Preventing Elbow Stiffness After Injury or Associated with ArthritisWhen it works well, no one thinks much about the elbow. It bends and straightens. But a stiff elbow after injury or associated with arthritis or other condition can be a real detriment to function. And even though it seems like a simple joint with two major movements, it's really made up of three separate articulations (places where the bones join and move).
In this article, hand surgeons from the Cleveland Clinic provide us with an in-depth review of elbow anatomy, injuries, and treatment of the stiff elbow. The focus and goal of treatment is actually prevention of elbow stiffness. Several strategies are presented based on the underlying problem.
For example, when inflammation from arthritis is present, the rheumatologist prescribes medications such as antiinflammatory drugs and disease modifying antirheumatic drugs (DMARDs). The design of these medications is to limit joint destruction. In the case of patients with hemophilia (a blood disorder), bleeding into the joints can be prevented by giving patients missing blood factors.
When surgery is needed for an elbow injury (dislocations, fractures, crush or soft tissue injuries), bleeding, swelling, and scar tissue must be limited. Continuous passive motion (a device used to slowly and repetitively move the elbow) is effective in keeping fluid from building up in and around the joint.
The role of the hand therapist is very important in the prevention of complications before and after surgery. Sometimes splinting the elbow is needed. The type of splint depends on the problem. There are two basic types of splints: static and dynamic.
Static splinting puts the elbow in a position and holds it there. The idea is to prevent the soft tissues from tightening up and forming contractures (loss of motion). Dynamic splinting has some give to it using adjustable springs or elastic. With dynamic splinting, it is possible to increase the tension over time in order to increase motion.
There are problems with splints that have led to the development of adjustable splints. They are more comfortable with less stress on the soft tissues. That makes it more likely that the patient will wear the splint. Patient compliance with splinting is extremely important in regaining elbow motion. In some cases, surgeons resort to serial casting. The elbow is placed in a position at the end range-of-motion and cast in place. As the soft tissues stretch and the elbow motion increases, the cast is removed and a new cast put on. This process is repeated several times until motion is restored.
If none of these methods works, then surgery is considered. It could be as simple as a manipulation where the surgeon gently moves the elbow through all of its motions while the patient is anesthetized. Or it may be necessary to perform a surgical release of the contracted soft tissues. The goal is to restore motion without losing joint stability. That sounds simple but it's much more complex than that.
The surgeon must take into consideration many factors when planning the type of surgery. First, where is the loss of motion coming from? Is it muscle or bone? Are the ligaments involved? Is it flexion or extension that's affected? Can the surgery be done arthroscopically or is an open incision needed to gain access to the area? Will it be possible to perform the procedure while avoiding damage to the nearby nerves and blood vessels?
Some patients have more than one problem going on. For example, there may be contractures of both the flexor and extensor muscles. There may be bone particles in the muscles, a condition called heterotropic ossification. There may be a nerve trapped in scar tissue. The combination of problems requires multiple steps in the surgical procedure. The surgeon may use both an open and an arthroscopic method for completing all of the repairs needed.
The authors provide surgeons with advice about surgical approaches and techniques to use. They discuss and provide drawings of the column procedure and the medial over-the-top approach to the stiff elbow. They offer ways to avoid damaging the neurovascular (nerves and blood vessels) structures when working within the elbow area. Techniques differ depending on whether the procedure can be done arthroscopically versus with an open incision.
A new technique in preventing elbow stiffness after traumatic injury is with the injection of Botulinum Toxin A (BOTOX). The BOTOX is injected into the muscles that are contracted. It acts as a paralyzing agent to prevent muscle contraction of the muscles injected. The muscles can no longer contract to hold the elbow. As they relax, joint motion is increased.
Another unique problem is the loss of forearm rotation (palm up or palm down motion). Because of the small area within the three elbow articulation, it isn't always possible to restore normal motion without damaging nerves. Sometimes, the surgeon must resect or remove portions of the bone that have gotten stuck and no longer move, thus limiting elbow motion.
Destruction of the elbow joint from arthritis can affect both young and old. The treatment varies depending on activity level and age of the patient. For younger, high-demand patients, a procedure called interposition arthroplasty may help save the joint.
The surgeon smoothes the joint surfaces and then uses a soft tissue graft to resurface the joint. Usually, it's necessary to release the joint capsule. This makes the joint unstable. The patient is placed in an external fixation device that allows joint motion but protects stability until healing occurs.
For older adults (60 years old and older) with significant joint damage (more than 50 per cent of the joint), a total elbow joint replacement is advised. This can work well in the patient who is not overly active.
Postoperative care is very important in preventing stiffness after any elbow surgery. Swelling is limited through the use of cold, compression, and motion during the first 72 hours. Static, progressive splinting is used starting six weeks after surgery. The hand therapist provides exercises and uses mobilization techniques to keep the soft tissues moving. A home program is necessary for up to six months to ensure continued success.
A smooth moving elbow is essential to hand and arm function. The authors hope for a better approach to preventing elbow stiffness in the future. Research to understand how and why soft tissues contract and stiffen up may help us step in earlier with better prevention techniques. Improved methods of prevention may help patients avoid surgery with all of its complications and disruption to the elbow.
Peter J. Evans, MD, PhD, et al. Prevention and Treatment of Elbow Stiffness. In The Journal of Hand Surgery. April 2009. Vol 34A. No. 4. Pp. 769-778.
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