ENNUMERATE IN DETAIL THE CAUSES OF STIFF ELBOW ?
B ) BRIEFLY DESCRIBE THE MANAGEMENT OF IT ?
A 9 INTRODUCTION
1 Elbow motion is essential for upper extremity function to position the hand in space.
2 The elbow is a highly constrained synovial hinge joint, intolerant of trauma, with a high propensity for stiffness and degeneration.
3 Articulations between the trochlea and capitellum of the humerus with the trochlear notch of the ulna and radial head, respectively, are the bony foundation of the elbow joint
4 The soft tissue boundary of the elbow joint is the articular capsule, which is weakest anteriorly and posteriorly but has well-defined lateral and medial ligamentous complexes
5 Functional arc of elbow motion during activities of daily living is 100 degree for both flexion - extension ( 30 to 130 degrees ) and pronation - supination ( 50 degree each )
ETIOLOGY / CAUSES
DIVIDED INTO 2 - ATRAUMATIC AND TRAUMATIC
ATRAUMATIC - 1 OSTEOARTHRITIS - an incongruous articular surface hinders elbow motion, as does osteophyte formation, a hallmark of the arthritic process.
2 INFLAMMATORY ARTHRITIS
3 POST SEPTIC ARTHRITIS
4 MULTIPLE HEMARTHROSIS ( HEMOPHILIACS )
5 CONGENITAL CONTRACTURES ( ARTHROGYROPOSIS , CONGENITAL RADIAL HEAD DISLOCATION )
TRAUMATIC - 1 CONTRACTURES SECONDARY TO FRACTURE , BURNS , HEAD INJURY
A ) ( Trauma has immediate effects on the elbow that are direct causes of stiffness, but may also lead to elbow stiffness through secondary processes
B ) ( A poorly aligned articular surface following intra-articular fracture impedes elbow motion )
C ) ( Similarly, osteochondral defects can prevent smooth motion at the articular surface, especially if a loose fragment remains within the joint )
2 SEQUELAE EFFECT - SECONDARY TO TRAUMA CAUSING HETEROTROPIC OSSIFICATION -
A ) ( Approximately 3% of simple elbow dislocations and up to 20% of elbow fracture–dislocations are complicated by heterotopic ossification )
B ) ( Five percent to 10% of patients with isolated closed head injury form heterotopic ossification, as do patients with spinal cord injuries below the level of their injury )
C ) ( Additional risk factors include - 2 incision distal biceps repair , elbow arthroscopy and multiple surgeries within 14 days of injury )
1 The two primary elbow stiffness classification systems are those of Kay and Morrey
2 While Kay’s classification is based on the structure
impeding elbow motion, Morrey’s classification is based on the etiology and its anatomic location
3 Kay’s five-part classification system includes -
A ) soft tissue contracture (type I)
B ) soft tissue contracture with ossification (type II)
C ) non-displaced articular fracture with soft tissue contracture (type III )
D ) displaced intra-articular fracture with soft tissue contracture (type IV)
E ) posttraumatic bony bars (type V)
4 Morrey’s three-part system classifies elbow stiffness as extrinsic, intrinsic, or mixed
Extrinsic - stiffness is due to extra-articular causes, including capsular, collateral ligament, and muscle contractures as well as heterotopic ossification and extra-articular malunions.
Intrinsic - stiffness is due to intra-articular adhesions, loose bodies, osteophyte formation, or malalignment of the articular surface.
Extrinsic contractures developing as a result of intrinsic pathology are classified as mixed.
1 The goals in treating the stiff elbow is to provide patients with a pain free , functional and stable elbow
2 Timing, severity, patient specific factors, and underlying pathology guide the selection of specific treatment protocols.
3 Non-operative treatment is considered upon initial presentation in those who have minimal contractures of 6-month duration or less
4 Operative treatment is appropriate for those patients who have failed to achieve adequate pain relief or functional range of motion after initial non-operative management
NON OPERATIVE TREATMENT
1 STATIC AND DYNAMIC SPLINTING -
A ) USE OF DYNAMIC SPLINTING FOR MODERATE LOSS OF ELBOW FLEXION OR EXTENSION
B ) REVERSED DYNAMIC SLINGS - TO INCREASE THE ROM BY 39 %
C ) STATIC PROGRESSIVE ADJUSTABLE SPLINT ( TURNBUCKLE SPLINT ) , ( FLEXION EXTENSION / SUPINATION PRONATION SPLINT ) - INCREASES RANGE UPTO 45 %
2 SERIAL CASTING - REDUCES CONTRACTURES BY 33 %
4 PT / OT
5 MANIPULATION - 55 % INCREASE IN ELBOW MOTION BUT IS ASSOCIATED WITH ULNAR NEUROPATHY
1 FLEXION CONTRACTURES / EXTENSION LAG GREATER THAN 30 DEGREE OR INABILITY TO FLEX THE ELBOW TO 130 DEGREE IS AN INDICATION FOR SURGERY
2 PROCEDURES SUCH AS -
A ) COLUMM PROCEDURE ( OPEN SURGERY USING A LATERAL APPROACH ) - DESCRIBED BY MORREY
B ) MOTT APPROACH ( MEDIAL OVER THE TOP ) - DESCRIBED BY HOTCHKISS
Both involve anterior and posterior capsulectomy and preservation of collateral ligaments and consideration of partial release only in severe contractures.
C ) FLEXION CONTRACTURES OF GREATER THAN 100 DEGREE REQUIRES ULNAR DECOMPRESSION SURGERY