The Stiff Elbow

Abstract

Treatment of stiff elbow due to causes other than post traumatic: 1-Arthrogryposis: The approach to patients with this problem must be divided into these who have the appearance of a near-normal joint with absence of certain muscles and those without elbow articular surfaces and greatly restricted passive motion. In the former, even when there is some loss of passive motion usually in flexion, improved function and strength can be anticipated through posterior capsule release and anterior muscle transfer (triceps or pectoralis major being preferred). (39) The lack of joint articular surfaces requires a more extensive program. A joint is first created, passive motion attained, and active function provided. To gain an effective joint, shortening of the humerus by 2 to 3 cm may be needed, and fascia1 interposition over both proximal and distal bone ends is helpful to ensure maintenance of the joint space. A hinge distraction arthroplasty procedure is recommended. Muscle transfers are necessary and soft tissue closure using rotation flaps may be required. Postoperative programs using static splinting to maintain elbow flexion stance and dynamic assisted flexion with hinged splints or passive elbow motion machines have been implemented to complement the results obtained from surgery. Caution expectation in patients who lack an elbow joint is advised and the long term goals of obtaining motion to provide better hand use for self-care must be remembered in recommending reconstructive surgery, both before and after surgery. (12) 73 2-Burn contractures: An aggressive preventive treatment program will help the majority of burn contractures. Following primary treatment of the burned extremity the static three-point splinting is used to maintain the elbow in extension. If the injury is associated with fractures or joint injuries external fixation with a hinge distractor is excellent for burn contractures, because it leaves most of the extremity exposed for dressings or skin grafting. Orthoplast splinting and bracing both static and dynamic are applied early in the burn treatment program. (12) Surgical treatment of burn contractures must address anterior, posterior, or generalized involvement. Posterior contracture is less common but is usually more severe. Ossification within the triceps muscle occurs and acts as a block to elbow extension. Surgical treatment requires excision of the heterotopic ossification when mature. The surgical excision is performed through a longitudinal posterior incision without skin flaps. The heterotopic bone, posterior capsule, and olecranon process are removed, and the raw bone surfaces are covered with bone wax, gel foam, or local fat. The ulnar nerve is always identified and if necessary transferred anteriorly. The anterior capsule, tendon, and muscles may undergo secondary contracture as a result of posterior heterotopic ossification. If they require tenolysis and capsular release, this should be performed through an anterior incision at the same operation as the excision of the heterotopic ossification. (6) 47 Anterior full-thickness contractures are the more common type of injury, involving skin, fascia, tendon, and muscle elements. The major problem is providing muscle and tendon release while maintaining adequate skin coverage because split-thickness skin grafts will not cover or heal over these structures. Both orthopedic and plastic surgical techniques are required to solve this problem. After skin Z-plasty and muscle and capsule release, the resultant soft tissue and skin defects are covered by an extended groin or thoraco-epigasteric flap, or an extended latissimus dorsi myo-cutaneous flap. The elbow can be splinted easily in extension with either flap. (21) 3-Ectopic Ossification: Guidelines