Today Europe about the causes, treatment and most importantly, the prevention of elbow stiffness.

A joint prone to stiffness

The elbow is a highly constrained joint that is prone to stiffness.

“Stiffness of the elbow after injury is rather common,” Shawn W. O’Driscoll, MD, PhD, professor of orthopaedics at the Mayo Clinic, College of Medicine, in Rochester, Minn., USA, told Orthopaedics Today Europe. “It also seems to be one of the joints in the body that has a predilection to losing motion after injury.”

The causes of elbow stiffness fall into three categories that Morrey identified in 1990: extrinsic, intrinsic and mixed. Extrinsic causes involve anything outside of the joint, such as contractures caused by burns, capsular and collateral ligament contractures and heterotopic ossification.

Intrinsic causes emanate from within the joint, including articular malunion and nonunion, cartilage problems and loose bodies that block or restrict elbow motion.

Most elbow stiffness cases are in the “mixed” category, which is a combination of extrinsic and intrinsic causes, Eygendaal said.

“The most common cause of elbow stiffness is trauma — a fracture of the distal humerus or a fracture of the proximal radius or the proximal ulna or a dislocation of the elbow joint,” she said.

Significant functional issues

Elbow stiffness causes significant functional issues since the elbow positions the hand in space within a sphere that is centered around the shoulder, according to O’Driscoll.

“As the reach is diminished due to elbow stiffness, the loss of volume of reach is proportional to the third power, so it is exponential,” he said. “As you lose more motion in the elbow, you suffer increasingly greater impact on function in the arm.”

Because even modest deficits can lead to significant functional impairment, preventing elbow stiffness is paramount. The first step to prevention is understanding the four stages of stiffness, O’Driscoll said. In stage one, fluid accumulates in the soft tissues in and around the elbow within minutes to hours of injury.

“The tissue becomes stiffer in the same way as when you inflate an inflatable structure, it becomes rigid,” he said. “When fully inflated, the elbow rests at 80° of flexion and will not extend or flex.”

Stage two, which occurs about 2 days to 5 days after injury, involves the laying down of molecules in the extracellular matrix.

“Molecules that we call proteoglycans convert the fluid into something more like a gel,” O’Driscoll said. “And that gel is not so easily extruded or eliminated from the tissues as the fluid is.”

If the gel is not eliminated, around day 5, tissue will form with the laying down of collagen fibers. “Once that tissue is present, that tissue can’t be eliminated as the fluid and gel can,” O’Driscoll said. “That tissue has to be stretched out and elongated. That makes the treatment of the stiffness even more difficult.”

The fourth and final stage is the organization of collagen into mature scar tissue.

“Once that strong scar tissue is in place, it is difficult to stretch it out,” O’Driscoll said. “It is like stretching leather. It takes long periods of time of sustained stretching to accomplish much benefit.”

The key to the prevention of elbow stiffness is to squeeze the fluid out of the tissues soon after injury, ideally within hours or at least the first day. That squeezing must continue until the fluid fails to recollect, he said.

“If you can manage to accomplish that, you can prevent the stiffness,” O’Driscoll said.

Prevention of stiffness

Continuous passive motion (CPM), which essentially wrings out the fluid from the tissues, is the first step in prevention, O’Driscoll said.

“That is, in our experience, a highly effective way of dramatically hastening the recovery of function and motion in the elbow,” he said.

He said CPM also plays a role after surgery, shortening the postoperative recovery period and accelerating the return to usual ADLs. Once stiffness is established, however, more intensive treatment is necessary. But first, the surgeon should examine the patient and visualize the joint with imaging.

“I always take a proper analysis to hear out when the problem started, to find out if there is a surgical background or a traumatic background,” said Bo Sanderhoff Olsen, MD, PhD, who is head of the section for shoulder and elbow surgery at Herlev Hospital, and an assistant professor in the orthopaedic department at Copenhagen University, in Denmark.

To assess range of motion, Olsen orders anteroposterior and lateral plain radiographs. A 3-D CT scan is also a useful tool because it allows the surgeon to visualize the cause of stiffness, such as heterotopic ossification, he said. If Olsen suspects a traumatic articular cartilage defect, he will get an MRI.

When Rymaszewski assesses patients for possible surgical treatment of stiff elbow, he documents their Oxford Elbow and DASH scores to evaluate functional limitations. He also has patients complete a VAS for pain at rest, at night, when lifting a heavy weight and with repeated elbow movements.

Rymaszewski uses a goniometer to record ROM restriction and determines whether there is pain in terminal flexion and extension. He also evaluates “grip and grind pain,” which involves loading the radiocapitellar joint while rotating the forearm. This is very reliable in localizing radiocapitellar problems.

“It is important record any ulnar nerve symptoms, loss of sensation and weakness of the intrinsics,” Rymaszewski said. “You should also check for complaints of locking and unlocking — that is mechanical symptoms usually due to loose bodies.”

Rymaszewski noted there is little evidence that passive stretching is an effective way to manage elbow stiffness. He never uses physiotherapy or manipulation under anesthesia after trauma or arthrolysis, but instead instructs his patients to mobilize their elbows actively.

“You tell the patient: The more you use it within the limits of discomfort, the better it will be and you definitely won’t be doing any harm,” Rymaszewski said.

Open repair of stiff elbows

Open arthrolysis is one treatment option, a technique that Rymaszewski performs on patients whose progress has plateaued or who have significant issues with stiffness, with or without pain.

“I personally don’t do arthroscopy,” Rymaszewski said. “The majority of my practice is post-traumatic [cases]. They usually have metal work that you have to remove and the ulnar nerve has to be decompressed or transposed in the majority of cases. Often after intra-articular fractures, it is necessary to release intra-articular adhesions or address incongruency. You can’t therefore do arthroscopic procedures in the majority of these cases in contrast to osteoarthritic cases.”

In an 81-patient study, Rymaszewski showed good results with the open arthrolysis without using passive stretching. At a mean follow-up of 16 months, the total arc of movement improved from 69° preoperatively to 109° postoperatively; mean flexion improved from 118° to 136° and mean extension improved from 49° to 27°.

After surgery, Rymaszewski gives his patients a self-care protocol at discharge; the ROM continues to improve spontaneously up to a year in nearly all cases, until a functional ROM is achieved.

Use of arthroscopy

Elbow stiffness treatment is shifting from open to arthroscopic procedures.

“If we go back 10 years, more or less all of the cases were treated with open surgery,” Olsen said. “Nowadays, more cases are treated with arthroscopic surgery. In my own practice, it is more or less 50%.”

The good results often achieved with arthroscopic procedures may also be driving this shift in practices.

Cefo and Eygendaal found that arthroscopic capsular release, while technically demanding, effectively improved the arc of motion in 27 patients with post-traumatic stiff elbows. Their results showed that preoperatively, mean flexion was 123°, extension was 7° and total ROM was 125°. The mean Elbow Function Assessment improved from 69 preoperatively to 91 postoperatively. Postoperative outcomes were similar at all time points.

There are several arthroscopic techniques available to surgeons; however, the more important point is there are different tasks that must be accomplished during surgery, which depend on the etiology of stiffness, O’Driscoll noted.

“If the patient has heterotopic ossification, it is important to be able to distinguish whether or not the bone that has formed potentially interferes with motion,” O’Driscoll said. “If it does, that bone needs to be removed.”

In these cases, it is critical to remove any existing scar tissue, as well, he said.

In arthritic patients, the surgeon should obtain a preoperative CT scan to understand the location, pattern and severity of osteophytes and plan where the bone must be reshaped, O’Driscoll said.

No matter which type surgery is performed — open or arthroscopic — the goal is the same: “Under anesthetic, you need to get as close to a full range of movement as possible,” Rymaszewski said. “Whatever you achieve during surgery, the final clinical result will be a bit less, at least 5° to 10° in both extension and flexion.” – by Colleen Owens

• References:
• Cefo I. J Shoulder Elbow Surg. 2011; doi:10.1016/j.jse.2010.11.018.
• Higgs ZCJ. J Bone Joint Surg Br. 2012; doi:10.1302/0301-620X.94B3.27278.
• Jayaram PR. J Shoulder Elbow Surg. 2014; doi:10.1016/j.jse.2013.11.006.
• Morrey BF. J Bone Joint Surg Am. 1981;63:872-877.
• Morrey BF. J Bone Joint Surg Am. 1990;72:601-618.
• Murry O. Treatment by open surgical techniques. In: Stanley D and Trail I, eds. Operative Elbow Surgery. London: Churchill Livingstone; 2012.
• Olsen BS. Orthopaedics and Trauma. 2012;26:397-404.
• For more information:
• Denise M. Eygendaal, MD, PhD, can be reached at the Department of Orthopaedics, Upper Limb Unit, Amphia Hospital Breda, P.O. Box 90158, 4800 RK Breda, Netherlands; email: denise@eygendaal.nl.
• Shawn W. O’Driscoll, MD, PhD, can be reached at 200 First St. SW, Rochester, MN 55905, USA; email: odriscoll.shawn@mayo.edu.
• Bo Sanderhoff Olsen, MD, PhD, can be reached at the Orthopaedic Department, Herlev Hospital, Copenhagen University, Denmark; email: bosolsen@jubii.dk.
• Lech A. Rymaszewski, MRCS, can be reached at Orthopaedic Unit, 84 Castle St., Glasgow G4 0SF, UK; email: lech.rymaszewski@ggc.scot.nhs.uk.

Disclosures: Eygendaal, O’Driscoll, Olsen and Rymaszewski have no relevant financial disclosures.

What is your workup for a patient with persistent elbow stiffness following open reduction and internal fixation?

Management can be challenging

Since elbow motion is crucial for placing of the hand in space, stiffness of the joint can severely limit function of the extremity. Following internal fixation of elbow joint fractures, some loss of range of motion can be expected — usually in extension — despite early mobilization and competent physiotherapy. To most patients a 30° to 130° range of motion is acceptable.

Patients with more severe restriction are often young to middle-aged and active; they often experience a severe activity limitation. Many of them can be helped if the stiffness is properly analyzed. Generally, if there is a malunion of an intra-articular fracture, good results are harder to achieve, especially since posttraumatic osteoarthritis can develop appallingly fast.

In most patients, the stiffness is present in a congruent joint and due to joint capsule contracture and occasionally heterotopic ossification (HO). In these, well-timed surgery with skilled postoperative physiotherapy often gives satisfactory results. Timing is crucial. The elbow must be “cold” — no active inflammation — which usually means waiting 6 months to 9 months, otherwise the rebound inflammation will disconcert any results achieved at surgery, which may mean resection of HO if present, resection of the anterior capsule and release of the posterior capsule. If pain is associated with stiffness, a low-grade infection can be anticipated.

Both surgery and after-treatment can be challenging and require collaboration with an experienced elbow team.

Johan Scheer, MD, PhD, is a consultant in the Department of Orthopaedic Surgery at Linköping University Hospital in Sweden.
Disclosure: Scheer has no relevant financial disclosures.

Careful patient review

When faced with the problem of persistent stiffness after open reduction internal fixation, I consider the following: How long is it from the time of surgery. I would normally advise that it is worth reviewing and examining the patient’s range of movement every 3 months for up to a year before deciding no further improvement is likely to occur. I would normally expect to see improvement in the range of movement at each 3-month review.

It is also important to review the postoperative anterior-posterior and lateral radiographs to assess the quality of the reconstruction. The radiographic appearances should be considered in respect to the normal anatomical appearance of the distal humerus, radial head and olecranon. If the reconstruction does not match the normal anatomy it is likely there is an osseous cause for the elbow stiffness.

Low-grade infection must be considered, and to evaluate this I perform screening blood tests. If these are abnormal, I will consider joint aspiration under radiographic control.

If there is no osseous abnormality and no evidence of infection, the likely explanation is a soft tissue contracture. If the patient cannot extend the elbow the problem will lie with contracture of the anterior capsule. If flexion is limited it will be contracture and scarring of the posterior capsule. If the distal humerus has been plated there may be scarring between the triceps and humerus.

David Stanley, MB BS, BSc, FRCS, is a consultant shoulder and elbow surgeon in the Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England.
Disclosure: Stanley has no relevant financial disclosures.

Prevention is critical

The key issue in the treatment of elbow stiffness is the prevention. While treating elbow fractures it is important to achieve good anatomical reduction and stable fixation that would allow early mobilization although there are some cases when the fixation is not sufficient enough to mobilize the elbow early, and then one has to accept the possibility of stiffness. In other cases stiffness occurs in spite of early mobilization.

Another point regarding prevention is gentle mobilization, which means vigorous rehabilitation should be avoided since it can cause swelling and pain that lead to stiffness.

In case of stiffness that is resistant to rehabilitation, I recommend the removal of the metalwork after 6 months when the bony healing is usually satisfactory. In some cases the removal of the screws and plates could lead to the improvement of the motion or the surgeon can make a decision during surgery if open arthrolysis would be beneficial at the same surgical setting. Though arthroscopic arthrolysis is popular, in my opinion post-fracture cases are far too complicated for this technique.

The surgery should be followed by a prolonged, gentle rehabilitation program.

Jeno Kiss, MD, PhD, CSc, is Consultant orthopaedic and trauma surgeon and head of Department of Orthopaedics and Trauma at Szent János Kórház in Budapest.
Disclosure: Kiss has no relevant financial disclosures.