The Stiff Elbow: Prevention and Management

The elbow is notoriously "unforgiving." The capsule is highly reactive to trauma, the congruency of the ulnohumeral joint is tight, and the muscles (brachialis) lie directly over the anterior capsule. As a result, a seemingly minor injury can result in profound, functional disability.

In elbow surgery, the best way to treat stiffness is to prevent it. But when it happens, we need a structured algorithm to restore the "Functional Arc."

Visual Element: Diagram of the "Functional Arc" (30-130° flexion, 50/50° rotation) overlaid on a daily activity (e.g., answering a phone).

1. Anatomy of Stiffness

Why does the elbow stiffen?

• Intrinsic Causes: Joint incongruity, osteophytes, loose bodies, adhesions within the joint.
• Extrinsic Causes: Capsule contracture (the most common culprit), muscle shortening, heterotopic ossification (HO), skin/burn scars.
• The Capsule: The anterior capsule is thin but sensitive. Trauma causes myofibroblast proliferation (alpha-SMA positive cells), leading to a thickened, fibrotic sheet that resists extension.

2. The Functional Goal

Normal elbow ROM is 0-145° flexion and 80°/85° pronation/supination. Morrey's Functional Arc: To perform most Activities of Daily Living (ADLs) like eating, grooming, and toileting, a patient needs:

• Flexion/Extension: 30° to 130°.
• Rotation: 50° Pronation, 50° Supination.
• Note: Losing extension is annoying (can't reach into a cupboard). Losing flexion is disabling (can't feed yourself).

3. Prevention: The Golden Rule

"Motion is Life."

• Stable Fixation: The goal of fracture surgery is rigid fixation that allows immediate active range of motion.
• Edema Control: Swelling is glue. Aggressive elevation and compression.
• CPM: Continuous Passive Motion is less favored now; Active Assist is better.

4. Conservative Management: The Splinting Ladder

If the elbow is stiff at 6 weeks, do not just "push harder" in physio. You need mechanical aid.

Static Progressive Splinting (SPS)

This is the gold standard (Turnbuckle splints, JAS braces).

• Principle: "Stress Relaxation." The tissue is stretched to a fixed length. As it relaxes, the stress decreases. Then you crank it again.
• Protocol: 30 minutes, 3 times a day.
• The Mantra: "Discomfort, not Pain." If it hurts too much, the muscle spasms (guarding), and it fails.

Dynamic Splinting

Spring-loaded splints (Creep principle). Generally less effective and less tolerated than SPS for stiff elbows.

5. Heterotopic Ossification (HO)

Bone forming where it shouldn't.

• Risk Factors: Neural axis injury (Head injury/Spine), Burns, Fracture-Dislocation ("Terrible Triad"), Delay to surgery.
• Prophylaxis: Indicated for high-risk patients.
  • NSAIDs: Indomethacin 75mg daily for 6 weeks. (Risk: GI bleed, non-union of fracture).
  • Radiation: 700 cGy single dose (within 72 hours). Safer for the fracture union?
• Treatment: Surgical excision. Historically, we waited 12-18 months for the bone to "mature" (cold bone scan). Modern evidence suggests we can operate earlier (6 months) once the inflammatory phase has settled.

6. Surgical Management: Arthrolysis

Indicated when functional impairment persists despite 6 months of intense non-operative therapy.

Open Release (Column Procedure)

The "Outerbridge-Kashiwagi" or "Column" procedure via a lateral approach (or combined medial/lateral).

• Anterior: Release the capsule from the humerus.
• Posterior: Remove olecranon tip, release posterior capsule, clear fossa.
• Medial: Decompress the Ulnar Nerve (Neurolysis).

Arthroscopic Release

• Pros: Less soft tissue trauma, better visualization of the joint.
• Cons: Technically demanding. High risk of nerve injury (Radial/Ulnar) as the capsule is thick and the joint space is obliterated.
• Contraindication: Previous ulnar nerve transposition (nerve position unknown).

7. Post-Operative Management

The surgery is only half the battle.

• Catheters: Indwelling brachial plexus block (catheter) for 3 days allows pain-free continuous motion.
• CPM: Used immediately post-op.
• Splinting: Alternating flexion/extension splints at night for 3-6 months.

Conclusion

The stiff elbow is a difficult beast.

1. Prevent it with early motion.
2. Treat it with Turnbuckle splints (Stress Relaxation).
3. Release it only when conservative measures fail, and respect the Ulnar Nerve.

Clinical Pearl: Extension Block. Often caused by osteophytes in the olecranon fossa or a tight anterior capsule. Flexion Block. Often caused by the posterior capsule or ulnar nerve tethering.