Post-traumatic Elbow Stiffness Research Articles

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness: Should We Really?

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness: Should We Really?

A structured exercise programme combined with proprioceptive neuromuscular facilitation stretching or static stretching in posttraumatic stiffness of the elbow: a randomized controlled trial

Objectives: To compare the different stretching techniques, proprioceptive neuromuscular facilitation (PNF) stretching and static stretching, in patients with elbow stiffness after a treated elbow fracture. Design: Randomized-controlled, single-blind study. Setting: Department of physiotherapy and rehabilitation. Subjects: Forty patients with posttraumatic elbow stiffness (24 women; mean age, 41.34 ± 7.57 years). Intervention: PNF stretching group (n = 20), hold-relax PNF stretching combined with a structured exercise programme (two days per week for six weeks); static stretching group (n = 20), static stretching combined with a structured exercise programme (two days per week for six weeks). Main measures: The primary outcome is the Disabilities of the Arm, Shoulder and Hand (DASH). The secondary outcomes are active range of motion (AROM), visual analogue scale (VAS), Tampa Scale for Kinesiophobia, Short Form-12 and Global Rating of Change. Participants were assessed at baseline, after a six-week intervention period and one-month later (follow-up). Results: After treatment, improvement in the mean DASH score was slightly better in the PNF stretching group (8.66 ± 6.15) compared with the static stretching group (19.25 ± 10.30) (p = 0.03). The overall group-by-time interaction for the 2 × 3 mixed-model analysis of covariance (ANCOVA) was also significant for elbow flexion AROM (mean change for PNF stretching group; static stretching group; 41.10, 34.42, p = 0.04), VAS-rest (–1.31, –1.08, p = 0.03) and VAS-activity (–3.78, –3.47, p = 0.01) in favour of PNF stretching group. The other outcomes did not differ significantly between the two groups. Conclusion: The study demonstrated that the structured exercise programme combined with PNF stretching might be effective in patients with posttraumatic elbow stiffness with regard to improving function, elbow flexion AROM, pain at rest and during activity.

Novel preclinical murine model of trauma-induced elbow stiffness

BackgroundPeri-articular injury may result in functional deficits and pain. In particular, post-traumatic elbow stiffness is a debilitating condition, precluding patients from performing activities of daily living. As such, clinicians and basic scientists alike, aim to develop novel therapeutic interventions to prevent and treat elbow stiffness; thereby reducing patient morbidity. Yet, there is a paucity of pre-clinical models of peri-articular stiffness, especially of the upper extremity, necessary to develop and test the efficacy of therapeutics. We set out to develop a pre-clinical murine model of elbow stiffness, resulting from soft tissue injury, with features characteristic of pathology observed in these patients.MethodsA soft tissue peri-elbow injury was inflicted in mice using cardiotoxin. Pathologic tissue repair was induced by creating an investigator-imposed deficiency of plasminogen, a protease essential for musculoskeletal tissue repair. Functional testing was conducted through analysis of grip strength and gait. Radiography, microcomputed tomography, and histological analyses were employed to quantify development of heterotopic ossification.ResultsAnimals with peri-elbow soft tissues injury in conjunction with an investigator-imposed plasminogen deficiency, developed a significant loss of elbow function measured by grip strength (2.387 ± 0.136 N vs 1.921 ± 0.157 N, ****, p < 0.0001) and gait analysis (35.05 ± 2.775 mm vs 29.87 ± 2.075 mm, ***, p < 0.0002). Additionally, plasminogen deficient animals developed capsule thickening, delayed skeletal muscle repair, fibrosis, chronic inflammation, and heterotopic ossification; all features characteristic of pathology observed in patients with trauma-induced elbow stiffness.ConclusionA soft tissue injury to the peri-elbow soft tissue with a concomitant deficiency in plasminogen, instigates elbow stiffness and pathologic features similar to those observed in humans. This pre-clinical model is valuable for translational studies designed to investigate the contributions of pathologic features to elbow stiffness or as a high-throughput model for testing therapeutic strategies designed to prevent and treat trauma-induced elbow stiffness.

Post-traumatic elbow stiffness: Pathogenesis and current treatments.

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

Manipulation Under Anesthesia as a Treatment of Posttraumatic Elbow Stiffness.

Evaluate the safety and efficacy of manipulation under anesthesia (MUA) for posttraumatic elbow stiffness. Retrospective, case series. Single institution; level 1 trauma center. Chart review of 45 patients over a 10-year period treated with MUA for posttraumatic elbow stiffness after elbow injuries treated both operatively and nonoperatively. None. Change in total flexion arc pre- to postmanipulation; time to manipulation; complications. Average time from most recent surgical procedure or date of injury to MUA was 115 days. Average premanipulation flexion arc was 57.9 degrees; average flexion arc at the final follow-up was 83.7 degrees. The improvement in elbow flexion arc of motion was statistically significant (P < 0.001). Post hoc analysis of the data revealed 2 distinct groups: 28 patients who underwent MUA within 3 months of their most recent surgical procedure (early manipulation), and 17 patients who underwent MUA after 3 months (late manipulation). Average improvement in elbow flexion arc in the early MUA group was 38.3 degrees (P < 0.001); improvement in the late MUA group was 3.1 degree. Comparison of improvement between the early and late MUA groups found a significant difference (P < 0.001) in mean flexion arc improvement from premanipulation to postmanipulation, favoring the early group. One patient had a complication directly attributable to MUA. Nineteen patients required additional procedures on the injured extremity after MUA. MUA is a safe and effective adjunct to improving motion in posttraumatic elbow stiffness when used within 3 months from the original injury or time of surgical fixation. After 3 months, MUA does not reliably increase elbow motion. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic total capsulectomy for post-traumatic elbow stiffness

Arthroscopic total capsulectomy for post-traumatic elbow stiffness

Posttraumatic Elbow Stiffness Treatment and Outcomes in Patients Wounded During Operations Enduring Freedom and Iraqi Freedom

Posttraumatic Elbow Stiffness Treatment and Outcomes in Patients Wounded During Operations Enduring Freedom and Iraqi Freedom

Reasons for surgical revision after conservatively treated radial head fractures-retrospective study of 70patients.

BackgroundAn inadequate clinical outcome after conservatively treated radial head fractures is not uncommon. We analyzed the subjective limitations, objective complaints, and surgical procedures for radial head fractures initially treated conservatively.Patients and methodBetween 2007 and 2016, 70 patients (42 men, 28 women) who suffered from fracture sequelae after conservatively treated radial head fractures were examined. Demographic (age, 41.8 years, range, 16–75 years) and clinical data (pain, range of motion, instability) were retrospectively evaluated.ResultsThe average time to surgery after trauma was 50 months (range, 5–360 months). In 38 cases, radial head fractures were initially treated with immobilization for 3.4 weeks (range, 1–8 weeks). Physiotherapeutic treatment was performed in 39 cases. In only half of the cases was retrospective Mason classification possible: 20 type I, 8 type II, 5 type III, and 2 type IV. Of the 70 patients, 53 had posttraumatic elbow stiffness; 34 had isolated lateral and four patients isolated medial ligament instability. There were eight cases with a combination of lateral and medial ligament instability and 27 cases of elbow stiffness combined with instability. An average of 1.2 (range, 1–4) surgical procedures per patient were performed. In all, 64 patients underwent elbow arthroscopy with arthrolysis and additional treatment depending on other injuries. The range of motion improved on average from preoperative flexion/extension of 131–15–0° to postoperative flexion/extension of 135–5–0° (gain in flexion: 4.2° and extension: 10.6°).ConclusionConservative treatment of radial head fractures does not always yield good results. Reasons for a poor outcome include chronic instability, cartilage damage, stiffness, or a combination thereof. Improved outcomes can be achieved via arthroscopic arthrolysis.

Mid-Term Outcomes of Arthroscopic Treatment in Patients with a Stiff Elbow.

IntroductionLoss of function and pain are the main complaints at the time of hospital admission for patients with a stiff elbow. In this study, we present mid-term radiological and functional results for the use of the arthroscopic release technique in patients admitted to the outpatient clinic with a stiff elbow.MethodsA total of 22 patients (six females, 16 males; mean age: 36 years, range: 18 to 56 years) who underwent an arthroscopic intervention for traumatic or non-traumatic stiff elbow and arthrosis between January 2005 and November 2015 were included in the study. All patients started elbow movement after the first day following surgery. Pre- and postoperative radiological evaluations of patients were carried out, in addition to functional evaluation to measure the range of motion of the elbow joint and the Disabilities of the Arm, Shoulder and Hand (DASH) scores before and after surgery.ResultsThe mean follow-up was 28.4 (range: 21 to 118) months. The mean preoperative flexion-extension arc of the patients was 89° (range: 0° to 115°), and the mean flexion-extension arc increased to 103.5° (range: 52° to 128°) at the final follow-up visit (p < 0.05). The mean preoperative DASH score was 42.17 (range: 33 to 81), decreasing to 30.35 (range: 9.7 to 41.3) postoperatively (p<0.05). In the final visit, none of the patients were found to require additional surgical interventions for the elbow.ConclusionsArthroscopic release can be considered a safe and effective option to obtain range of motion in joints in post-traumatic stiff elbow cases.

Post-traumatic stiff elbow.

Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.The following presentation reviews the recent literature on pathomechanisms and treatment alternatives.Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062

Impact of different glucose metabolism status on clinical outcomes of open arthrolysis for post-traumatic elbow stiffness

Diabetes and prediabetes are worldwide public health problems and are considered predisposing factors for adverse functional outcomes after various orthopedic operations. The purpose of this retrospective study was to determine the impact of glucose metabolism status on functional outcomes and complications after open arthrolysis for post-traumatic elbow stiffness. The study included 152 patients with post-traumatic elbow stiffness undergoing arthrolysis, including 120 in the normoglycemic group, 21 in the impaired glucose regulation group, and 11 in the diabetes mellitus group. General patient data, functional performance, and complications were documented and analyzed. Demographic data and disease characteristics were comparable at baseline. Postoperatively, significant differences were found in range of motion and the Mayo Elbow Performance Score: the diabetes mellitus group had the poorest clinical outcomes. However, there were no significant differences in forearm rotation, visual analog scale pain scores, and complication rates. Patients with post-traumatic elbow stiffness and abnormal glucose metabolism were at increased risk of poorer outcomes after open arthrolysis, and patients with diabetes mellitus had the poorest performance. This study underlines the importance of glycemic control in patients with abnormal glucose metabolism before open arthrolysis.

Rehabilitation with continuous brachial plexus block after surgical treatment for posttraumatic stiff elbow -Two case reports

Rehabilitation with continuous brachial plexus block after surgical treatment for posttraumatic stiff elbow -Two case reports

The timing of open surgical release of post-traumatic elbow stiffness: A systematic review.

Background:Open release of post-traumatic elbow stiffness is effective in restoring elbow function, but there is no guideline on the optimal time point of surgical release so far. The purpose of this article was to summarize the current available literature reporting on the timing of open release of post-traumatic elbow stiffness.Methods:The PubMed, Cochrane Library, and EMBASE were searched with a set of predefined inclusion and exclusion criteria. Manual searches for references were performed to find potential relevant studies. Two authors separately extracted data from all the articles selected.Results:27 articles published between 1989 and 2017 were included with an overall enrollment of 836 patients. We divided all included studies into 3 groups according to the timing of surgical release: group 1 (6–10 months after injury), group 2 (11–20 months after injury), and group 3(>20 months after injury). The mean postoperative Mayo Elbow Performance Score (MEPS) and recurrence rate were similar among the 3 groups; however, the mean gain in arc of motion in group 1 was the highest with the lowest complication rate among the 3 groups.Conclusion:There was a trend toward a shorter waiting time from injury to open arthrolysis from 12 months to 6 months. The shorter waiting period of 6 to 10 months yielded better results. Therefore, early surgical release of stiff elbows is recommended for a shorter rehabilitation time and earlier return to work.Level of evidence: Level IV, Systematic Review.

Continuous passive motion and physical therapy (CPM) versus physical therapy (PT) versus delayed physical therapy (DPT) after surgical release for elbow contractures; a study protocol for a prospective randomized controlled trial

BackgroundThe elbow is prone to stiffness after trauma. To regain functional elbow motion several conservative- and surgical treatment options are available. Conservative treatment includes physical therapy, intra-articular injections with corticosteroids and a static progressive or dynamic splinting program. If conservative treatment fails, an operative release of the posttraumatic stiff elbow is often performed. The best Evidence-Based rehabilitation protocol for patients after an operative release is unknown to date and differs per surgeon, hospital and country. Options include early- or delayed motion supervised by a physical therapist, immediate continuous passive motion (CPM), (night) splinting and a static progressive or dynamic splinting program.Methods/designThe SET-Study (Stiff Elbow Trial) is a single-centre, prospective, randomized controlled trial. The primary objective of this study is to compare the active Range of Motion (ROM) (flexion arc and rotational arc) twelve months after surgery between three groups. The first group will receive in-hospital CPM in combination with early motion Physical Therapy (PT) supervised by a physical therapist, the second group will receive only in-hospital early motion PT supervised by a physical therapist and the third group will receive outpatient supervised PT from postoperative day seven till ten. Secondary outcome measures will be Patient Reported Outcome Measures (PROMs) including the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), the quick Disabilities of Arm, Shoulder and Hand (qDASH) score, Visual Analogue pain Scale in rest and activity (VAS), Pain Catastrophizing Scale (PCS), the Short Form (SF)-36, the Centre for Epidemiological Studies Depression Scale Revised (CESD-R) and the Work Rehabilitation Questionnaire (WORQ) for the upper limb.DiscussionA successful completion of this trial will provide evidence on the best rehabilitation protocol in order to (re)gain optimal motion after surgical release of the stiff elbow.Trial registrationThe trial is registered at the Dutch Trial Register: NTR6067, 31–8-2016.

Risk factors for development of severe post-traumatic elbow stiffness.

The purpose of this study was to compare different grades of elbow stiffness and investigate demographic, injury, and treatment factors potentially associated with the development of severe elbow stiffness. We performed a retrospective study involving 169 patients with post-traumatic elbow stiffness between June 2014 and June 2016. Patient demographics, injury, and treatment details were reviewed. Patients were classified into three groups according to the elbow motion. Ordinal regression analyses were performed to examine the independent factors. Patients were classified into: mild (49 patients), moderate (59 patients), and severe (61 patients) groups. Patients with severe stiffness had a significantly worse elbow functional performance. Univariate ordinal regression revealed that severe elbow stiffness was associated with high-energy injury (odds ratio [OR] 4.73), olecranon fracture (OR 1.92), fracture-dislocation (OR 2.28), and open fracture (OR 3.24). Multivariate regression showed that higher-energy injuries were associated with severe stiffness (OR 4.45, p=0.003). Elbow stiffness after fracture surgery often results in joint stiffness. Severe stiffness often resulted in more significant functional impairment. Our study suggested that high-energy injuries were associated with the development of severe elbow stiffness.

Rehabilitation of elbow fractures and dislocations

Elbow fractures and dislocations cause injury to important stabilizing structures and require specific treatment in order to regain functionality of the elbow joint. Regardless of whether surgical or non-surgical treatment is performed, correct rehabilitation following diagnosis of the injury pattern is crucial to achieve the best possible outcome in each individual case. After osteosynthesis, as well as after total elbow arthroplasty of distal humerus fractures, the postoperative protocol depends on whether a triceps-on or triceps-off approach was used. While triceps-on approaches allow active extension immediately postoperatively, triceps-off approaches require a more restrictive protocol. Radial head fractures are frequently accompanied by additional osteoligamentous injuries. Rehabilitation following radial head fractures usually involves active-assisted mobilization over the full range of motion; however, concomitant injuries need to be considered when formulating a treatment plan. Rehabilitation of surgically treated olecranon fractures commonly includes active flexion and gravity-assisted extension. Coronoid fractures are often the result of posterior elbow dislocation, which needs to be kept in mind during rehabilitation of these injuries. Complex proximal ulna fractures (e. g. Monteggia-like injuries) are frequently associated with persisting disability. Simple elbow dislocations are usually treated non-surgically. Early functional treatment should be preferred over prolonged immobilization as it decreases the risk of post-traumatic elbow stiffness without increasing the possibility of persistent instability.

Effect on muscle strength of the upper extremities after open elbow arthrolysis

BackgroundOpen elbow arthrolysis manipulates tendons and soft tissues surrounding the elbow and may lead to strength decline after the operation. We hypothesized that strength of elbow and wrist motions and handgrip could be compromised after the procedure and that the strength recovery pattern may differ between men and women and between the dominant and nondominant side.MethodsThis was a prospective cohort study. We monitored 32 patients with post-traumatic elbow stiffness who underwent open arthrolysis between June 2014 and December 2014. All patients underwent standardized postoperative physical therapy. Preoperative and postoperative isometric strength were measured by a handheld dynamometer. Mayo Elbow Performance Score (MEPS) and arc of motion (AOM) were also analyzed.ResultsMean follow-up was 26.13 months. Significant improvement was noticed in mean AOM (from 46° to 127°) and MEPS (from 67.97 to 96.86). No significant decline was noted in isometric strength at the last follow-up day. The strength ratios between men and women showed no significant difference from postoperative day 7 to the last follow-up day. At all follow-up assessments, isometric strength showed no significant difference between the dominant and nondominant side.ConclusionsAOM and MEPS achieved significant enhancement after open elbow arthrolysis. The procedure did not lead to isometric strength decline. Postoperative gain of strength was proportional to the baseline strength level of each muscle group, and men had a more prominent gain of strength than women during the entire follow-up. Dominance had no effect on postoperative strength recovery.

The influence of body mass index on outcome of open arthrolysis for post-traumatic elbow stiffness

Being overweight has become a serious public health concern in China. Higher body mass index has been proven to be associated with poor outcome after orthopedic surgery. The purpose of this study was to examine the effect of being overweight on functional outcomes and complications after open arthrolysis for post-traumatic elbow stiffness. We performed a retrospective study including 122 patients with post-traumatic elbow stiffness undergoing arthrolysis, including 84 in the normal weight group and 38 in the overweight group. Demographic data, surgical data, and data on preoperative and postoperative functional performance and complications were obtained. Demographic data and disease characteristics were comparable between the 2 groups at baseline. All patients showed significant improvement after elbow arthrolysis. Postoperatively, the range of motion and Mayo Elbow Performance Score of the normal weight group were significantly better than those of the overweight group. Sixteen patients developed postoperative complications. No significant differences in complication rates between the 2 groups were found. Most patients showed satisfactory functional outcomes after arthrolysis. The postoperative functional outcomes of the overweight group were inferior to those of the normal weight group to a certain extent. This study underlines the importance of detailed rehabilitation instructions in patients with higher body mass index.

Posttraumatic stiff elbow

Posttraumatic stiff elbow is a frequent and disabling complication and poses serious challenges for its management. In this review forty studies were included to know about the magnitude of the problem, causes, pathology, prevention, and treatment of posttraumatic stiff elbow. These studies show that simple measures such as internal fixation, immobilization in extension, and early motion of elbow joint are the most important steps that can prevent elbow stiffness. It also supports conservative treatment in selected cases. There are no clear guidelines about the choice between the numerous procedures described in literature. However, this review article disproves two major beliefs-heterotopic ossification is a bad prognostic feature, and passive mobilization of elbow causes elbow stiffness.

Impact of Smoking on Clinical Outcomes of Open Arthrolysis for Post-Traumatic Elbow Stiffness

Background: Neck of femur fractures have a high incidence in old people, and they come together with a high mortality rate. Nottingham Hip Fracture Score (NHFS) was validated as a tool to predict the mortality in patients with a hip fracture. Methods: The predictive capability of NHFS for 30-day mortality for Greek patients who had an operation on a neck of femur fracture was assessed, and then the original NHFS model was compared to a modified one. Practically, we performed the NHFS to the Greek population, and at the same time, we implemented a modified model of the NHFS by replacing the institution with the New Mobility Score (NMS) (Parker and Palmer, 1993) to the evaluated parameters. From April 2009 to November 2012, we ran a prospective study in our institution, collecting full details from 349 patients. We used Statistical Package for Social Sciences (SPSS), version 20 to analyze data. Univariate logistic regression analysis was utilized for expressing the significance, and the odds ratio for every risk factor participated in our research. Multinomial logistic regression analysis was used for predicting statistical indexes for finding the suitability between two important models consisted of just about the same risk factors. Results: Only 85 (24.4%) of a total of 349 patients (average age 80, 82 years) were men. Follow-up for all patients was at least 30 days. NHFS and modified NHFS predictability were compared with the actual mortality rate of the patients. NMS, Admission Abbreviated Mental Test score (AMTS), Sex, Age, and malignancy were found to be the most important individual factors in hip fracture 30-day mortality. We found both the original and the modified NHFS significant predictors of 30-day mortality, but the modified one with the NMS was better for the Greek population. Conclusions: NHFS is a useful tool to predict the mortality in elderly patients with a neck of femur fracture. Replacing the parameter institution with the NMS improves the predictive capacity of the NHFS to the Greek population.