Leonid I. Katolik and Mark S. Cohen
DEFINITION
Extrinsic elbow contracture refers to elbow stiffness secondary to fibrosis, thickening, and, occasionally, ossification of the elbow capsule and periarticular soft tissues.
In contrast to intrinsic contracture, the articular surface is either uninvolved or minimally involved, without the presence of intra-articular adhesions or articular cartilage destruction.
While a distinction is made between extrinsic and intrinsic causes of contracture, these entities often overlap.
ANATOMY
The elbow is a compound uniaxial synovial joint comprising three highly congruous articulations.
The ulnohumeral joint is a ginglymus, or hinge, joint. The radiocapitellar and proximal radioulnar joints are gliding joints.
All three articulations exist within a single capsule and are further stabilized by the proximity of the articular surface and capsule to the intracapsular ligaments and overlying extracapsular musculature.
PATHOGENESIS
The propensity for elbow stiffness after even trivial elbow trauma is well recognized. After even seemingly trivial injuries, the capsule can undergo structural and biochemical alterations leading to thickening, decreased compliance, and loss of motion.
Causes of extrinsic elbow contracture include capsular contracture, damage to and fibrosis of the flexor–extensor muscular origins, collateral ligament scarring, heterotopic bone, and skin contracture.
Prolonged immobilization after trauma may be a separate risk factor for the development of stiffness.
NATURAL HISTORY
Little consensus exists regarding the natural history of capsular contracture. It is felt that appropriate recognition and treatment of acute elbow injuries, avoidance of prolonged immobilization, and early active range of motion may limit the severity of posttraumatic extrinsic contracture.
Patients typically do not tolerate elbow stiffness well since adjacent joints do not provide adequate compensatory motion.
Morrey10 showed that the performance of most activities of daily living requires a functional arc of motion from 30 to 130 degrees.
Vasen and colleagues11 have demonstrated that volunteers with uninjured elbows may adapt to a functional arc of motion from 70 to 120 degrees to perform 12 tasks of daily living.
Patients typically request treatment for elbow contracture when loss of extension approaches 40 degrees and flexion does not exceed 120 degrees.
Patients who do not improve with a concerted effort at nonoperative treatment often require surgical release.
Stiffness of the elbow typically is incited by soft tissue trauma, hemarthrosis, and the patient's response to pain. Elbow trauma may cause tearing and contusion of the periarticular soft tissues. The patient typically holds the injured elbow in a flexed position to reduce pain. A fibrous tissue response then ensues within the hematoma and damaged muscular tissues. This fibrous tissue may ossify. In addition, overly aggressive therapy may further exacerbate these injuries, potentiating the cycle of pain, swelling, and limitation in motion that leads ultimately to frank contracture.
Collateral ligament injury may contribute to contracture. Primary fibrosis may develop within the collateral ligaments because of the initial injury. Alternatively, secondary fibrosis may result from immobilization and scar formation.
Significant injury to the anterior joint capsule and the overlying brachialis muscle may also result in capsular hypertrophy and fibrotic reaction contributing to ankylosis. This is particularly common in association with fracture-dislocations of the elbow.
PATIENT HISTORY AND PHYSICAL FINDINGS
The cause of contracture should generally be easily elucidated from the history. Particular notation should be made of concomitant injuries, including closed head injury or associated burn injury.
The duration and possible progression of symptoms should be noted.
The impact of the contracture on the patient's upper extremity function and any limitations in activities of daily living should be noted.
Any previous treatment for contracture should be elucidated. This should include the appropriateness, duration, and results of prior physical therapy, splinting, intra-articular injections, and surgeries.
For patients with prior elbow surgery, the presence and type of any residual internal fixation devices should be noted. In addition, attention should be paid to any remote history of elbow infection.
Physical examination should include a general physical examination as well as a detailed examination of the involved extremity.
Attention must be paid to the examination of the skin and soft tissue envelope about the elbow, with notation made of prior incisions, skin grafts, flaps, or areas of wound breakdown.
Elbow motion should be measured with a goniometer and active and passive motion should be compared.
Notation should be made whether motion improves with the forearm in full pronation, which may suggest posterolateral rotatory instability. This effectively “spins” the forearm away from the humerus, causing gapping of the ulnohumeral joint and posterior subluxation of the radial head from the capitellum. While frank dislocation is not possible in the unanesthetized patient, guarding is effectively a positive sign.
While rare, symptomatic incompetence of the ulnar collateral ligament may elucidated by examination.
Strength of the involved limb should be assessed, as a joint without adequate strength is unlikely to maintain motion after release.
Since many posttraumatic and inflammatory contractures about the elbow are associated with ulnar nerve symptoms, a careful neurologic examination should be performed. A positive Tinel test over the cubital tunnel as well as a positive elbow flexion test should increase the suspicion for concomitant ulnar nerve pathology.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Anteroposterior (AP) and lateral radiographs are often all that is needed for preoperative planning (FIG 1).
Cross-sectional imaging with computed tomography is helpful in visualizing the articular surfaces, particularly after fracture.
We advocate the use of computed tomography for preoperative planning in cases of moderate to severe heterotopic ossification.
Extracapsular contracture is typically not painful through the remaining arc of motion and is not painful at rest. If pain is a significant component of the patient's symptoms, serologic workup for infection, including a complete blood count, erythrocyte sedimentation rate, and C-reactive protein, is indicated.
DIFFERENTIAL DIAGNOSIS
Conversion disorder
Infection
Inflammatory arthropathy
Intracapsular contracture
NONOPERATIVE MANAGEMENT
Alternative measures to improve elbow stiffness include conservative modalities to decrease joint swelling and inflammation and relax or stretch contracted soft tissues. For protracted swelling, edema control sleeves, ice, elevation, active motion (including the forearm, wrist, and hand), and oral agents such as anti-inflammatory medication can be useful.
A short-term oral prednisone taper can be very effective in difficult cases. In addition, one can consider an intra-articular cortisone injection to decrease inflammation and joint synovitis.
Rarely, when patients exhibit guarding and involuntary cocontraction, biofeedback may be a helpful adjunct.
Dynamic splints, which apply a constant tension to the soft tissues, may be helpful.
Patient-adjusted static braces appear to be more effective. These braces use the principle of passive progressive stretch, allowing for stress relaxation of the soft tissues. They are applied for much shorter periods of time and are better tolerated by patients.
SURGICAL MANAGEMENT
To improve elbow flexion, one must release any soft tissue structures posteriorly that might be tethering the joint. These include the posterior joint capsule and the triceps muscle and tendon, which can become adherent to the humerus.
Any bony or soft tissue impingement also must be removed anteriorly, including osteophytes off the coronoid process and any bony or soft tissue overgrowth in both the coronoid and radial fossae.
There must be a concavity above the humeral trochlea to accept both the coronoid centrally and the radial head laterally for full flexion to occur.
Similarly, to improve elbow extension, posterior impingement must be removed between the olecranon tip and the olecranon fossa.
Anteriorly, any tethering soft tissues must be released, namely the anterior joint capsule and any adhesions between the brachialis and the humerus.
Preoperative Planning
All radiographic studies should be reviewed.
The presence and type of any retained implants is noted.
Range-of-motion and pivot-shift testing is performed under anesthesia as well as under live fluoroscopy.
Positioning
Patients are positioned supine with the arm on a hand table.
The patient's torso is brought to the edge of the operating table to ensure adequate elbow exposure for fluoroscopic imaging.
A towel bump may be placed under the medial elbow.
Approach
A direct posterior skin incision or a lateral incision is used.
A direct posterior incision has been criticized for an increased propensity toward postoperative seroma formation.
FIG 1 • Routine preoperative AP (A) and lateral (B) radiographs are obtained in all cases. Contracture may occur after subtle injury. This patient developed stiffness after nonoperative treatment of a nondisplaced radial neck fracture.
It has the advantage of being a utilitarian incision that allows access to the medial and lateral sides simultaneously.
Advantages to the lateral exposure include its simplicity, less extensor and flexor–pronator disruption, and access to all three joint articulations.
The main disadvantage of the lateral exposure is the inability to address the ulnar nerve when indicated.
The deep interval for exposure of the anterior capsule lies between the extensor carpi radialis longus (ECRL) proximally and the extensor carpi radialis brevis (ECRB) distally. Posterior access is achieved between the triceps and the humerus.
TECHNIQUES
SURGICAL APPROACH
The procedure can be performed under general anesthesia or under regional anesthesia with a long-acting regional block.
For the posterior incision, care is taken to avoid placing the line of incision directly over the prominence of the olecranon. Full-thickness fasciocutaneous flaps are elevated laterally to expose the extensor muscle mass.
For a lateral incision, an extended Köcher approach is used, beginning along the lateral supracondylar ridge of the humerus and passing distally in the interval between the anconeus and the extensor carpi ulnaris (ECU).
POSTERIOR RELEASE
TECH FIG 1 • A,B. Exposure of the lateral and posterior ulnohumeral joint. The anconeus and triceps are reflected posteriorly, exposing the posterior capsule, olecranon tip, and olecranon fossa. C. Visualization of the posterior compartment permits débridement of the posterior joint, including removing impinging tissue of osteophytes in the olecranon fossa and the tip of the olecranon.
The Köcher interval between the anconeus and ECU is developed.
The anconeus is reflected posteriorly in continuity with the triceps. This exposes the posterior and posterolateral joint capsule (TECH FIG 1A,B).
A triceps tenolysis is carried out with an elevator, releasing any adhesions between the muscle and the posterior humerus. The humeroulnar joint is identified posteriorly and the olecranon fossa is cleared of any fibrous tissue or scar that would restrict terminal extension. The tip of the olecranon is removed if there was evidence of overgrowth or impingement (TECH FIG 1C).
The posterior aspect of the radiocapitellar joint is inspected after excision of the elbow capsule just proximal to the conjoined lateral collateral and annular ligament complex through the “soft spot” on the lateral side of the elbow. The proximal edge of this complex lies along the proximal border of the radial head.
ANTERIOR RELEASE
Once the posterior release is completed, dissection is carried anteriorly. The anterior interval proximally is between the lateral supracondylar column and the brachioradialis and ECRL. Distally the interval is between the ECRL and extensor digitorum communis (EDC) (TECH FIG 2A).
The brachialis is then mobilized off the humerus and anterior capsule with an elevator, releasing any adhesions between the muscle and the anterior humerus (TECH FIG 2B).
The brachioradialis and ECRL released from the lateral supracondylar ridge of the humerus (TECH FIG 2C).
This dissection is continued distally between the ECRL and ECRB, allowing exposure of the anterior capsule with preservation of the lateral collateral ligament and the origins of the ECRB, the EDC and minimi, and the ECU from the lateral epicondyle.
Dissection is then carried out beneath the elbow capsule between the joint and the brachialis. The capsule is excised as far as the medial side of the joint.
The radial and coronoid fossae are cleared of fibrous tissue and the tip of the coronoid is removed if overgrowth or impingement was noted in flexion. Loose bodies are removed (TECH FIG 2D,E).
After release of the anterior capsule, gentle extension of the elbow with applied pressure usually brings the joint out to nearly full extension.
In longstanding cases of contracture, the brachialis muscle can be tight, inhibiting full terminal elbow extension. This myostatic contracture can be stretched for several minutes during the procedure and requires attention at subsequent physiotherapy (TECH FIG 2F).
TECH FIG 2 • A. The lateral view of a dissected elbow. Blue lines mark the fascial intervals for access to the anterior and posterior aspect of the joint, which leaves the extensor carpi ulnaris (ECU), extensor digitorum communis (EDC), and extensor carpi radialis longus (ECRL) origins intact as well as the underlying lateral collateral ligament complex. The anterior elbow capsule is exposed by releasing the extensor carpi radialis longus from the lateral supracondylar ridge. Distally the exposure continues between the ECRL and ECRB. T, triceps; BR, brachioradialis. B,C. The anterior exposure for release. The anterior capsule is exposed by detaching the humeral origin of the ECRL proximally and the interval between the ECRL and ECRB distally. The brachialis is released from the anterior capsule. The capsule should be visualized all the way over to the medial joint with all muscle reflected anteriorly. D,E. Anterior compartment débridement removes the tip of the coronoid and clears the coronoid and radial fossae. F. Intraoperative extension after contracture release.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
Although several rehabilitation programs may be effective, we have found continuous passive motion, begun immediately in the recovery room and used continuously until the following morning, to be helpful in maintaining the motion gained at surgery (FIG 2A).
Formal therapy is begun on postoperative day 1.
The dressing is removed and edema control modalities (eg, an edema sleeve or Ace wrap, ice) are used to limit swelling.
Active and gentle passive elbow motion is combined with intermittent continuous passive motion.
To help maintain extension, weighted passive stretches using a two-pound wrist weight with the arm extended over a bolster are performed several times daily for 10 to 15 minutes as tolerated.
Because the collateral ligaments are not released at surgery, no restrictions are typically placed on therapy.
Static progressive elbow bracing is begun early in the postoperative period. The brace is worn for about 30 minutes, two or three times a day. Flexion and extension are alternated based on the preoperative deficit and the early progress of the elbow (FIG 2B).
FIG 2 • A. Elbow continuous passive motion device. B. Patientadjusted static elbow brace.
A nonsteroidal anti-inflammatory agent (Indocin) is commonly prescribed as a prophylaxis against heterotopic ossification for several weeks postoperatively. This also helps to limit inflammation of the joint and soft tissues during rehabilitation.
Patients are typically discharged home on postoperative day 1. Home therapy is performed daily thereafter, including active and passive exercises, continuous passive motion, weighted stretches, and patient-adjusted bracing.
Progress should be closely monitored by a therapist who is familiar with the protocol. The physician must also follow these patients closely.
Although the bulk of ultimate elbow motion is gained during the first 6 to 8 weeks, patients can continue to make gains in terminal flexion and extension for several months postoperatively. This is especially true for elbow flexion.
Continuous passive motion is typically discontinued at 3 to 4 weeks, but bracing is continued for several months as required. As long as the patient is able to obtain full elbow flexion and extension once per day (eg, in the brace), a favorable prognosis exists with respect to the ultimate outcome if vigilance is maintained.
OUTCOMES
In appropriate patients, release of the contracted elbow can be a reliable and satisfying procedure with predictable results.
We reviewed our results for 22 patents treated for posttraumatic elbow stiffness using a soft tissue release of the elbow through a lateral approach. The average length of follow-up was 29 months.
Total elbow motion improved in all subjects. Extension increased from an average of 39 ± 10 degrees preoperatively to 8 ± 6 degrees at follow-up. Elbow flexion increased from 113 ± 18 degrees preoperatively to 137 ± 9 degrees at follow-up. Thus, total ulnohumeral joint motion increased an average of 55 degrees (P <0.001).
Elbow pain, as determined by visual analogue scales, decreased in all patients. Elbow function, as determined by standardized scales, also significantly improved.
Radiographic analysis revealed no patients with regrowth of excised osteophytes or loose bodies at follow-up.
COMPLICATIONS
Ulnar nerv.
The most common complication after elbow release surgery involves the ulnar nerve. This may be related in part to improved elbow flexion after surgery, as ulnar nerve tension increases with flexion. This may precipitate symptoms in a nerve that is already subclinically compromised.
Patients with preoperative signs and symptoms of ulnar nerve irritability should undergo neurolysis and transposition of the ulnar nerve.
Although no strict guidelines exist, patients with preoperative flexion less than 100 degrees generally undergo concurrent ulnar nerve release even in the absence of preoperative symptoms.
Median nerve and brachial arter.
Although generally well protected by the brachialis muscle, these structures are at risk with anterior dissection. Their safety is increased if dissection proceeds in the interval between the elbow capsule and the brachialis.
In addition, transient median neuritis is known to occur in our practices after release. This is likely due to stretch of the median nerve with extension of the severely contracted elbow.
Radial nerve injur.
The posterior interosseous nerve may be encountered as extracapsular dissection proceeds distal to the radiocapitellar joint.
Except in cases of significant anterolateral heterotopic ossification, the radial nerve does not typically require identification.
Persistent stiffnes.
The importance of prolonged postoperative rehabilitation cannot be stressed enough. A program of active and passive range of motion, weighted elbow stretches with wrist weights, formal therapy, and patient-adjusted elbow bracing is common for 3 to 6 months after surgery. All of our patients meet preoperatively both with the therapists at our home institutions as well as with their local therapists.
REFERENCES
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