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Prevention and Treatment of Elbow Stiffness

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The elbow is as prone to stiffness as it is essential for upper-extremity function. The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury. Elbow contracture is challenging to treat, and therefore prevention is of paramount importance. When this approach fails, nonoperative followed by operative treatment modalities can be pursued. In the future, efforts to prevent and treat elbow stiffness may target the basic science mechanisms involved.

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Etiologies

Traumatic causes of elbow stiffness include fractures, dislocations, soft tissue crush or burns, and head injury with a degree of stiffness that is typically directly proportional to the severity of the insult.2 Elective elbow surgery results in controlled trauma to the tissues and may also be complicated by postoperative stiffness. Atraumatic causes of elbow stiffness include rheumatoid arthritis, osteoarthritis, post-septic arthritis, multiple hemarthroses in hemophiliacs, and congenital

Classification

The 2 primary elbow stiffness classification systems are those of Kay and Morrey.3, 22 Whereas Kay's classification is based on the structure impeding elbow motion, Morrey's classification is based on the etiology and its anatomic location.3 Kay's 5-part classification system includes soft tissue contracture (type I), soft tissue contracture with ossification (type II), nondisplaced articular fracture with soft tissue contracture (type III), displaced intra-articular fracture with soft tissue

Evaluation

A thorough history and physical examination complemented by imaging studies comprises the requisite evaluation for elbow stiffness. The history should include the onset, duration, character, and progression of symptoms. Inquiries should be made into elbow trauma or pathology, especially infection, and prior nonsurgical or surgical treatments. Comorbid conditions should be investigated as they may have implications on the elbow, such as hemophilia with resulting hemarthroses or neurologic

Prevention

Elbow stiffness is minimized with the effective treatment of disease processes that damage the elbow articular surface and compromise motion. The underlying processes involved in inflammatory arthropathies should be medically controlled by a rheumatologist prescribing anti-inflammatory medications and disease-modifying antirheumatologic drugs to slow joint destruction. Hemophiliacs should receive appropriate blood factor repletion to prevent multiple hemarthroses. Joint degeneration may also be

Nonsurgical Treatment

The goals in treating the stiff elbow are to provide patients with a pain-free, functional, and stable elbow. Timing, severity, patient-specific factors, and underlying pathology guide the selection of specific treatment protocols. Nonoperative treatment is considered upon initial presentation in those who have minimal contractures of 6 months duration or less.3, 17, 26 Nonoperative treatments for elbow stiffness include static and dynamic splinting, serial casting, continuous passive motion,

Surgical Treatment

Operative treatment is appropriate for those patients who have failed to achieve adequate pain relief or functional range of motion after initial nonoperative management or who have substantial bony blocks. The decision to operate is based on elbow function, patient factors, and surgeon preference. Flexion contractures greater than 30° or the inability to flex the elbow to at least 130° are often an indication for surgery. However, surgery may be pursued for smaller deficiencies in elbow motion

Postoperative Care

Whether the patient is treated as an inpatient or an outpatient, our preference is to splint the elbow in extension for 24 hours then remove the splint and suction drains and encourage activities of daily living with a compression dressing. Judicious use of ice or a compression ice system is used for the first 72 hours with gentle squeezing of a light compression foam block to augment venous and lymphatic return. If insurance allows, continuous passive motion for flexion-extension and

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