Contracture Release of the Elbow

Chapter 9 Contracture Release of the Elbow



Aviva Wolff, OTR/L, CHT, Emily Altman, PT, DPT, CHT


Elbow contractures have many causes. The choice of intervention for the stiff elbow is dictated by the cause of stiffness and the specific pathophysiology. Posttraumatic stiffness following elbow fractures and dislocations is the most common cause of elbow contracture. Other causes include osteoarthritis or inflammatory arthritis, congenital or developmental deformities, burns, and head injury.


The elbow joint is prone to stiffness for several reasons. Anatomically, the joint is highly congruent. In most joints of the body, the tendinous portions of the muscles that act on the joint lie over the joint capsule. In the elbow, however, the brachialis muscle belly lies directly over the anterior joint capsule, making adhesion formation between the two structures inevitable following injury. The elbow is often held in 70 to 90 degrees of flexion postinjury because that is the position of greatest intracapsular volume for accommodation of edema. The thin joint capsule responds to trauma by thickening and becoming fibrotic, and quickly accommodating to this flexed position of the elbow. This results in a tethering of joint motion, particularly in the direction of extension. Biomechanically, the strong (and often co-contracting) elbow flexors overpower the weaker elbow extensors, which challenges the ability to regain extension. Last, the elbow joint is prone to heterotopic ossification following trauma and surgery.



Surgical Overview



• Elbow contractures are classified as intrinsic or extrinsic.
1 Extrinsic contractures result from extra-articular pathology, involving the skin, neurovascular structures, joint capsule, ligaments, muscle tendon units, and heterotopic bone.

2 Intrinsic contractures result from intra-articular pathology, such as joint incongruity, fracture, deformity, and intra-articular heterotopic bone.

• Posttraumatic elbow contractures that are of short duration may respond well to conservative treatment.

• Typically, extrinsic contractures that are 6 to 12 months postinjury have minimal articular incongruity and a soft or firm end feel that will improve with therapy.

• When conservative intervention fails, surgical release is indicated. Surgical options for releasing the joint range from simple arthroscopy to the placement of hinged, external fixation (see Chapter 10).

• Arthroscopic release is generally reserved for patients with minimal joint stiffness, small osteophytes at the coronoid or olecranon, or loose bodies. The anterior joint capsule is well visualized arthroscopically.

• An open release is indicated for more involved cases that may require any one or combination of the following: anterior and posterior capsulectomy, ulnar nerve transposition, removal of large osteophytes, and removal of hardware.
1 The open release is performed via a medial, lateral, or posterior incision, or any combination of the three. The approach selected is determined by the type of contracture and location of pathology.
– The lateral approach is selected for simple flexion contractures, such as those that result from radial head fractures. The lateral approach is the most simple to perform, yet it provides the least exposure.

– Situations that present with ulnar nerve involvement require medial exposure. A medial “over-the-top” approach has been advocated by Hotchkiss. This technique allows exposure of the joint, while protecting the ulnar nerve, anterior collateral ligament, and posterolateral ulnohumeral ligament complex. It also allows both anterior and posterior access to the joint.

– If heterotopic bone is present on the lateral side, a combined medial and lateral approach is used.

– Heterotopic bone that is present on the olecranon warrants a posterior approach.
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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Contracture Release of the Elbow

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