The elbow’s primary function is to position the hand in space. The stiff elbow, therefore, is fraught with the morbidity of functional disability. It is a frequently encountered problem for the orthopaedic surgeon in the management of elbow pathology. Trauma is the most common etiology. The causes are generally divided into intrinsic and extrinsic factors. “Intrinsic factors” refers to any cause within the joint itself such as arthritis, osteophytosis, capsular contracture and adhesions, or joint incongruity. “Extrinsic factors” include muscle contractions, heterotopic ossification, and skin contractures (1). Stiffness can also result secondary to varied conditions such as brain or spinal cord injuries, burns, or paralytic deformities (2). Prolonged joint immobilization leads to progressive contracture of the capsule and pericapsular tissues, intra-articular fibrofatty connective tissue, and articular cartilage fibrillation (3). The preferred treatment is as varied as the etiology and includes both open and arthroscopic management. For severe injuries that involve the articular surface, interposition arthroplasty has been shown to be effective but is a very technically demanding procedure. Joint replacement arthroplasty generally is not considered as a treatment for stiffness unless the patient is older than 65 years (4).

The elbow is a complex joint that acts as a link for the body to adjust the hand in space. The distal humerus is anteriorly angulated 30 degrees, is internally rotated 5 to 7 degrees, and is in 6 to 8 degrees of valgus (5). Secondary to the complex anatomic interactions at the elbow joint, even a relatively minor injury can result in significant stiffness (3). Normal motion of the elbow was defined by Boone as 0 to 145 degrees flexion and 86 to 93 degrees in supination (6). Based on Morrey’s work, motion consisting of flexion from 30 to 130 degrees and 50 degrees each of pronation and supination is thought to be sufficient to accomplish most activities of daily living (7). Motion loss usually consists of loss of extension, but loss of flexion is also common (4).

Nonsurgical treatment consisting of physical therapy and splinting for loss of motion is generally attempted for at least 3 months before surgery is considered. Use of a custom-fit turnbuckle orthotic has been shown to increase the overall arc of flexion by 43 degrees (8). Bupivacaine hydrochloride with or without steroid injections, protected range of motion using a double-hinged elbow brace, and physical therapy may prove efficacious (3). Manipulation under general anesthesia has also been reported with favorable results (9).

The primary surgical indication would be loss of the functional range of motion of the elbow that fails conservative treatment. There are certain vocational and personal needs whereby individuals with an apparently adequate arc of motion may request additional motion. The justification of indication for surgical intervention is thus highly individualized regarding the patient’s needs and expectations (4). Based on the above data concerning range of motion, surgical release has been generally indicated for patients with flexion contractures greater than 30 degrees. There is also a subpopulation, such as high-level athletes, in whom loss of terminal extension is unacceptable and impairing, thus
expanding the indications to include functional impairment secondary to contracture (10). Open surgical management may increase scar production around the elbow, thereby contributing to contracture, prompting one to consider arthroscopic management. Advantages of an arthroscopic approach include minimal incision size, decreased blood loss, decreased postoperative pain, better visualization of the articular surface, and decreased soft tissue dissection, theoretically leading to easier rehab (1,11).

Contraindications for elbow arthroscopy would include bony ankylosis or significant heterotopic ossification around one of the nerves preventing the safe establishment of arthroscopic portals (12). Heterotopic ossification is extracapsular and often closely located to neurologic structures, particularly the ulnar nerve (13). Prior ulnar nerve transposition can be considered a relative contraindication secondary to increased risk of iatrogenic nerve injury. Though not contraindications, disadvantages include the need for advanced arthroscopic skills and the risk of nerve injury (1). A relatively small incision over the ulnar and/or radial nerves to allow their localization and protection is often a useful adjunct to the management of the stiff elbow.

A thorough history and physical are the pillars on which the treatment is going to be directed. Specific elements of the history that need clarification include the following: What is the mechanism (if posttraumatic), what is the timeline, previous procedures (for which one may want to acquire the operative reports), including previous ulnar nerve transposition, previous conservative treatment, and a careful neurovascular exam with documentation of preexisting signs of neural irritation or deficits. In some instances, patients may not notice subtle changes in ulnar innervated musculatures secondary to a greater focus on the impaired function of the elbow (9). One element of the history that deserves special attention is pain. Posttraumatic stiffness is generally not overly painful. Individuals who have pain with motion may have a problem with the articular surface, meaning an intrinsic component, and thus may be in need of a resurfacing or an interposition type of intervention (4). Previous physical therapy and the use of any splinting—either short or long term—should be documented (3).

Physical examination must include careful evaluation of the soft tissues around the elbow looking for scars, burns, or soft tissue deficit. A goniometer is the most accurate way to monitor the range of motion of the elbow. Radiographs consisting of anteroposterior, lateral, and oblique views of the elbow (Fig. 15-1) are routinely obtained to assist in identifying potential sources of loss of motion. In addition to this routine imaging, advanced imaging consisting of computed tomography with three dimensional reconstructions can be obtained for further characterization of osseous anatomy. Magnetic resonance imaging may also be employed to evaluate the ligamentous structures about the elbow and to identify cartilaginous loose bodies.

Conservative treatment with physical therapy and splinting is generally the mainstay of treatment for mild contractures. Caution always should be observed during therapy to prevent additional capsular damage and worsening of the arthrofibrotic condition (3). A variety of open techniques have historically been shown to be effective in treating the stiff elbow. Arthroscopy offers the advantages of a limited soft tissue dissection and skin incision, which should lower the risk of subsequent scarring and also allow less impedance to postoperative physical therapy. Various techniques used in the past such as open or mini-open: capsulectomy, extensive capsular release, capsular release with biceps tendon lengthening, brachialis myotomy, and release of the more anterior fibers of the collateral ligaments have paved the way for arthroscopic management (14).

Management of the arthrofibrotic elbow is one of the more complex procedures a patient may undergo. The risk of potential complications, including recurrence and nerve injury, is quite real, and most likely underreported. The surgeon and patient willing to undertake this treatment must be aware of the real possibility of significant complications associated with treatment. Despite the surgeon’s best intentions, infection, stiffness, pain, and transient and permanent neuropathy should be considered likely to occur. The chance of these complications must be understood and accepted by both the treating physician and the patient before surgery is considered.