What is elbow stiffness?
Elbow joint is formed by three bones humerus (upper arm bone), radius and ulna (forearm bones) supported by ligaments to keep them in proper ailment. The elbow joint is the second most mobile joint of our body after shoulder joint. Because of the complex anatomy with ligaments, muscles and three bones, the elbow is prone for stiffness and new bone formation.
Elbow stiffness is easily preventable, however one of the most difficult condition to treat. It is caused usually by an injury or trauma or fracture or surgery of the elbow joint, especially when it is kept immobile for a certain period of time. Other causes can be infections, burns, inflammatory diseases like rheumatoid arthritis, osteoarthritis and congenital conditions. The stiffness of the elbow is commonly caused by trauma in 3 to 20 % of cases. It is caused by injuries to the soft tissues and damage to the surfaces of the joint. According to a study, 20% of elbow dislocation, 38% fracture and dislocation and 10 % of radial fractures can lead to elbow stiffness.
What are the symptoms of elbow stiffness?
The main symptom of elbow stiffness is limited range of motion of your elbow. Thought most of them are painless restrictions, some patients’ presents with pain and swelling with restricted range of movements. Loss of movements is frustrating for most patients as they struggle to feed themselves, do their hair and restricts their activities of daily living.
How is it diagnosed?
Your orthopaedic surgeon will take a medical history and examine your elbow joint to assess its mobility and flexibility. Following examination, he will ask for x-rays, ct-scan or MRI scan to assess the extent of any damage and to plan for further management.
What happens if nothing is done?
If it is left untreated, the movement could improve a bit and you may get used to the deformity and start using your other arm more. However, in majority of patients have marked disability in performing their activities of daily living. Besides, it becomes more and more difficult for your surgeon to sort out your problems with the elbow with passing time.
How is it treated?
Treatment of elbow stiffness depends on the underlying cause, amount of stiffness, patient requirements and congruity of the joint. The treatment is difficult and takes time to restore functional range of movements. It can be treated conservatively or surgically. Conservative treatment is indicated in mild stiffness as severe and moderate stiffness does not get better without surgical intervention. The functional range of movement in an elbow is 300 to 1300 and the aim of both conservative and surgical movement is to get your elbow movement as close to this as possible.
Surgery is indicated in
- Contractures in the capsules, ligament of the elbow joint
- Moderate or severe elbow stiffness
- Elbow arthritis
- Bone spurs or bony projections
- Adhesions in the joint
- Scarring of the capsules of the joint
- Heterotopic ossifications (bone formation in muscles)
What are the non-operative treatments?
The non-operative treatment is indicated and successful in mild elbow stiffness. It includes anti-inflammatory medicines, physiotherapy and splinting.
- Anti-inflammatory medicines- Indomethacin or ibuprofen is usually given for 6 weeks to prevent new bone formation and to relieve stiffness and swelling.
- Physiotherapy- is the main stay of treatment and is recommended under the supervision of your orthopaedic surgeon and physiotherapists.
- Splinting- an elbow brace (turnbuckle splint) could be used in mild stiffness and could help you in getting another 15-30 degrees. However, in some patients this may not help with increasing the range of movements.
What does the operation involve?
The surgery aims at the restoration of the functional range of motion of the elbow joint (300 to 1300). Elbow stiffness could be released by either arthroscopy (keyhole surgery) or open surgery and this is dependent on the complexity of the primary injury, pathology, fracture personality and patient factors. Total arthroplasty is recommended in cases where elderly patients have diffuse arthritis.
- The operation is conducted as an inpatient surgery under general anaesthetic. The skin is incised based on the type of surgery selected.
- The contractures of the capsule are released to increase the joint space. Bony projections or bone spurs, scar tissues and new bone growth are excised out, hardware removed if they reduce the joint space.
- The skin is then stitched with absorbable sutures, an elbow brace is applied to the elbow. The operation takes 1- 2 hours and most patients are discharged on the same day after 4 hours of operation.
- Radiotherapy – In selected cases, single dose of radiotherapy is given in the first few days after the procedure to reduce the new bone formation and stiffness
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and shoulder. This is necessary to prevent further stiffness and to maintain the strength of the muscles.
- The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks
- The patient is reviewed at 2 weeks and referred for physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
- The physical therapy elbow stiffness release is paramount and is essential to start them as soon as possible after surgery. Gentle exercises as tolerated by the patient after surgery and are progressed to passive stretching exercises around 2 weeks. This will be guided by your surgeon and physiotherapists. The improvement in movements happens over a period of 6months to a year and is dependent on the complexity of the primary problem and the intervention.
- In around 20-50% of the patients’ further surgeries might be needed to improve the range of movement.
Are there any risks?
- Persistent elbow stiffness
- Ulnar or Median or Radial nerve injury
- Vascular injury (uncommon, brachial artery)
- Myositis ossificans
- Hardware failure
- Posttraumatic arthritis
- Recurrent contracture
- Anaesthetic complications
- Chronic Regional Pain Syndrome “CRPS”.
- Any surgery can end up with rare complications and leave a patient worse than before surgery and is rare in this surgery
What are the results of the operation?
90 % of patients achieve more than functional range of movement (300 to 1300) after surgery, however to achieve this the patients might need 1-3 surgical release and adherence to physiotherapy for 1-2 years. The outcome of the surgery is more predictable under the author’s experience.
When can I return to driving and work?
You can get back to work, return to contact sports and resume driving in 2-6 weeks. The above time line could vary based on the complexity of the problem and the treatment modality. Your physician will be able to advise you.