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Post-traumatic elbow stiffness: Prevention not cure
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One key outcome measure for any research on the management of fractures close to or involving the elbow joint is elbow range of motion. That is because stiffness after such fractures is seen as inevitable and the degree to which it affects the joint is a surrogate measure of treatment efficacy.
The research of Bernard F. Morrey, MD, decades ago revealed the range of motion needed for “normal” everyday functions is flexion from 30° to 130°, and 50° each of pronation and supination. That is being challenged by modern technology (and who knows how that will evolve in the coming decades) such that a greater amount of flexion is needed to use a mobile phone comfortably and more pronation is needed to use a keyboard effectively. Patient expectations are also increasing across the board, so we need to evaluate the techniques used to manage the stiff elbow.
It was said that the timing of surgical intervention was crucial, and a rule of thumb was to wait a year after trauma before attempting any form of arthrolysis. There is consensus that it is not usually necessary to wait that long, but we still do not know when is too soon to attempt arthrolysis. Operate too early and recurrent fibrosis and heterotopic ossification is to be expected. However, the range of movement after trauma often improves slowly — often over 6 months to 9 months — so early intervention may also be unnecessary. Until we have proven methods, observation until the improvement truly plateaus and any heterotopic ossification has distinct borders is a good rule of thumb and usually takes us to the 6-month mark.
Arthrolysis indications
What intervention shall we choose? Those trained as arthroscopic surgeons will say arthroscopic arthrolysis is the procedure of choice, but even in expert hands the complication rate is high and some of the neurological complications can be devastating, particularly in the elbow that starts off with significant restriction in the range of movement. Furthermore, there are few high-volume elbow arthroscopists. Open arthrolysis is probably the gold standard, but even here, do we do a straight posterior approach and develop a sub-fascial plane to get around the front of the elbow both medially and laterally, or use separate medial and lateral incisions?
Whatever surgery is chosen, systematic reviews suggest there is a complication rate of about 15% to 20%, with ulnar nerve neuropraxia being the commonest complication. The same reviews show patients regain about 40° to 60° flexion and that is maintained beyond 5 years. Patients who start off with the stiffest elbows regain the most. However, patients with only modest flexion contractures are most amenable to a simple arthroscopic approach, elevating the anterior contracted capsule off of the humerus.
For stiffer elbows, there is a tendency for the so-called column procedure to be performed, which involves a lateral approach initially and developing the plane between capsule/heterotopic bone and the normal overlying muscle, tendon and neurovascular structures. Once this is developed across the front and/or back of the joint, the entire capsule and its scar tissue and ectopic bone can be excised as one block, preserving the lateral ulnar collateral ligament.
A separate medial incision can then be used, if range is not restored, to decompress the ulnar nerve and release the posterior band of the medial ligament. Post-surgery, we rely on the sort of pain control programs that are improving length of stay in hip and knee surgery to allow early active mobilization and avoid recurrence. This procedure also can be combined with distraction arthroplasty using an articulated external fixator, though pin sites that are too close to the elbow may be storing future problems if ever the patient needs an elbow arthroplasty.
Consider basic science
However, this sort of surgery would less often be necessary if we account for some basic science in managing fractures. Clearly, anatomical reduction of articular fractures is paramount. Secondly, stable fixation is needed: stable enough to allow early range of motion exercises. I am always amazed and disappointed to see patients referred with stiff elbows who had a fracture that was treated, either with surgery or conservatively, with anatomic reduction, but were placed in a plaster cast for 3 weeks or more before mobilization. Sarcomere degeneration and molecular changes in the muscles can be detected after only 6 hours of immobilization.
The message is, treat all fractures involving the elbow to allow mobilization immediately, or after splinting for a few days only to let soft tissue problems settle. If the injury is too complex for that to be done by you, send it to someone who can handle it. Nothing is worse than trying to do an arthrolysis on a patient who has already undergone a previous, inadequate attempt. Stiff elbows should be operated on by people who regularly operate on stiff elbows.
- For more information:
- David Limb, FRCS-Ed(Orth), is Secretary General of EFORT. He can be reached at Leeds General Infirmary, Leeds West Yorkshire LS1 3EX, United Kingdom; email: david.limb@efort.org.
Disclosure: Limb reports no relevant financial disclosures.