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Ebow Flexion Contracture / Stiff Elbow

- Discussion:
    - generally the functional range of motion for the elbow is between 30 to 130 deg;
    - flexion contractures greater than 45 deg will significantly limit ADLs;
    - hetertopic ossfication:
           - may occur after isolated spinal cord injury (3-5%), but will tend to occur in the majority of patients w/ spinal cord injuries and elbow trauma;
    - diff dx of elbow stiffness:
           - loss of the normal 30° anterior tilt of the distal humeral articular surface;
           - narrowing or distortion of the trochlear articular surface;
           - obstruction of the coronoid and olecranon fossae;
           - ulnohumeral arthrosis;

- PreOp Planning:
    - it is necessary to determine whether these patients have loss of motion due to soft tissue contracture or due to osseous impingment;
    - need to determine whether the loss of motion is flexion, extension, or flexion and extension and whether osteophytes or heterotopic bone contributes;
    - if hetertopic ossfication has caused loss of motion, consider allowing process to mature (sharp cortical and trabecular markings) before operative resection;
           - attempt to determine from radiographs, the anatomic location of the ossification, ie, between the brachialis and anterior capsule or
                     between the triceps and the posterior capsule;

- Non Operative Treatment:
    - indicated for patients whose contracture is due to soft tissues rather than bony impingment.
    - some patients may expect a 30 deg increase in elbow range of motion with use of a turnbuckle splint over 5 months;
    - some authors will not procede with surgery until the patient has undergone 12 weeks of PT and until 5 months have passed since the time of surgery;
    - serial casting and/or bracing:
           - may expect 30 deg improvement in some patients;
           - casts are changed every 3-5 days for 2 months;
           - in study by Gelinas JJ, et al (2000): 22 patients treated w/ elbow contracture using a static progressive turnbuckle splint for 4.5 ± 1.8 months;
                 - mean range of flexion before splintage was from 32 ± 10° to 108 ± 19° and afterwards from 26 ± 10° (p = 0.02) to 127 ± 12° (p = 0.0001);
                 - total of 11 patients gained a 'functional arc of movement,' defined as at least 30° to 130°
                 - in eight patients movement improved with turnbuckle splinting, but the functional arc was not achieved;
                 - 6 of these were satisfied and did not wish to proceed with surgical treatment and two had release of the elbow contracture.
                 - 3 patients movement did not improve with the use of the turnbuckle splint and one subsequently had surgical treatment;
    - references:
           - The effectiveness of turnbuckle splinting for elbow contractures.

- Operative Treatment:
    - postero-lateral release of anterior capsule;
          - allows both anterior and posterior access to the elbow, and therefore, can address both flexion and extension contractures;
          - w/ callus impinging into the olecranon, this approach allows the tip of the olecranon to be removed;
    - medial release:
patients that lack flexion (past 90 deg) will have a contracture of the posterior band of the MCL, and this structure will require surgical release;
          - posterior band of the MCL lies on the floor of the cubital tunnel, and excessive scarring can also lead to ulnar nerve compression;
          - Wada et al (2000) treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows);
                - single medial approach, posterior oblique bundle of medial collateral ligament was resected, followed by posterior and anterior capsulectomies;
                - all 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament;
                - additional lateral release through a separate incision was required in only four elbows;
                - at a mean interval of 57 months after operation, active extension improved from 43° to 17° and active flexion improved from 89° to 127 deg;
          - references:
                - The medial approach for operative release of post-traumatic contracture of the elbow. T. Wada,  J Bone Joint Surg [Br] 2000;82-B:68-73. 
                - Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness

    - anterior approach (Urbaniak):
          - allows direct release of the capsule;
          - references:
                - Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy.
                - Anterior capsulotomy and continuous passive motion in the treatment of post-traumatic flexion contracture of the elbow. A prospective study.

    - ulna-humeral arthroplasty:
    - olecranon osteotomy:
          - allows release of posterior capsule and will allow concomitant release of the anterior capsule if a non union is present;

- Post Operative Care:
    - continuous passive motion: traditionally this has been associated w/ RSD, but there is little evidence to support this;
    - forced passive manipulation: may be associated w/ hetertopic ossification (again little evidence to support this)
    - references:
             - Delayed-onset ulnar neuritis after release of elbow contractures: clinical presentation, pathological findings, and treatment.
             - Delayed-Onset Ulnar Neuritis After Release of Elbow Contracture: Preventive Strategies Derived From a Study of 563 Cases

Manipulation of the stiff elbow with patient under anesthesia.

Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty.

Flexorplasty of the elbow.

Elbow flexorplasty. An analysis of long-term results.

The surgical treatment of heterotopic ossification at the elbow following long-term coma.

Turnbuckle orthotic correction of elbow flexion contractures after acute injuries

Radial nerve palsy after arthroscopic anterior capsular release for degenerative elbow contracture.

Complete transection of the median and radial nerves during arthroscopic release of post-traumatic elbow contracture.

Management of severe extra-articular contracture of the elbow by open arthrolysis and a monolateral hinged external fixator

Limited Medial and Lateral Approaches to Treat Stiff Elbows