Stiff Elbow

The elbow joint is comprised of three bones; the upper arm bone is called the humerus and the two bones of the forearm are called the radius and ulna. These bones are very closely matched with each other and whilst this does aid stability and excellent function it also makes them prone t injury. In such circumstances stiffness can also develop.

Stiffness can affect the ability to bend the elbow resulting in the loss of flexion or extension, but it can also affect forearm rotation. When the palm of the hand is rotated to that the palm faces up, the movement is termed suppination and when the palm is facing down it is termed pronation. After even a mild injury, a loss of movement, and in particular elbow extension, can occur however if the joint surface is also damaged or if post traumatic osteoarthritis develops then painful movement may occur in addition to the stiffness.

The stiffness can be caused by ether soft tissue contractures around the elbow or may be secondary to a bony block to movement. After an elbow fracture, a loss of bony congruity of the elbow may result in stiffness. Alternatively any degenerative changes caused by the onset of osteoarthritis may result in the build up of bone around the periphery of the joint. This bone is termed an osteophyte and may also result in stiffness.

bones of the elbow are perfectly matched to their opposing bones. This helps maintain the elbows stability, which unlike other joints, is involved in both a hinge like movement as well as forearm rotation. This complexity can however make it prone to degenerative conditions such as osteoarthritis, particularly if the joint surfaces are damaged.

Symptoms

The symptoms associated with elbow arthritis include;

• Stiffness; restrictions in the range of elbow movement affecting both flexion and forearm rotation.
• Pain; pain can occur at the end of any restricted range of movement, or it can occur throughout the range of movement. If it is the latter it may be secondary to arthritis affect the bones of the elbow joint.
• Locking and ‘clunking’ of the joint may be noticed by those affected and can be due to the development of loose bodies, which impede joint movement. Episodes of locking will often settle spontaneously but will also often recur.

Causes & Risk factors

There are several cause for elbow stiffness. these include;

• post traumatic stiffness (as occurs following a fracture)
• osteoarthritis
• rheumatoid arthritis secondary to chronic inflammatory joint disease.
• septic arthritis following a joint infection

Diagnosis

The diagnosis of elbow stiffness is easily made on a history and examination however to determine the underlying cause of the stiffness x-rays or a CT scan will be necessary. X-rays can reveal irregular joint surfaces, osteophytes and possibly bone loss and CT scans can be used to further investigate the anatomy of the joint surfaces in more detail. CT is also helpful in confirming the presence of any loose bodies and osteophytes that might be restricting elbow movement.

Treatment

The treatment for elbow stiffness is always tailored to the particular patient.

1. Physiotherapy can prove beneficial in the early stages of the development of stiffness and can help maintain motion and strength of the elbow. It is however, less effective in any stiffness that has been present for a log time or if there is any associated elbow pain.
2. Outerbridge – Kashiwagi (OK) procedure;this procedure is used to debride the elbow joint thereby removing any loose bodies as well as releasing any soft tissue contractures so that any restricted movement can be addressed. It is undertaken as an open procedure through an incision at the back of the elbow, or sometimes as an arthroscopic procedure. A fenestration is made through the bone of humerus from within the elbow joint, so that both the back and front aspects of the joint can be accessed. Any loose bodies, osteophytes and capsular contractions can then be addressed.
3. Elbow debridement and arthrolysis;this is a surgical procedure performed either as a keyhole or open procedure. The aim of the operation is to assess the severity of the cartilage damage following which any loose bodies and osteophytes can also be removed to allow greater movement. At the same time, the capsule enveloping the elbow can be released, which, combined with the osteophyte removal, usually results in an improved range of elbow movement. This is usually undertaken if the stiffness or any associated arthritic change is more advanced such that an OK procedure is not indicated