Flexion Deformity of Elbow

Original Editor - Shreya Pavaskar
Top Contributors - Shreya Pavaskar, Kim Jackson and Nupur Smit Shah

Definition

The stiff or contracted elbow is defined as an elbow with a reduction in extension greater than 30 degrees, and/or a flexion less than 120 degrees. Although supination and pronation are often reduced as well, this will not be considered further as contracture of the elbow is not related to forearm rotation.

The elbow is more prone to stiffness because -

• Brachialis muscle lies directly over the anterior capsule.
• The anterior capsule tends to tear more frequently than posterior.
• All 3 elbow articulations exist in 1 capsule
• The elbow is prone to development of Heterotrophic ossification

Clinical anatomy

The elbow joint is where the distal humerus meets the proximal radius and ulna bones. It is an extremely congruent and stable joint. Due to its complexity, even after severe injury, it is more prone to stiffness than instability. The joint capsule of the elbow surrounds all 3 joints. There are thickening medially and laterally of the joint capsule that blends with the MCLC and LCLC respectively and contributes to the stability of the elbow.

There are 4 main muscle groups at the elbow. The anterior bicep group, the posterior tricep group, the lateral extensor-supinator group and the medial flexor-pronator group of which the flexors and extensors are more prone to tightness.

Etiology

Loss of terminal extension is less disabling than loss of the same degree of terminal flexion. The loss of motion is due primarily to contracture of the anterior capsule and thickening of the lateral collateral ligament complex, and the joint surfaces in nearly all cases are well preserved. The most convenient and important classification of the posttraumatic stiff elbow is based on the pathologies responsible for the loss of motion and these can be divided into intra-articular and extra-articular causes. The intrinsic or intra-articular causes are due either to intra-articular adhesions or to a deformity secondary to an intra-articular fracture, which mechanically limits the elbow motion.

• Contracture of the capsule, collateral ligaments or the muscles following a severe trauma or just a simple posterior dislocation.
• a bony bridging of the joint
• formation of heterotopic bone
• Following elbow injury, patients often have trouble recruiting and firing the triceps muscle. This may be due to reciprocal inhibition resulting from hyperactivity of the biceps.

Most cases however represent due to mixed factors.

Clinical Features

Pain throughout the range of motion

A stretching pain at end range

Flexion less than 120 degrees

Extension lacks 30 degrees

Diagnostic Procedures

Active range of motion

Passive range of motion

Muscle length

Plain Radiographs

MRI/CT scan for further evaluation

Management / Interventions

In clinical practice, most patients can tolerate a flexion loss of about 30 degrees and an extension loss of 45 degrees, but if the decrease in motion reduces the overall range of motion to less than 100 degrees, most patients will complain of loss of function.

Examining and working the triceps with the patient in supine position and the shoulder at 90 degrees of forward flexion can be effective. The pull of gravity on the biceps is eliminated so that reciprocal inhibition of the triceps is decreased, and the therapist can easily assist extension if the patient is not able to fully overcome the force of gravity. Aggressive, painful PROM or stretching is contraindicated, as it provokes episodes of repeated, involuntary muscle guarding. Superficial heat (hot pack) is applied in a tolerable end-range position for 10 to 15 minutes. Soft tissue mobilization techniques such as MFR and IASTM can be further used.

Joint mobilizations using maitland and mulligan - medial/lateral glides, humeroradial, humeroulnar glides, radial and ulnar traction.

Outside of therapy, patients may carry a bag with a light object during prolonged walking activities to improve extension.

Splinting - For moderate extension or flexion deficiencies, provided the contracture is caused by the soft tissues, and is less than 1 year’s duration in adults, and in children, independently of the duration of the contracture, we first use a dynamic splinting treatment

In severe cases, Arthroscopic release of the osteophytes, posterolateral release of anterior capsule and lateral collateral ligament complex, Distraction arthroplasty, Total elbow replacement,etc are performed

Resources

https://www.elsevier.com/books/orthopedic-physical-assessment/magee/978-0-323-52299-1

https://archive.org/details/KisnerColbyTherapeuticEXERCISE