Posttraumatic contracture of the elbow: current management issues.
The elbow joint is composed of three articulations, the ulnohumeral, radiocapitellar, and proximal radioulnar joints. The ulnohumeral joint is a hinge joint providing flexion and extension. The radiocapitellar and proximal radioulnar joints are trochoid, or pivot, joints that allow for pronation and supination. Elbow stiffness often involves disruption of either the ulnohumeral joint (with resultant loss of flexion and extension) or the proximal radioulnar joint (with resultant loss of pronation and supination). Widespread joint ankylosis can result in losses of both types of motion.
The distal humerus is anteriorly angulated 30[degrees], internally rotated 5[degrees] to 7[degrees] and tilted in 6[degrees] to 8[degrees] of valgus, resulting in a final valgus carrying angle. The distal humerus is composed of the trochlea medially and the capitellum laterally. The trochlea has a 300[degrees] arc of cartilage on its anterior surface that articulates with the semilunar notch of the proximal ulna. The semilunar notch forms an arc of 190[degrees], which must be restored when internally fixing olecranon fractures to prevent joint incongruity and loss of motion. (2)
The capitellum contains thick hyaline cartilage anteriorly that articulates with the proximal radius. This is important to note when performing internal fixation on the posterior aspect of the lateral column of the distal humerus; screws placed distally must either be directed proximally to avoid the articular surface or headless screws should be used. The radiocapitellar joint is a secondary stabilizer to both valgus stress of the elbow and proximal migration of the radius. Two-thirds of the outer circumference of the radial head is covered with hyaline cartilage allowing for an excursion of 100[degrees] of pronation and supination. When internally fixing radial head fractures, hardware must be placed outside this cartilaginous zone to prevent impingement at the radioulnar articulation; this safe zone of 100[degrees] is centered on the equator in the neutral position. (3)
The anterior capsule extends proximally to the coronoid and radial fossae and distally to the anterior margin of the coranoid process and annular ligament. This structure is taut in extension and when scarred can shorten and limit extension. The posterior capsule extends proximally to the olecranon fossa and distally to the medial and lateral aspects of the semilunar notch and annular ligament. This structure is taut in flexion and when scarred can limit elbow flexion. The anterior and posterior capsules of the elbow joint are often scarred after trauma; this is the central pathology in cases of posttraumatic elbow contracture.
Ligaments on the medial and lateral aspects of the elbow are important for maintaining elbow stability. The medial collateral ligament is composed of three bundles: the anterior bundle, posterior bundle, and transverse bundle. The anterior bundle of the medial collateral ligament is functionally most important for valgus stability. (4) Its fibers originate on the antero-inferior aspect of the medial epicondyle and insert onto the medial aspect of the coronoid process. The posterior bundle of the medial collateral ligament originates from the medial epicondyle and inserts onto the medial aspect of the semilunar notch. Its functional contribution is as a secondary stabilizer to the elbow in flexion beyond 90[degrees] or when the anterior bundle is disrupted. The transverse bundle is a thickening of the joint capsule that widens at the semilunar notch and does not cross the elbow joint. (4)
The lateral aspect of the elbow is supported by several ligaments including the radial collateral ligament, the annular ligament, the quadrate ligament, and the lateral ulnar collateral ligament. The lateral ulnar collateral ligament is the primary lateral stabilizer of the elbow. It originates at the lateral epicondyle with the radial collateral ligament and inserts at the supinator crest of the ulna. Disruption of this ligament results in posterolateral rotatory instability. (5)
Trauma is the most common cause of elbow stiffness. Posttraumatic causes of elbow contracture include elbow fracture-dislocations, heterotopic ossification, burns, and distal humerus and olecranon nonunions as well as posttraumatic arthritis. Fracture-dislocations are the most common type of trauma causing elbow contractures. Fracture-dislocations of the elbow with associated radial head and coronoid fractures ("terrible triad") should undergo repair of bony and ligamentous structures in order to facilitate early motion. Unreconstructable radial head fractures should undergo prosthetic replacement. Persistent elbow instability should receive medial collateral ligament repair or application of a hinged external fixator (Fig. 1). (6,7)
[FIGURE 1 OMITTED]
The incidence of heterotopic ossification (HO) following elbow injuries when associated with head trauma has been reported to be as high as 80% to 90%.8 Heterotopic ossification usually forms in the flexor compartment of the elbow and can cause significant posttraumatic contractures. Physical signs include tenderness, swelling, and limited motion. Prophylaxis strategies include nonsteroidal anti-inflammatory medications and low dose external beam radiation. Indomethacin may be administered within 24 hours of elbow trauma. (9) Postoperative radiation (700 cGy) within 72 hours of open reduction internal fixation of elbow fracture-dislocations may also lessen the incidence of functionally significant HO. (10) Surgery to resect heterotopic bone is indicated in cases with functional impairment and established HO and can result in functional elbow range of motion in 90% of patients. (11-13) Resection may be performed when the ectopic bone demonstrates a mature appearance on radiographs, marked by the presence of trabeculations and well-corticated margins; this is usually observed at four to six months after injury. Bone scans and alkaline phosphatase levels are not reliable indicators for timing of heterotopic bone resection. (12-14) Ring and Jupiter resected HO from nine posttraumatic ankylosed elbows through an extensive posterior approach. The patients in their series obtained a 28[degrees] increase in range of motion at an average follow-up of 40 months. (12,13) Functional rotational range of motion has also been obtained following surgical resection of proximal radioulnar synostosis. (11)
In general, the common pathology noted in these various causes of posttraumatic elbow stiffness is capsular contracture. (15) Elbow contractures have been classified into extrinsic or intrinsic types based on involvement of the articular surface. (16) Extrinsic contractures include contractures of extra-articular structures: skin, subcutaneous tissue, musculature, and joint capsule. Intrinsic contractures involve intra-articular pathology: arthritis, arthrofibrosis, and loose bodies. Extrinsic contractures typically require resection of the contracted structures, while intrinsic contractures require addressing the articular surface.
A thorough history, physical examination, and appropriate imaging studies are essential to guide the management of posttraumatic elbow stiffness. History should include the effect of the restricted range of motion on the patient's function. Some patients, for occupational or recreational activities, may require elbow motion outside of the accepted functional flexion-extension ranges of 30[degrees] to 130[degrees] and pronation-supination ranges of 50[degrees] to 50[degrees]. The duration of stiffness is important, because patients who have had contractures for less than one year are likely to make greater gains in range of motion after treatment than those with more long-standing stiffness. A detailed description of the precipitating trauma as well as previous nonsurgical and surgical treatments and associated neurologic injury or infection should be noted.
Physical examination includes inspection of the skin for scarring, open wounds, and previous incisions. All bony prominences are palpated to detect areas of tenderness that may limit motion secondary to pain. The elbow should be put through extension-flexion and pronation-supination arcs of motion and these ranges quantified with a goniometer. Rotational stability, motor strength and neurovascular status of the extremity should be assessed.
Standard anteroposterior and lateral radiographs are routinely obtained. On true lateral films, the three arcs of the capitellum, trochlear sulcus, and medial trochlea will be concentric. (17,18) Radial head fracture pathology can be detected on a "Greenspan" view of the radiocapitellar joint. (17,18) Restrictions of pronation and supination may require dedicated forearm and wrist films to evaluate the distal radio-ulnar joint and the entire two-bone forearm complex. Heterotopic ossification and intra-articular pathology may require CT scanning with reconstruction to precisely locate the ectopic bone and evaluate articular osseous anatomy.
The prevention of the development of posttraumatic elbow contractures begins with early stable internal fixation of fractures about the elbow joint (Fig. 2). The goal is to obtain a stable construct that can withstand early range of motion exercises. Simple elbow dislocations (without associated fractures) should be immobilized for no more than one week and then the patient can begin active assisted range of motion exercises. Nonsteroidal anti-inflammatory medications, ice, muscle strengthening, and gentle physical therapy will help patients increase their active range of motion. Forced passive manipulation can result in trauma to the brachialis and anterior capsule with subsequent inflammation, hemarthrosis, heterotopic ossification, and worsening of elbow contractures.
[FIGURE 2 OMITTED]
Once contractures have become fixed and patients have failed the above modes of treatment, static-progressive splinting should be started. Green and McCoy treated 15 patients with elbow stiffness with daily intermittent staticprogressive splinting. These patients demonstrated a 43[degrees] average increase in elbow motion. (19) Similarly, Bonutti and colleagues noted an average increase of 31[degrees] in the arc of motion of 20 patients with elbow stiffness treated with static-progressive splinting. (20)
If patients have failed a course of nonoperative management and have significant functional impairment impeding the performance of daily activities, they may be candidates for surgical intervention. These patients must be willing to participate in the necessary postoperative rehabilitation and must understand that they will probably not achieve pre-injury range of motion.
The choice of surgical approach to the elbow is based on the location of the pathology and condition of the skin. The medial approach requires elevating the brachialis and anterior half of the flexor pronator mass from the medial supracondylar ridge. The medial triceps is elevated off the posterior aspect of the humerus. (21) The anterior bundle of the medial collateral should be preserved to prevent valgus instability. The median nerve, brachial artery and vein are superficial to the brachialis muscle and are not identified. The anterior and posterior ulnohumeral joints can be visualized through this approach, and the ulnar nerve can be explored and transposed. Pathology at the radiocapitellar joint, however, cannot be addressed through the medial approach. (21)
The lateral approach involves elevating the extensor carpi radialis longus and brachioradialis from the lateral supracondylar ridge. Distally, the interval between the extensor carpi radialis longus and extensor carpi radialis brevis or the interval between the extensor carpi radialis brevis and extensor digitorum communis is developed. The lateral triceps is elevated off the posterior aspect of the humerus. This approach can also be extended distally into Kocher's interval (extensor carpi ulnaris and anconeus). The lateral approach allows for visualization of the radiocapitellar joint and the anterior and posterior ulnohumeral joints. The lateral ulnar collateral ligament is either spared or, if released, repaired through drill holes in the humerus, preventing posterolateral rotatory instability. A separate medial incision is necessary to decompress the ulnar nerve. (22-24)
The anterior approach utilizes the interval between the brachioradialis and biceps brachialis. This approach affords direct access to anterior pathology, including contractures of the biceps, brachialis, and anterior capsule. Disadvantages include the proximity of the brachial artery and median nerve to the dissection and the inability to visualize posterior pathology in the olecranon fossa. (25)
In the posterior triceps-sparing approach, the triceps is elevated as a sleeve from the humerus leaving its insertion intact and obviating the need for an olecranon osteotomy. (26) This provides excellent visualization of the ulnohumeral articular surface and allows for internal fixation of intra-articular distal humerus fractures and total elbow arthroplasty. Additionally, medial and lateral access to the elbow joint can be created by elevating the triceps medially and laterally from the posterior aspect of the distal humerus.
Arthroscopy can be used in select cases to perform capsular releases, debride synovium, osteophytes, internally fix fractures, and resect the radial head. (27,28) Timmerman and Andrews reported on 19 cases of posttraumatic elbow stiffness treated with arthroscopic debridement. Postoperative motion increased by 29[degrees] at 29 months. (29) Ball and colleagues reported on 14 patients with posttraumatic elbow stiffness who underwent elbow arthroscopy and capsular release. Postoperative motion increased by 42[degrees] at one year. (30) The diminished capsular volume in the arthrofibrotic elbow may increase the incidence of neurovascular injury during arthroscopy. (31) Furthermore, the posttraumatic elbow may alter bony landmarks, which makes safe portal placement difficult. Complete transections of the median and radial nerves during arthroscopic contracture release of a posttraumatic elbow has been reported. (32)
Surgical Procedures for Extrinsic Contractures
There are several surgical procedures that may be used to treat elbow contractures. The choice of technique depends on whether the contractures are extrinsic or intrinsic and the degree of arthritis (Table 1). Patients with little evidence of posttraumatic arthritis may benefit from removal of bony and soft tissue impingement and soft tissue releases (Fig. 3). Bony impingement is often secondary to overgrowth at the tip of the olecranon or coronoid process. Procedures include capsulectomy, proximal mobilization of the anterior compartment musculature, and resection of heterotopic ossification. Morrey and colleagues treated 6 patients with posttraumatic elbow contractures with anterior and posterior capsulectomy and soft tissue releases through a lateral approach. These patients demonstrated an improvement in flexion of 24[degrees] and extension of 18[degrees] at 57 months follow-up. (16) Similarly, Husband and Hastings performed anterior and posterior capsulectomy through a lateral approach on 7 patients with posttraumatic elbow contracture; flexion increased by 13[degrees] and extension by 33[degrees] at 38 months follow-up. (24)
[FIGURE 3 OMITTED]
The techniques presented above often included release of the lateral collateral ligament during the approach and repair at the end of the procedure. (16,24) To prevent potential posterolateral rotatory instability, lateral-collateral ligament sparing techniques were proposed. (5,22,23) The column procedure, a limited lateral Kocher approach to the anterior and posterior capsule that spares the lateral collateral ligament, can be used to treat extrinsic contractures. This approach involves elevation of the extensor carpi radialis longus and brachioradialis anteriorly and the triceps posteriorly, thus allowing for resection of the capsule, soft tissue, and bony impingement. Mansat and Morrey reported results on 38 stiff elbows that demonstrated an increase in flexion of 20[degrees] and extension of 25[degrees] at a mean interval of 43 months after the column procedure. (23) Cohen and Hastings reported on 22 patients with elbow contractures who underwent an increase in flexion of 24[degrees] and extension of 31[degrees] at a mean interval of 26 months following this procedure. (22)
Surgical Procedures for Intrinsic Contractures
Patients with posttraumatic arthritic changes along with stiffness may benefit from more aggressive bony debridement procedures. Elbow debridement arthroplasty, originally described by Tsuge and colleagues, consists of obtaining a wide exposure of the elbow joint by dividing the lateral collateral ligament and elevating the triceps attachment. The elbow joint is hinged open with a varus stress and contracted soft tissue. Heterotopic ossification and impinging osteophytes are excised from the coranoid, olecranon, all fossae, and the radial head. After debridement, the lateral collateral ligament is repaired. (33,34) Tsuge and colleagues reported on 43 patients who demonstrated a 59[degrees] improvement in motion at 110 months following this procedure. (33) In a later study, Tsuge and Misuzeki reported on 29 patients with elbow contractures who demonstrated a 34[degrees] improvement in elbow motion at 64 months following arthroplasty. (34)
Wada and colleagues reported on 33 elbows treated with debridement arthroplasty through a medial approach with preservation of the anterior bundle of the medial collateral ligament and ulnar nerve transposition. (35) These patients, mostly with elbow stiffness secondary to osteoarthritis, demonstrated a 24[degrees] improvement in motion at a mean interval of 121 months following this procedure. (35) These investigators suggested that more severe contractures should be approached laterally with division of the lateral collateral, because the elbow can be subluxed providing a more extensive view of the joint. (34)
The Outerbridge-Kashiwagi arthroplasty allows for debridement of both anterior and posterior compartments through a drill hole created with a trephine in the olecranon fossa. Morrey and colleagues treated 15 patients with elbow stiffness secondary to osteoarthritis with this technique; this cohort demonstrated a 21[degrees] improvement in motion following surgery. (36) Savoie and colleagues described an arthroscopic version of the Outerbridge-Kashiwagi ulnohumeral arthroplasty. Twenty-four patients underwent arthroscopic debridement, fenestration of the olecranon fossa, and partial resection of the coronoid and olecranon processes. The radial head was excised arthroscopically in 18 of the 24 cases. These patients demonstrated an 81[degrees] improvement in motion at an average follow-up of 32 months. (27) Good outcomes following the Outerbridge-Kashiwagi arthroplasty appear to be associated with less than two years of symptoms, considerable preoperative pain, or cubital tunnel syndrome; a history of trauma is not associated with outcome. (37)
Young, active patients with advanced degenerative arthritis and incongruity of more than half the ulnohumeral articular surface may benefit from fascial interpositional arthroplasty with fascia lata, cutis graft, or Achilles tendon allograft and a hinged spanning distraction external fixator. The joint is approached posteriorly, the distal humeral and proximal ulnar articular surfaces are smoothly contoured and an interpositional graft is sutured to the articular surface of the distal humerus. A hinged spanning external fixator is applied for one month to protect the graft and allow for immediate motion. Morrey treated 6 elbows with posttraumatic arthritis and contracture with distraction interpositional arthroplasty. This cohort demonstrated an 80[degrees] increase in motion at 2.8 years follow-up. (16) In a five-year follow-up of 13 patients with painful mobile arthritic elbows treated by distraction interposition arthroplasty using fascia lata, Cheng and Morrey observed a 31% revision rate to total elbow arthroplasty at a mean of 30 months; this suggests that the long-term durability of distraction interpositional arthroplasty in younger, active patients is poor. (38)
For management of patients with posttraumatic radiocapitellar or proximal radioulnar joint dysfunction, interpositional arthroplasties using the anconeus muscle have been proposed. (39) This technique has advantages to radial head resection alone in cases of interosseus membrane disruption (the Essex-Lopresti lesion), which can result in proximal radial migration and wrist pain. (3) Morrey and colleagues have described three interposition patterns: interposition at the radiocapitellar joint, interposition at the radiocapitellar and proximal radioulnar joints, and proximal radioulnar interposition. Twelve of 14 patients treated with one of the three types of anconeus interposition arthroplasty had satisfactory subjective results at a minimum follow-up of two years. Pronation-supination motion increased from 36[degrees] to 33[degrees] preoperatively to 66[degrees] to 49[degrees] postoperatively. (39)
Semiconstrained total elbow arthroplasty is indicated in older, less active patients with severe posttraumatic elbow arthritis and stiffness. Fifty-three Coonrad-Morrey semiconstrained total elbow arthroplasties were performed for posttraumatic arthritis of the elbow. This cohort demonstrated a 22[degrees] increase in motion at an average of 6.3 years of follow-up. (40) Mansat and Morrey reported on 14 Coonrad-Morrey semiconstrained total elbow arthroplasties (nine performed for ankylosed elbows). These patients demonstrated a 60[degrees] increase in motion at a mean follow-up of five years. (41) However, revision rates for complications such as loosening and periprosthetic fracture are high. (40,41)
There are several complications that may occur following surgical release of posttraumatic elbow contracture. Ulnar neuritis after surgical release, often seen in patients with preoperative ulnar nerve symptoms or severe flexion contracture, may require ulnar nerve transposition. (42) Heterotopic ossification, if limiting postoperative rehabilitation, will require resection when mature. (9) Reflex sympathetic dystrophy, characterized by pain and trophic changes at the elbow joint, is treated with gentle active physical therapy and sympathetic blocks. (43) Neuropathic arthropathy, resulting from denervation of the elbow joint, presents as a painless destructive arthropathy. These patients should be treated with physical therapy; arthroplasty is contraindicated in this population. (7)
Posttraumatic elbow stiffness can impose severe functional limitations on the performance of activities of daily living. Prevention is key to avoiding a motion-limiting condition. Fractures should be anatomically reduced and stabilized with active and active-assisted range of motion exercises instituted as early as possible to minimize the development of stiffness. Established contractures should be treated initially with physical therapy and static-progressive splinting. Patients who have failed a minimum of six months of nonsurgical management and who are motivated to comply with postoperative rehabilitation are candidates for surgical release. There are several effective surgical approaches and techniques available. The choice of surgical approach and technique is dictated by the location of the pathology, condition of the skin, and degree of arthritic changes. A major challenge to care is the management of the young patient with posttraumatic elbow contracture and advanced degenerative changes for which there is currently no reliable long-term surgical treatment.
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Paul S. Issack, M.D., Ph.D., is Senior Resident in the NYU-Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York. Kenneth A. Egol, M.D., is Assistant Professor of Orthopaedic Surgery in the NYU-Hospital for Joint Diseases Department of Orthopaedic Surgery, New York, New York.
Correspondence: Kenneth A. Egol, M.D., NYU-Hospital for Joint Diseases Department of Orthopaedic Surgery, 301 East 17th Street, New York, New York 10003.
Table 1 Indications and Surgical Procedures for Elbow Contracture Release Contracture Type Procedures Comments Extrinsic contractures Arthroscopic soft Technical skill; tissue releases potential neuro- vascular injury open soft tissue Allows for a wide releases release; lateral approach may result in posterolateral rotatory instability Column procedure LUCL-sparing proce- dure; may need separate medial incision for ulnar nerve decompression Intrinsic contractures Arthroscopic bony Technical skill; debridement potential neuro- vascular injury (Moderate arthritis) Open bony debride- Allows for a wide ment arthroplasty release; lateral approach may result in posterolateral rotatory instability Outerbridge-Kash- Indicated for iwagi ulnohumeral impingement at arthroplasty terminal extension/ flexion; contra- indicated in cases of extensive joint arthritis Intrinsic contractures Fascial inter- Younger patients; positional long-term results arthroplasty unreliable (Severe arthritis) Anconeus arthro- RC or PRUJ arthritis plasty Total elbow Physiologically arthroplasty older patients
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|Author:||Issack, Paul S.; Egol, Kenneth A.|
|Publication:||Bulletin of the NYU Hospital for Joint Diseases|
|Date:||Jan 1, 2006|
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