History and Physical Examination

Patients with post-traumatic stiffness typically present with limitation of motion. Important aspects of the history include the mechanism of trauma, the initial treatment, and whether they have plateaued in their motion during rehabilitation. Loss of elbow extension is more common than loss of flexion. The examination must include observation of the upper extremity, looking specifically for deformity, swelling, atrophy, and other diagnostic characteristics.

Range-of-motion evaluation should include the hand, wrist, forearm, and elbow. Motion should be compared with the contralateral, uninjured side. Motor and sensory testing is required to evaluate nerve function. In patients with elbow stiffness, it is important to evaluate the ulnar nerve in the cubital tunnel. The nerve lies along the medial elbow joint capsule, and it can become scarred and adherent to the surrounding soft tissues along the medial joint line after trauma. Although some patients may report tingling and numbness in their ulnar digits (especially with elbow flexion), traction neuritis can manifest as medial elbow pain alone. It may even be a factor contributing to elbow stiffness. It is important to document ulnar nerve sensitivity to percussion (i.e., Tinel’s sign) and any medial joint pain or neurologic symptoms that occur at maximum elbow flexion.

Diagnostic Imaging

Plain radiographs of the elbow should include frontal, lateral, and oblique projections. In some cases, such as after fracture, advanced imaging can help to define joint congruity. A requirement for elbow release surgery includes a congruous joint with an adequate ulnohumeral joint space, at least centrally. This can typically be determined by plain radiographs. Occasionally, computed tomography is required to document joint congruency, especially in the post-traumatic setting. It also can document that there is no bony impingement or overgrowth in the olecranon and coronoid fossae.

Indications and Contraindications

Patients are candidates for contracture release if they have restricted elbow motion, with a flexion contracture of at least 25 to 30 degrees or less than 110 to 115 degrees of flexion, or both. Patients typically should have failed a course of supervised therapy, including proper splinting. A congruous ulnohumeral joint is required, as is adequate soft tissue coverage of the operative site. An interval from injury to operation of at least 3 to 4 months allows for resolution of post-traumatic inflammation.

Relative contraindications to arthroscopic elbow release include severe elbow contractures with minimal joint motion, prior ulnar nerve transposition surgery, and the presence of significant heterotopic bone. Surgical release of a contracted elbow is also contraindicated if a patient is deemed unable or unwilling to comply with the extensive program of postoperative therapy. Operative results depend on participation in a structured rehabilitation program. This is especially true for adolescents, who may not be dedicated to improving their elbow motion. If the ulnohumeral joint is incongruous, a simple release of the joint may not lead to improved motion and may worsen pain. Although pain at the extremes is common, patients who are candidates for elbow release surgery typically are pain free within their allowable arc of motion. If advanced post-traumatic arthritis exists in the ulnohumeral articulation, salvage-type procedures are required if surgery is undertaken.³

Conservative Management

Patients who are candidates for elbow release surgery should undergo a course of structured rehabilitation. This ensures compliance and helps document that they have reached a plateau in their motion and function. In the past, dynamic splints that apply a constant tension to the soft tissues over long periods (e.g., 23 hours per day) were popular. However, patient-adjusted static braces are more effective for the elbow (Fig. 7-2). These braces use the principle of passive progressive stretch, allowing for stress relaxation of the soft tissues. They are applied for much shorter periods and are better tolerated by patients. Only when conservative measures fail and there remains a significant loss of mobility is surgical intervention considered.

FIGURE 7-2 A patient-adjusted elbow brace is used to improve elbow motion. This device uses the principles of passive, progressive stretch. It is much more effective than dynamic braces and better tolerated, because it requires only short periods of use.

Arthroscopic Technique

Arthroscopic release of a post-traumatic elbow is much more difficult and complicated than arthroscopy for simpler conditions, such as loose bodies. The technique requires experience and knowledge of elbow stiffness surgery and demands advanced skills in elbow arthroscopy. Multiple portals are required, fluid management is essential, and arthroscopic joint retractors are helpful to aid in visualization. This is especially true after capsulectomy, when joint distention is more difficult.

Specialized instruments can be helpful, such as cannulas that do not have any holes near the tip (Fig. 7-3). Because the elbow is smaller than, for example, the knee, and has less intra-articular space, standard cannulas can lead to fluid inadvertently entering the soft tissues while visualizing the joint.

FIGURE 7-3 Close-up view shows the arthroscopic cannulas used for the elbow. Traditional cannulas (top) for larger joints commonly have an oblique end with holes near the tip to facilitate flow. Specialized cannulas (bottom) for the elbow do not have outflow holes. This is important because the distance between the cannula tip and the joint capsule can be quite small in the elbow, allowing fluid to extravasate inadvertently into the soft tissues. Fluid management is important when performing an elbow release arthroscopically.

In very experienced hands, the procedure appears equivalent to more traditional open methods. However, there is clearly a learning curve, and potential complications must be appreciated. They include nerve injury, excessive fluid extravasation, and iatrogenic chondral damage.^4–9 If there is a question regarding visualization or safely, the surgeon must be prepared to convert the procedure to an open approach.^10–13

From a purely mechanical standpoint, to improve elbow extension, posterior impingement must be removed between the olecranon tip and the olecranon fossa. Anteriorly, tethering soft tissues, such as the anterior joint capsule and any adhesions between the brachialis and the humerus, must be released (Fig. 7-4). Similarly, to improve elbow flexion, the surgeon must release any soft tissue structures posteriorly that may be tethering the joint. They include the posterior joint capsule and the triceps muscle, which can become adherent to the humerus. The surgeon must remove any bony or soft tissue impingement anteriorly, including any soft tissue overgrowth in the coronoid and radial fossae (see Fig. 7-4). There must be a concavity above the humeral trochlea and capitellum to accept the coronoid centrally and the radial head laterally for full flexion to occur.

FIGURE 7-4 A, Improving elbow extension in stiff joints requires removal of posterior bony impingement and release of the anterior joint capsule. B, Improvement of flexion requires posterior soft tissue release and removal of any soft tissue or bony impingement anteriorly.

(Courtesy of Hill Hastings II, MD, The Indiana Hand Center, Indianapolis, IN.)

Elbow release surgery is typically performed under regional anesthesia with a long-acting block that allows postoperative muscular relaxation and pain control. An indwelling axillary catheter also can be effective. We prefer the prone position for elbow arthroscopy. The lateral decubitus position may also be used. It is facilitated by arthroscopic arm-holding devices (Fig. 7-5). The prone position is more complicated from an anesthesia perspective, but it does completely free the shoulder and makes conversion to an open approach easier if required.

FIGURE 7-5 The patient is in the lateral decubitus position for elbow arthroscopy. Notice the specialized arm holder required to free the joint and allow maximum access in which to work.

Bony landmarks and portals are drawn. It is imperative to document the path of the ulnar nerve through the cubital tunnel. It lies posterior to the palpable intermuscular septum, which separates the triceps from the anterior musculature in the distal arm. Wrapping the hand and forearm in Coban tape helps with fluid extravasation in the dependent position.

The elbow is insufflated with saline introduced through the soft spot (direct midlateral) portal (Fig. 7-6). The anteromedial portal is established by placing a blunt trocar or switching stick along the anterior humerus, aiming toward the radial head laterally. This is started several centimeters proximal and anterior to the medial epicondyle (see Fig. 7-6). In cases of post-traumatic stiffness with a contracted capsule, it can be difficult to enter the joint. Care must be taken to hug the anterior humeral cortex because the capsule can be quite adherent, pushing the instrument into an extra-articular plane. Beneath the capsule and in the joint, the trocar or switching stick can be used to lever anteriorly to help strip the capsule and develop a space in which to work. The anterolateral portal is established using an inside-out technique. It is most effectively placed just anterior to the radiocapitellar articulation (Fig. 7-7).

FIGURE 7-6 A, In the intra-operative photograph of elbow arthroscopy, notice how the bony landmarks and portals have been defined. The joint is being insufflated through the soft spot (i.e., direct midlateral portal). B, The medial portal has been established for viewing. It is started several centimeters proximal and anterior to the medial epicondyle. Notice how the path of the ulnar nerve has been documented.

FIGURE 7-7 A, The initial intraoperative view of the anterior elbow joint in a patient with a post-traumatic joint contracture is seen from the anteromedial portal. The anterolateral portal has been established using an inside-out technique. It is positioned just anterior to the radiocapitellar joint. B, The coronoid and radial fossa have been débrided above the articular surface, creating a concavity. This removes anything that would cause impingement in flexion. C, The anterior concavity above the trochlea is viewed from the lateral side. D, The anterior capsule has been resected, revealing the undersurface of the brachialis muscle. Notice how the capsular release has been done at the level of the humerus above the joint line. The radial nerve is located just anterior to the capsule at the level of the radiocapitellar joint. Capsular removal more distally places this structure at risk. E, In the initial view of the posterior joint, the tip of the olecranon is seen, and the olecranon fossa is filled with fibrous tissue and scar. F, After posterior débridement, the olecranon fossa is clear, and the olecranon tip has been débrided to remove any posterior impingement that might limit extension. Lateral (G) and medial (H) views of the olecranon and gutters show the shaping of the olecranon tip to remove any impinging osteophytes.

The anterior joint is cleared of any synovitis or adhesions that are present. Mechanical instruments are typically used, although thermal devices can be quite effective at removing soft tissue. Care is taken to temporarily increase the inflow while using a thermal device to decrease heat generation within the joint. The coronoid fossa is cleared and deepened, removing any fibrous tissue down to the bony floor. This is also true of the radial fossa just above the capitellum. The radial fossa must be free to accept the radial head during elbow flexion. The arthroscope and the working instruments must be switched rapidly and effectively from medial to lateral positions during this work (see Fig. 7-7).

After the fossae are cleared and any necessary bony work is completed, the anterior capsule is addressed. It is first well defined and then partially or completely resected. The radial (posterior interosseous) nerve lives just anterior to the joint capsule and near the midline of the radiocapitellar joint. Removing the capsule proximal to the trochlea is much safer than distal excision. Any capsule work done at the level of the joint line must be done with great care. Retractors can be helpful to aid visualization. They can obviate the need for increased fluid pressure to distend the joint for visualization and are helpful for fluid management. After part of the capsule is released, fluid distention is less effective, and fluid extravasation into the periarticular soft tissues more readily occurs. This must be limited, because it is much more difficult to work within the elbow after a significant amount of fluid has extravasated. The capsule must be released all the way out to the supracondylar ridges to achieve a complete release (see Fig. 7-7).

After the anterior joint work is completed, attention is focused posteriorly. We typically leave a cannula in the anterior joint while working in the back. This helps to maintain outflow during the procedure. With the elbow extended maximally to protect the posterior trochlea, a blunt elevator is used to blindly strip and clear the olecranon fossa and elevate the posterior joint capsule. Identification of the concavity of the fossa should be possible using tactile feedback. The arthroscope is introduced into the posterior or the posterolateral portal. The latter is started approximately 1 cm proximal to the midpoint between a line drawn from the olecranon tip to the lateral epicondyle. The posterior portal is established 3 to 4 cm above the olecranon tip in the midline. The camera is then turned to look in a distal direction. In cases of post-traumatic stiffness, soft tissue often must be débrided in the olecranon fossa to allow for full visualization of the articular surfaces (see Fig. 7-7). Proximal retractors are also very helpful in the posterior joint. The posterior capsule is freed from the humerus proximally, and it can be partially resected. Typically, this capsule is less hypertrophic than the anterior capsule. Establishing a soft spot portal (direct midlateral) may facilitate visualization and help to free the posterolateral gutter. Any soft tissue or bony overgrowth at the tip of the olecranon is removed, including the medial and lateral corners (see Fig. 7-7).

The ulnar nerve requires special mention. It lies along the medial joint capsule in the cubital tunnel, and it can become adherent to the surrounding soft tissues after trauma. We recommend that the ulnar nerve be released in all cases when nerve symptoms are present or when nerve tension signs exist (i.e., positive Tinel’s sign or positive elbow flexion test). This is also recommended when significant elbow extension contracture exists, for which acute improvement in joint flexion may precipitate ulnar nerve symptoms. Although the exact degree of flexion loss has not been determined, it is recommended that ulnar nerve release be considered when preoperative elbow flexion is limited below 90 to 110 degrees.

Because of the location of the ulnar nerve relative to the capsule, any mechanical or thermal instruments used along the medial ulnohumeral joint and medial gutter can place the nerve at risk. Suction makes the mechanical burrs and shavers more dangerous. Even when releasing the elbow joint arthroscopically, we prefer to address the ulnar nerve through a limited open approach. When there is significant loss of elbow flexion, the posteromedial capsule (which lies beneath the nerve in the cubital tunnel) may also need to be released. The nerve is approached through a limited incision centered on the cubital tunnel. After it is decompressed and isolated, the posteromedial joint capsule can be safely addressed. Release of this capsule can be done arthroscopically in experienced hands, but it can place the nerve at risk. If a limited open approach is chosen for the nerve, it is much easier to perform before the arthroscopic joint release. Swelling of the soft tissues can obliterate tissue planes, making nerve dissection more difficult. In post-traumatic cases with significant loss of flexion, we routinely dissect out the ulnar nerve before starting the arthroscopic procedure.

After the joint release is completed, care is taken to document recovery of elbow motion intra-operatively. Although soft tissue swelling can make this difficult, it is important to achieve terminal flexion and extension before leaving the operating room. If the ulnar nerve was decompressed, it can be left in the cubital tunnel (i.e., in situ decompression) or formally transposed anteriorly, depending on the surgeon’s preference. A drain can be placed if significant bleeding is anticipated. The elbow is wrapped in a soft, compressive dressing. Cutting out some of the dressing anteriorly (in the antecubital fossa) allows greater mobility postoperatively.

Postoperative Rehabilitation

Several rehabilitation programs may be effective after elbow release surgery. We typically use continuous passive motion that is begun immediately in the recovery room (Fig. 7-8). It is used the next morning to help maintain the motion gained at surgery. Formal therapy is commonly begun on postoperative day 1. The dressing is removed, and edema-control modalities (e.g., edema sleeve, Ace wrap) are used to limit swelling. Active and gentle passive elbow motion is combined with intermittent continuous passive motion. Static progressive elbow bracing is begun early in the postoperative period. Flexion and extension are alternated based on the preoperative deficit and the early progress of the elbow.

FIGURE 7-8 The patient is in a continuous passive motion machine after arthroscopic elbow release. At our institution, we use a long-acting regional block that allows immediate use of this modality.

A nonsteroidal anti-inflammatory agent (e.g., Indocin) is commonly prescribed as a prophylaxis against heterotopic ossification for several weeks postoperatively. This also helps to limit inflammation of the joint and soft tissues during rehabilitation. The physician must follow these patients closely. Although most ultimate elbow motion is gained during the first 6 to 8 weeks, patients can continue to make gains in terminal flexion and extension for several months postoperatively. With proper patient selection, results can be gratifying, with predictable recovery of a functional arc of elbow motion and pain relief (Fig. 7-9).^14–18

FIGURE 7-9 Preoperative (A) and postoperative (B) lateral radiographs were obtained for the patient depicted in Figure 7-7. He developed a post-traumatic elbow contracture, with preoperative motion measuring approximately 45 to 105 degrees. Notice the deepening of the anterior fossa above the trochlea and capitellum and removal of the posterior olecranon spur. Clinical photographs taken 1 week after arthroscopic elbow release show early improvement in elbow extension (C) and flexion (D).