Open Elbow Contracture Release

• Elbow stiffness is common after injury.

• A stiff capsule can usually be stretched with confident exercises; patience is warranted, because intentionally hurting one’s elbow after injury or surgery can be counterintuitive.

• Operative treatment is necessary when heterotopic ossification, implants, malunion, nonunion, or articular damage hinders motion and when there is compression of the ulnar nerve.

• Knowledge of both the medial and the lateral approaches to elbow contracture release allows the surgeon to address all forms of posttraumatic elbow stiffness.

Important Points

• Have patience with pure capsular contracture.

• Examine closely for signs of ulnar nerve compression.

• Heterotopic ossification has a better prognosis than pure capsular contracture. It is probably best to plan surgery for 3 to 4 months after injury to allow the bone to mature and the soft tissues to become more mobile.

Clinical and Surgical Pearls

• A single posterior skin incision gives access to the entire elbow.

• Good anterior exposure is possible through either lateral or medial muscle intervals.

• The anterior interval on the lateral side is roughly between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC) (it is difficult to be precise). On the medial side the anterior interval is a 50 : 50 split of the flexor pronator mass anterior to the ulnar nerve.

Clinical and Surgical Pitfalls

• For release of capsular contracture, remove the implants after having pushed the elbow into maximum flexion and extension.

• It is better to keep the implants used to repair the fracture in place when heterotopic bone is removed. The combined removal of bone and implants creates a notable risk of fracture.

• The better one understands where the pathology is, the easier the surgery (i.e., the better the planning). Three-dimensional computed tomography should be performed to allow study of the precise location of the heterotopic bone that is blocking motion.

Elbow motion can be restricted by contracture of the skin, capsule, and muscles; heterotopic ossification, osteophytes, or implants; articular incongruity or damage; and malunion or nonunion.¹ Ulnar neuropathy is commonly associated with elbow contracture and can be precipitated or exacerbated by surgeries that increase mobility.² The best candidate for an arthroscopic elbow contracture release is a patient with capsular contracture with or without osteophytes. Most patients with pure capsular contractures after trauma can achieve functional motion with time and exercises (including static progressive or dynamic elbow splinting).^3,4 Primary elbow arthritis is uncommon. Ulnar nerve decompression is worth considering in patients with less than 100 degrees of flexion even when there are no signs or symptoms of ulnar neuropathy.² Once the ulnar nerve has been released, performance of a capsular excision from the medial side is straightforward.⁵ Arthroscopic elbow contracture release is more difficult and more dangerous than open contracture release, particularly because elbow arthroscopy is an uncommon procedure at which most of us are not well practiced.^6–10 For all of these reasons, operative treatment of elbow stiffness is best reserved for patients with heterotopic bone, errant implants, or ulnar neuropathy—situations in which an open procedure is preferable.

Preoperative Considerations

History

It is helpful to be aware of the details of prior trauma, burn, or central nervous system injury, prior surgeries in particular. In patients with prior central nervous system injury, one must determine the ability of the patient to participate in a postoperative rehabilitation protocol.¹¹ A painful contracture suggests arthritis or ulnar neuropathy. Numbness and dexterity problems suggest ulnar neuropathy.

Physical Examination

The quality of the skin is important, particularly in postburn contractures.¹² The status of the skin with respect to prior injury and operative treatment will influence the operative tactics. When planning operative treatment of a posttraumatic contracture, we prefer to wait until the skin and scar are mobile and soft and no longer edematous or adherent. A complete motor and sensory examination of the ulnar nerve is performed, along with evaluation for a Tinel sign and an elbow flexion test.

Imaging

Standard anteroposterior and lateral radiographs of the elbow are usually sufficient to identify and to characterize arthritis, heterotopic ossification, and nonunions, but computed tomography is occasionally of use. In more complex cases the computed tomographic scan can help with preoperative planning.¹¹ Three-dimensional reconstructions are particularly easy to interpret. Computed tomographic scans may be particularly useful for characterizing malunion of the articular surface of the distal humerus.¹³

Neurophysiologic testing should be considered when there is any possibility of preoperative ulnar neuropathy.

Indications and Contraindications

Morrey and colleagues ¹⁴ found that 15 daily activities could be accomplished with an arc of ulnohumeral motion of 30 to 130 degrees of flexion and an arc of forearm rotation of 50 degrees of pronation to 50 degrees of supination. However, these numbers should not be used to decide when to operate for elbow stiffness. Patients can adapt to and function well with much less motion,¹⁵ perhaps more so when the stiffness is in the nondominant elbow. Therefore the indication for operative contracture release is a combination of diminished elbow motion and disability directly related to stiffness.

Simple capsular contracture (no heterotopic bone, no malunion or nonunion, no implants blocking motion, no ulnar neuropathy) usually responds to reassurance and encouragement of exercises, time, and static progressive or dynamic elbow splinting.³ Therefore one should never rush into operative treatment of capsular contracture; patience and frequent visits for reassurance and encouragement are worthwhile.

Obvious hindrances to motion, including heterotopic bone, malunion, nonunion, prominent implants, and ulnar neuropathy, merit operative treatment. Heterotopic ossification can be resected within 3 or 4 months of injury (when it is radiographically mature and the skin is mobile with little or no edema) regardless of activity on bone scans.11,12,16,17 Stiffness associated with advanced arthrosis or unsalvageable nonunion or malunion should be treated by interpositional or prosthetic elbow arthroplasty.^18,19

Surgical Planning

Elbow capsulectomy can be performed simultaneously with debridement of a deep infection. It also forms an integral part of the treatment of malunion,¹³ nonunion,¹⁹ and instability.²⁰ Unstable skin can be treated with either prior or concomitant procedures to improve soft tissue coverage.¹²

Patients with capsular contracture who desire extension can be treated with lateral capsulectomy (Fig. 48-1).^21,22 Patients with concomitant ulnar neuropathy or limitation of elbow flexion are best treated with medial capsulectomy (Fig. 48-2).^5,23 Patients with heterotopic bone, prominent implants, or complex contracture that cannot be adequately released from medial or lateral alone may benefit from a combined release.^5,12 Preoperative (within 24 hours) radiation therapy (a single 7-Gy dose) is administered to patients with heterotopic bone to be excised.