Etiopathogenesis and management of stiff elbow

1. Dr. Sushil Paudel

2. Anatomy
Comprises of
Humero-ulnar joint:
Hinge joint
Determinant of osseous stability
Humero-radial joint
Pivot joint
Radial head acts as secondary stabilizer to
valgus stress
More stable in extreme flexion and extension
rather than mid-range

3. Anatomy
Stabilizers
Static:
Bony articulation
Capsule
Medial Collateral ligament
Lateral Collateral ligament
Dynamic:
Muscles

4. Anatomy

5. Anatomy

6. Anatomy

7. Anatomy

8. Anatomy
Range of Motion
Extension: 0o
Flexion: 145o
Pronation: 80o
Supination: 75o

9. Functional Range of Motion
Range of motion necessary for a individual
to perform 90% of normal daily activity.
Arc of elbow flexion of 100o
, ranging from 30o
to 130o
.
Arc of forearm rotation of 100o
, ranging from
50o
pronation to 50o
supination.
Morrey et al . A biomechanical study of normal function elbow motion.
J Bone joint Surg 63 A: 872 – 877, 1981.

10. Aetiology
Post traumatic:
Joint incongruity
Dislocation/Subluxation
Heterotopic Ossification
Burns
Coronoid/Olecranon/Radial Osteophytes
Loose Bodies
Triceps/Biceps adhesions
Chronic Infection
Inflammatory Arthritis
Patient Noncompliance
Post Surgery

11. Classification
Extrinsic Contractures:
(Sparing of joint surface)
Soft Tissue Ectopic Ossification
Capsulo-
ligamentous
Muscular

12. Classification
Intrinsic Contractures :
usually associated with intraarticular
fractures
Intraarticular adhesions from healed congruous
joint fracture
Loss of articular cartilage due to avascular
necrosis
Gross distortion resulting from inadequate or failed
reduction

13. Pathogenesis
Predisposing factors for posttraumatic
elbow stiffness
High degree of articular congruity & conformity
of joint predispose to limited motion after
articular injury
Brachialis muscle covers anterior capsule
predisposing it to posttraumatic ectopic
ossification
Delayed mobilization after elbow injury usually
because of inability to achieve rigid fixation

14. Management
Conservative:
Splints
Static
Dynamic
Range of motion exercises
Active Exercises
Continuous Passive Motion

15. Conservative
Management
Static Splints

16. Conservative
Management
Dynamic Splints

17. Conservative
Management
Continuous Passive Motion

18. Management
Operative :
Considerations before Planning Surgery
Patients expectations and limitations
Patients functional needs
Likelihood that procedure will satisfy these
needs.

19. Management
Operative:
Risk associated with surgery
Postoperative pain
Instability: as release of collateral ligament
required for
Adequate soft tissue release
Removal of Ectopic Bone
Adequate exposure if Intraarticular pathology
Weakness

20. Anterior Contracture Release
Indications:
Loss of extension > 45o
Minimal changes in articular surface
Contraindications:
Significant alteration of the articular
contour
loss of joint cartilage > 50%
pathology requiring release of one or
both collateral ligaments
Motor deficiency or spasticity

21. Anterior Contracture Release
Technique: (Column procedure)
Posterolateral incision
Dissection between Extensor Carpi
ulnaris and Anconeus
Separate extensor tendon from joint
capsule and LCL
Anterior capsule exposed and incision made
over anterior capsule anterior and parallel to
LCL
As wide a capsular excision is done as
possible

22. Anterior Contracture Release

23. Posterior Contracture Release
If flexion limited:
Interval between Triceps and ECRL
exposed
Triceps elevated from posterior aspect of
humerus
Posterior capsule excised

24. Posterior Contracture Release

25. Anterior Contracture Release
Excision of osteophytes at tip of
Olecranon & Coronoid process

26. Anterior Contracture Release
Postoperative Management
Adequate analgesia
Continuous passive motion:
started immediately
for 3 weeks
Reassessed at 3 weeks and static splints
given
Splintage primarily in extension for 3
months
Gradual weaning from splints

27. Contracture Release
Complications:
Ulnar nerve injury
Median nerve injury if
contracture > 90o
Morrey B F . Master techniques in orthopaedic surgery – The Elbow

28. Arthrolysis (Bhattacharya
Procedure)
Removal of capsular contracture
Mobilizing Brachialis & Triceps from lower humerus ,
Restoration of trochlear pulley
Minimal removal of Bone block without excising
articular surface
Postoperative Management:
After closure of wound 25 mg inj. Hydrocortisone
acetate injected in joint with 2 – 5 cc of Hyalase.
Compression bandage with splint in full extension
Second dose of Hydrocortisone is given with 2 – 4
cc lignocaine (2%) on 7th
or 10th
day.

29. Distraction Arthroplasty
Simultaneous joint motion while ensuring stability by
protecting collateral lig.
Indications:
Reconstructive
Adjuvant to capsule release if ligaments
damaged
Significant dissection making intraoperative
motion difficult
> 50% joint surface void of cartilage
Modified joint contour

30. Distraction Arthroplasty

31. Distraction Arthroplasty

32. Distraction Arthroplasty
Goals
Separate joint surfaces
Reorient joint surface
Protect ligament healing
Allow motion
Contraindications
Inexperience
Local sepsis
# distal humerus or proximal ulna

33. Distraction Arthroplasty
If as adjuvant to capsular release
Caution
Identification of Ulnar Nerve important at
three steps
Reflecting Triceps
Capsular Dissection
Pin Placement

34. Distraction Arthroplasty
Technique: Pin Placement
Tubercle of capitellum (Lat) to just anterior
and inferior to medial epicondyle
Two Ulnar pins anterior and posterior to
center of articulation
Pins should be placed parallel
3 – 5 mm distraction

35. Distraction Arthroplasty
Postoperative management
Adequate analgesia
Continuous passive motion for 3 weeks
Distraction device removed at 3 weeks
Flexion – Extension splints till 6 – 12 weeks
Morrey B F . Master techniques in orthopaedic surgery – The Elbow

36. Fascial Interposition Arthroplasty
Indications:
Young adults with posttraumatic ankylosis
of elbow with intact broad contour of distal
humerus
Young adult Stage I & II Rheumatoid
arthritis,with intact bone
Contraindications:
Active infection
Grossly unstable elbow
Congenital ankylosis (lacks soft ts support)

37. Fascial Interposition Arthroplasty
Preoperative planning:
Selection of donor site
Avoid hairy donor site (risk of inclusion cysts)
Cutis – preferred material
Cutis – thick dermal layer of skin remaining
after superficial epidermis has been peeled
off.

38. Fascial Interposition Arthroplasty
Technique:
Extended Kocher’s lateral approach
Extensor mass,periosteum and LCL dissected off
the lateral condyle
Medial collateral lig sectioned from within
Elbow dislocated and distal end of humerus is
prepared – removal of osteophytes,articular
cartilage, bone fragments
Smooth rounded surface obtained ~ 4 cm wide &
~ 2 cm anterior to posterior
Radial head removed only if necessary to restore
pronation & supination

39. Fascial Interposition Arthroplasty
Technique: (contd…..)
Split thickness graft taken from donor site
Deep dermal layer is excised from
subcutaneous fat (Cutis)
Cutis graft draped over distal humerus with
superficial cut surface of dermis applied to bone
Dermal graft sutured with drill holes in medial
and lateral ridges

40. Fascial Interposition Arthroplasty

41. Fascial Interposition Arthroplasty

42. Fascial Interposition Arthroplasty
Postoperative Management:
Posterior plaster splint in 90o
flexion for 2 weeks
Hinged cast brace for 4 weeks
Resistive flexion exercises started at 1 month
Extension strengthening exercises started at
6 weeks
Complications:
Medial-lateral laxity

43. Elbow Arthroscopy
Applications in Stiff elbow:
Removal of loose bodies
Debridement of joint surface or
adhesions
Release of Capsular contractures
Excision of osteophytes causing
impingement (as in early osteoarthritis
of ulnohumeral joint)

44. Elbow Arthroscopy
Contraindications:
Altered Neuro-vascular anatomy
Extraarticular deformity like ectopic bone or
displaced radial neck
Severely contracted or fibrotic joint

45. Elbow Arthroscopy
Technique:
Patient lying in lateral or supine position
Elbow flexed at 90o
Ports

46. Elbow Arthroscopy
Advantages:
Complete examination & treatment options
Debridement of intraarticular adhesions
improve ROM as well as relieve pain
Relatively less soft ts trauma & post op
scarring reduce risk of recurrent
contractures.

47. Elbow Arthroscopy
Complications:
Permanent nerve injuries
Vicinity of Radial & median nerves to
anterior portals
Restricted Capsular Distension (Capsular
distension achieved with 15 – 25 ml saline,
intracapsular capacity ~ 6 ml in contractures)

48. Elbow Arthroscopy

49. Ectopic Ossification
Types:
Heterotopic Ossification : formation of
mature lamellar bone in non-osseous tissue
Myositis Ossificans
Periarticular calcification : collection of
calcium pyrophosphate crystals in soft
tissue (lacks trabecular pattern)

50. Ectopic Ossification
Predisposing factors:
Elbow trauma
Neural axis trauma
Burns
Diffuse skeletal Hyperostosis
Hypertrophic osteoarthrosis
Ankylosing spondylitis
Paget’s Disease
History of Ectopic ossification

51. Ectopic Ossification
Presentation:
Usually at 2 weeks after insult
Localized swelling, bone pain, Hyperemia,
local tenderness
Elbow stiffness after 1 – 4 months
Nerve entrapment syndromes – ulnar
nerve most common

52. Ectopic Ossification
Radiological features:
Early
Absence of trabeculae
Indistinct margins
Mature
Well defined trabeculae
distinct margins

53. Ectopic Ossification
ZONE phenomenon
Myositis Ossificans matures from inside to
Outside , i.e. Core is composed of immature
osseous tissue , while the most superficial
region is composed of most mature osseous
tissue.

54. Ectopic Ossification
Classification:
Based on Location:

55. Ectopic Ossification
Classification:
Randal W V et al
Type I : ossification of Proximal radio-ulnar
joint
Type II : ossification of proximal RUJ with distal
extension involving the bicipital tuberosity
Type III : ossification of radius & ulna distal to proximal
RUJ
Subtype A – Anterior involvement
Subtype B – Posterior involvement
Subtype C – intraarticular involvement of PRUJ

56. Ectopic Ossification
Classification:
Functional classification
Class I : Radiologically evident elbow ectopic ossification
without clinical limitation
Class II : Subtotal, functional, limitation of motion
A: in flexion & extension plane
B: in pronation & supination plane
C: in both planes
Class III : Ankylosis that eliminates motion
A:, B:, C:.
Hastings H, Graham TJ : The classification and treatment of heterotopic
ossification about elbow and forearm. Hand Clin 10:417-437, 1994.

57. Ectopic Ossification
Prophylaxis:
Chemotherapeutic agents:
Diphosphonates:
? interfere with ossification of osteoid
? Rebound calcification
NSAIDS: Indomethacin
prevent precursor cells from differentiation
Radiation Therapy:
low dose external beam radiation

58. Ectopic Ossification
Non-operative treatment:
Aggressive motion programme
Active Exercises
Slow & aggressive passive Force
? Enhance ectopic ossification &
exacerbate elbow stiffness *
Dynamic splinting
*Stover SL, Hataway CJ: Heterotopic ossification in spinal cord-injured
patients. Arch Phys Med Rehabil 56:199-204, 1975.

59. Ectopic Ossification
Operative Treatment:
Indications / Criteria
Functionally limiting elbow stiffness
Radiographic union of fracture
Radiographic evidence of intact ulno-humeral
articular surface
Stage of maturation
Stabilization of traumatic brain injury & motivation
to complete therapy
Soft tissue stability

60. Ectopic Ossification
Operative Treatment:
Timing of surgery
Advantages of Delayed intervention
Metabolic quiescent ectopic bone
Maximal neurological recovery
Problems with delayed Intervention
Progressive soft tissue contracture
Potential articular cartilage destruction
Prolonged infirmity

61. Ectopic Ossification
Essentials
Select incision allowing resection of all ectopic
ossification
Decompression of compressed nerve
Resection of anterior and posterior capsule
Clearing of coronoid fossa
Debridement of coronoid process
Clearing of Olecranon fossa
Excision of terminal 1 – 1.5 cm of olecranon
Correction of elbow instability
Transposition of ulnar nerve
Preserve anterior band of MCL & LCL & Orbicular
cartilage even in presence of periarticular
calcification

62. Ectopic Ossification
Operative Treatment:
Complications:
Recurrent stiff elbow
Triceps rupture
Aseptic resorption of Capitellum
Skin necrosis
Hematoma formation
Randall WV, Hastings H II: Treatment of Ectopic Ossification about
Elbow . CORR 370: 65 – 86, 2000.

63. Indications:
Age > 60
Advanced arthritis or posttraumatic destruction
of joints
Total Elbow Arthroplasty
Types
Semi constrained or linked prosthesis
Unconstrained or unlinked prosthesis

64. Total Elbow Arthroplasty
Unconstrained / Unlinked prosthesis
Prerequisite
Good Bone Stock
Little Deformity
Stable Capsulo-ligamentous support
Uncommon in a Posttraumatic elbow
Indications
Elderly patients with primary Rheumatoid
joint
Painless ankylosed elbow at 90o
in young
patient with Juvenile Rheumatoid Arthritis
Kudo Elbow
IBP Elbow

65. Total Elbow Arthroplasty

66. Total Elbow Arthroplasty
Unconstrained / Unlinked prosthesis
Extended Kocher’s Approach
Post operative Management
Elbow placed in 60o
flexion & full pronation
ROM exercises started usually by 2nd
day
Active Assisted elbow flexion & passive
gravity extension
Forearm placed in pronation to protect LCL for 6 wks
Resting splint in 90o
flexion
Extension beyond 30o
avoided for first 3 - 4 weeks

67. Total Elbow Arthroplasty
Semi constrained / linked prosthesis
Predominant role in reconstruction of posttraumatic
elbow
Indication
Elderly patient with post traumatic / arthritic
joint destruction with
Deficit Bone Stock
Unstable Capsulo-ligamentous support
Deformity

68. Total Elbow Arthroplasty

69. Total Elbow Arthroplasty
Semi constrained / linked prosthesis
Posterior / Bryan-Morrey Approach
Post operative Management
Postoperative splintage in full extension
Assisted flexion & forearm rotation started 2nd
day
with gravity assisted extension
Daytime resting splint in 90o
flexion for 6 weeks
Night time extension splint for 12 weeks
GSB III

70. Total Elbow Arthroplasty
Baksi’s Sloppy Hinge prosthesis
79 ( 69 Ankylosed ) elbows replaced with
sloppy hinge prosthesis ,followed over 10 years.
Painless stable motion in 59 ( 86.8 % )
ankylosed elbows with average arc 88.8o
.
Aseptic loosening in 4 patients
Bakshi : Sloppy Hinge prosthetic elbow replacement for posttraumatic
ankylosis or instability. J Bone Joint Surg 80 (B):614-619,1998.

71. Total Elbow Arthroplasty
Life Time Restrictions
Lifting weight not more than 5 kg
Avoid upper limb impact sports
Morrey BF:Master Techniques in Orthopaedics – The Elbow
Moro JK, King GJ: Total Elbow Arthroplasty in the Treatment of
Posttraumatic Conditions of the Elbow. CORR 370:102-114,2000.

72. Total Elbow Arthroplasty
Expected to improve valgus and
rotational stability#
 ? Increased incidence of loosening of
humeral component*
Proper position & orientation of
prosthesis ????
#
O’Driscoll, King GJW: Treatment of instability after total elbow
arthroplasty. Orthop Clin North Am 2001,32:679-695
* Ewald FC et al.: Capitellocondylar total elbow arthroplasty. J Bone Joint
Surg 62(A) :1259,1980.
??#!!/??
Role of Radial Head Replacement

73. Adjuvant Procedures
Lengthening of Triceps Aponeurosis
Debridement & Synovectomy
Manipulation under Anesthesia
Radial Head Excision

74. Posttraumatic Stiff Elbow
Age < 60, motion < 45-115o,stability intact
Pain less, strength - normal
Acute Sub acute Chronic
Rigid ORIF ?
CPM
Splints
<6 mths
Splints
Anti-inflammatory
Close follow-up
6-12 mths
X-Ray + Tomo
No Ectopic Ossification Ectopic Ossification
Extrinsic Intrinsic Bone bridge Soft tissue
Posterior capsule
Anterior capsule
Adhesions
Articular deformity
Resect Muscle (Myositis Ossificans)
Capsule
Ligaments
May need distraction

75. Impingement
Coronoid
Olecranon
Articular
Acceptable Surface
Release
Distract if Unstable
Poor Articular
Surface
< 50% articular cartilage
>50% cartilage avulsed
Malunion of surface
Resurface fracture
Distraction
Intrinsic

76. References
Reconstructive Surgery of joints. Bernard F. Morrey.
Master Techniques in Orthopaedic Surgery- The
Elbow. Bernard F. Morrey.
The Athletes Elbow. David W. Altchek
Green’s Operative hand Surgery
Textbook of orthopaedics & Trauma . Kulkarni.
Clin Orthop 370,2000.
J Bone Joint Surg 83-B,1998
Current Opinion in Orthopaedics:Vol.1(4),2002.

78. KEEP
CONFERENCE
HALL
CLEAN
PLEASE DISPOSE
EMPTY BOXES
OUTSIDE THE HALL