Stiff Elbow

Etiology

Various factors can cause elbow stiffness, including posttraumatic arthritis, heterotopic ossification, nonunion or malunion, and soft tissue contracture around the elbow.[2][3] Regan and Reilly identified 3 contributors to elbow contracture: complex anatomy, the anterior brachial muscle covering the anterior capsule that promotes ossification, and prolonged immobilization caused by challenges in achieving stable osteosynthesis, particularly in complex fractures.

The degree of joint injury primarily determines elbow stiffness, with additional influence from periosteum loss and the duration of immobilization. These factors may explain the occurrence of significant contractures in undisplaced fractures or displaced ones that have been adequately reduced and stabilized. Nontraumatic causes of stiffness include hemophilia, infection sequelae, rheumatoid arthritis, and osteoarthritis.[4] Congenital etiologies include arthrogryposis and congenital dislocation of the radial head.

Stiffness Due to Heterotopic Ossification

The formation of mature bone in nonbony locations frequently occurs in the elbow, although the exact cause behind this process remains unknown. Amorphous calcium deposits affecting the capsule and collateral ligaments may consolidate into periarticular calcifications, making differentiation from heterotopic ossification crucial.

Heterotopic ossification typically presents after direct elbow trauma. Post-dislocation incidence rises to 3%, according to the literature, and up to 20% in cases involving fractures and complex dislocations. Incidence ranges from 5% to 10% in patients with isolated encephalic trauma, occurring more often on the hemiplegic side. When encephalic trauma coincides with elbow trauma, the incidence increases to between 75% and 90%. Specific surgical procedures have also been linked to heterotopic ossification. Medical treatments are only partially effective, emphasizing the importance of prevention. Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown utility within the first 3 to 5 days of development, with indomethacin, ibuprofen, naproxen, and aspirin being the most effective options.[5]

Elbow Stiffness Secondary to Malunion and Nonunions

The specific etiology guides the treatment of malunions and nonunions, which often result from articular fractures. These conditions disrupt elbow biomechanics, leading to stiffness. Nonunion of the distal humerus causes pain and instability, further restricting motion. Management should address the nonunion itself, often supplemented by procedures such as arthrolysis to restore function. A comprehensive evaluation of the affected limb is essential to identify associated injuries, including burns, infections, and neurovascular lesions.

Epidemiology

The loss of elbow mobility after a traumatic event occurs in 5% of cases. One study found that young individuals experiencing rapid musculoskeletal growth were more likely than older patients to develop posttraumatic elbow stiffness. Lower muscle strength and high-energy trauma were also cited as major risk factors for this condition. In patients treated conservatively after a traumatic elbow injury, prolonged cast immobilization was associated with increased stiffness occurrence.[6]

Elbow stiffness does not exhibit a strong sex predilection but tends to be influenced by age and activity level. The condition is more common in adults, particularly those who experience trauma, undergo surgery, or engage in repetitive use of the elbow. Pediatric cases often arise from fractures, while degenerative conditions contributing to stiffness are more prevalent in older adults.[7][8][9]

Pathophysiology

Acute or repeated traumas represent the most frequent causes of elbow stiffness. Extension loss is more common than flexion loss.[10][11]

Cellular events following trauma and their role in stiffness remain under investigation. Findings suggest that relaxin contributes to capsular laxity, while increased cross-collagen bridges, reduced proteoglycan levels, and diminished water content are associated with abnormal tissue formation in trauma-induced contractures.

Reduced range of motion depends on factors such as the type of joint trauma, soft tissue involvement, treatment approach, rehabilitation, and patient response. Evaluation should include a thorough review of prior surgeries, the nature of the initial trauma and surgical intervention, soft tissue involvement, immobilization duration, and the rehabilitation process.[12]

History and Physical

The normal arc of flexion-extension ranges from 0° to 145°, and pronosupination spans 75° to 85°. A movement arc of 30° to 130° in flexion-extension and 50° in pronosupination provides sufficient range for most daily life activities. The degree of compromised range of motion should be individualized, as it may vary based on activity level. For instance, an arc suitable for the general population may not meet the needs of athletes or musicians. Pain is uncommon in cases of stiffness but may occur during flexion-extension when related to arthritis or at rest during an infectious process.

Heterotopic Ossification

Local inflammation, pain, and increased temperature are the most common manifestations of this condition. This inflammatory phenomenon should not be confused with an infection. Pain may not always be present but typically occurs at the end of the movement arc. Laboratory findings may show decreased calcium levels and increased phosphate levels. Serum alkaline phosphatase rises between 2 and 4 weeks after symptom onset, reaching 3 to 4 times the normal limit after 3 to 10 months. A bone scintigraphy with technetium-99m usually reveals increased metabolic activity during the 1st week, which can last up to a year. X-rays are the preferred method for evaluation and monitoring. Mature bone appears as a well-defined cortical presence on imaging, typically occurring 3 to 5 months after onset, after which a surgical approach may be considered.

Evaluation

Anteroposterior and lateral x-rays are useful in most cases. When the range of motion is reduced to below 45°, obtaining an anteroposterior view becomes challenging. A computed tomography scan is valuable when complications of complex fractures must be assessed or uncertainties regarding treatment planning remain.

Classification

For optimal evaluation and understanding of the eventual treatment, stiffness may be classified according to origin as follows:

• Extrinsic: Ligaments, muscles, and the capsule may be damaged, but the joint is intact.
• Intrinsic: The articular surfaces are compromised, possibly due to adhesions, osteophytes, chondrolysis, or trauma.
• Mixed: Stiffness arises from combined intrinsic and extrinsic causes. These cases are most frequent. Most of the time, intrinsic conditions produce extrinsic stiffness.

Stiffness may also be classified based on the arc of movement ie, flexion-extension, as follows:

• Mild: Less than 90°
• Moderate: Between 60° and 90°
• Serious: Between 30° and 60°
• Severe: Less than 30°

A guide to differentiate simple from complex contractures includes the following criteria for simple compromise:

• Moderate contracture with a movement range of 80° or greater.
• No or minimal prior surgery.
• No previous ulnar nerve transposition.
• No osteosynthesis or minimal surgical material.
• No or minimal heterotopic ossification.
• Normal bone anatomy.

The contracture is considered complex if at least 1 of these criteria is absent.

Treatment / Management

Treatment options include both surgical and nonsurgical approaches, such as arthrolysis (open or arthroscopic), interposition arthroplasties, and prosthetic replacements. A thorough clinical evaluation is essential to guide treatment, as it helps assess the extent of stiffness and the degree of disability, which can vary based on the patient’s activities and expectations. The duration and cause of stiffness also play key roles in determining the most appropriate treatment strategy.

Nonsurgical Treatment

Among nonsurgical options, supervised stretching, dynamic and static splints, serial plasters, and physical therapy have been shown to be effective. Splint treatment yields better outcomes when the contracture has a shorter clinical evolution and no significant joint involvement (extrinsic causes). Mobilization under anesthesia has been linked to heterotopic ossification. Some experts suggest that extrinsic causes of stiffness respond well to nonsurgical treatment, with favorable results.[13][14](A1)

Surgical Treatment

The indications for surgical treatment include intrinsic causes that do not improve with nonsurgical treatment, severe stiffness (ie, < 30° range), and poor outcomes with rehabilitation, such as in cases of heterotopic ossification. As mentioned, identifying the cause of stiffness is crucial for proper preoperative planning. The type of surgery (open or arthroscopic), the appropriate approach, and the specific procedure will be determined based on this information.

Surgical Approaches

The choice of surgical approach depends on the location of previous scars, the need for nerve decompression, and the presence and extent of ossification.[15][16][17] The medial approach is indicated for medial articular injuries, ulnar nerve disease, medial ectopic bone, ossification, or ligament insufficiency. The lateral approach allows for anterior and posterior capsulectomy. Mobility should be evaluated after the procedure.[18] During both lateral and medial approaches, ligaments are generally retained, but release may be occasionally necessary. A partial ligament release may be required in severe or long-term contracture cases. If the preoperative restriction is less than 110° to 120°, releasing the posterior fascicle of the medial collateral ligament and the posterolateral capsule is necessary to restore flexion.

The posterior approach provides access to the posteromedial and posterolateral capsules. A cutaneous incision is made along the posterior midline, lateral to the olecranon, with identification and protection of the ulnar nerve.

Capsular contractures cause a significant decrease in capsule volume, making joint entry difficult. Multiple portals should be considered for an arthroscopic release. Based on clinical experience, some authors have proposed a 4-step approach:

1. Entrance
2. Preparation
3. Bone removal and free bodies
4. Capsulectomy [19][20][21]

Surgery for Heterotopic Ossification

Surgical treatment is indicated when heterotopic ossification causes functional limitations. The approach will be determined based on the location and extent of the ossification.[22](B2)

Postoperative Care

Neurological integrity should be immediately evaluated. A padded bandage with a splint must be applied to reduce bleeding and manage postoperative edema. Placement of an axillary catheter or anesthetic blockade has been proposed. Continuous passive motion is recommended. The effectiveness of the continuous motion splint must be evaluated based on the patient's ability to mobilize without it (3 to 4 weeks). This treatment may be followed by static splints. Indomethacin has been recommended to prevent ossification.

Surgical Outcomes

Both open and arthroscopic approaches have shown good outcomes. Bibliographic reviews suggest that up to 90% of patients experience an increase in mobility range of at least 10°, with approximately 80% achieving a functional range, which is between 30° and 130°. However, mobility gained through surgery may be lost. Insufficient evidence from randomized clinical trials supports the advantages of the arthroscopic technique over the open approach.

Rehabilitation

The postoperative program should be individualized according to etiology and patient preferences. However, certain objectives can be defined, including the following:

• Restoration of a functional arc of motion
• Return of muscle strength
• Integration of the limb into functional activities

Regarding the initiation of mobilization, some authors recommend starting within 2 days after arthrolysis, provided adequate pain control is achieved. Continuous passive motion (CPM) offers the advantage of reaching the extension and flexion limits achieved during surgery. This strategy is not recommended when ligaments have been reconstructed or repaired. Rehabilitation efforts should continue until the patient attains adequate movement degrees. Static or dynamic splints may also be helpful. Some authors recommend using NSAIDs or low doses of radiation to prevent ossification.

Differential Diagnosis

Elbow stiffness is often a symptom of an underlying pathology. The differential diagnosis of this manifestation includes various conditions, most notably the following:

• Posttraumatic elbow stiffness
• Congenital contractures found in arthrogryposis
• Congenital radial head dislocation
• Inflammatory arthritis
• Multiple hemarthroses in haemophiliacs
• Osteoarthritis
• Postseptic arthritis

Accurate diagnosis relies on a comprehensive evaluation of the patient’s history, clinical examination, and laboratory and imaging findings. Proper differentiation of these conditions is essential to guide appropriate treatment and improve functional outcomes.

Prognosis

The prognosis of elbow stiffness depends on the underlying cause, duration, and treatment approach. Early intervention, including physical therapy and splinting, generally leads to better outcomes, especially in cases with minimal joint damage. Surgical procedures, such as arthrolysis, often restore a significant range of motion, although some loss of mobility may recur over time. Severe or long-standing stiffness, particularly with intrinsic joint involvement, can result in more limited functional recovery despite treatment.

Complications

Complications of elbow stiffness include persistent functional limitations, chronic pain, and poor quality of life. Surgical interventions may lead to hematoma formation, pain, infection, nerve injuries (eg, ulnar neuritis), ossification, hypertrophic scarring, joint instability, and recurrence or worsening of stiffness. In cases with heterotopic ossification, untreated stiffness can progress, further impairing mobility and necessitating complex surgical management.