Treatment of the stiff elbow joint
Bo Sanderhoff Olsen

Elbow joint stiffness is a significant problem after elbow trauma, in degenerative and arthritic elbow joint disease, and following surgery to the elbow joint. Treatment of the disease can be difficult and it requires a team that can access a range of conservative and surgical treatment options. This paper describes the clinical presentation of the disease, its causes, diagnosis and management. The results obtained after treatment will be discussed, based both on the current literature and the senior authors extensive personal experience in treating patients with elbow joint stiffness.

motion deficits can severely affect the volume of this sphere by shortening the radius.2,3 The joint consists of articulations between the humerus, the ulna and the radius. The humeroulnar joint is a functional hinge joint with a high degree of congruency between the deep trochlea of the humerus and the greater sigmoid notch of the ulna. The articulation is stabilized through its bony anatomy and through strong lateral collateral ligaments (LCL) and medial collateral ligaments (MCL). Furthermore, the anterior capsule has some stabilizing effect in the extended joint position. The articulation allows flexion and extension movements of the forearm relative to the humerus . The humeroradial joint and the proximal radioulnar joint cooperate to allow rotational or pivoting movements of the forearm around the forearm axis. The proximal surface of the radial head, with its concavity, and the spherical capitellum articulate with concavity compression, with constraint from the annular ligament that surrounds the radial head.3e7

Keywords arthroscopy; elbow; elbow stiffness; elbow surgery; elbow

Pathogenesis of stiffness
Lack of elbow joint extension: is often the most troublesome problem for the patient. It is usually caused either by anterior capsular stiffness, with or without calcification and/or osteophytes on the olecranon, free bodies located in the olecranon fossa or stiff synovial tissue in the same location. These causes can often be successfully treated surgically (Figure 1). Lack of elbow joint flexion: is usually caused by stiffness of the posterior and posterolateral joint capsule and/or osteophytes on the coronoid process, free bodies located in the coronoid fossa or heterotopic/periarticular calcifications in the anterior compartment

Stiffness of the elbow joint is a relatively common problem. It can be caused by congenital defects, trauma or degenerative joint disease. In an increasing number of adult patients this condition can be successfully treated with surgery, whereas congenital elbow joint stiffness or stiffness that developed in childhood rarely requires surgery. In 1981 Morrey et al. described the range of elbow joint motion needed to lead a relatively normal life.1 The authors showed that most everyday tasks can be performed with forearm rotation between 50 supination and 50 pronation, and a range of flexion from 30 to 130 . This has become the reference range of motion (ROM) that surgeons aim to obtain by surgical treatment. It is important to understand that even minor elbow motion deficits can cause major problems for patients in specific situations, however, and the tolerance of elbow motion deficits is individual.2 The objective of this paper is to describe current indications and treatment options in the management of elbow joint stiffness in adults.

The elbow joint is a complex trocho-ginglymoid joint, which allows positioning of the hand inside a sphere around the body created by shoulder movement and with the length of the arm and forearm forming the radius. Therefore, even minor elbow
Figure 1 Preoperative lateral radiograph of a 34 years old female 1½ years after an operatively treated acute elbow joint dislocation treated by external fixation initially. There is calcification extending from the olecranon into the triceps tendon and a bone anchor that was used for reinsertion of the LCL. This patient was treated with operative removal of the posterior calcification.

Bo Sanderhoff Olsen MD PhD Senior Consultant, Ass. Professor, Section for Surgery on the Shoulder and the Elbow, Orthopaedic Department T, Herlev Hospital, Copenhagen University, Denmark. Conflicts of interests: none.



Ó 2012 Elsevier Ltd. All rights reserved.

Finally. In these cases the treatment involves internal fixation with osteotomy and/or grafting as indicated.or a hemielbow implant is indicated. Infrequently calcifications or synostosis involving the interosseous membrane of the forearm can be caused by fracture dislocations or. In the case of synostosis following distal biceps tendon repair. Occasionally the cause can be articular incongruency of the elbow following trauma. resection of the mature bone may improve rotation. These causes can often be successfully treated surgically (Figure 2). Treatment can involve radial head resection or surgical lysis of adhesions between the radial head and the capsule.ELBOW Figure 2 Preoperative lateral radiograph of an arthritic elbow joint in a 54 years old male carpenter with no history of trauma. degenerative or inflammatory joint disease in the radiohumeral joint can cause pain and stiffness (Figure 4). for example. degenerative or inflammatory joint disease. of the joint. on occasions a total. Simple resection may be indicated accompanied by surgical joint release (arthrolysis) (Figure 3). be responsible for diminished elbow joint motion. Note anterior and posterior degenerative changes limiting elbow range of movement. through degeneration. Figure 3 Preoperative lateral radiograph of a 62 years old female teacher following a radial head fracture. blocking flexion. This patient was treated with open release and radial head resection. These causes can be dealt with surgically without a prosthesis. forearm fractures and wrist problems can cause a lack of forearm rotation.8 Lack of forearm rotation Lack of rotation can impose significant disability. This patient was treated with synovectomy. All rights reserved. leading secondarily to the above described soft tissue changes (Figure 4). Joint changes that might impair flexion The radial head might. In the elbow joint the condition is usually caused by radial head fractures with resulting incongruence or adhesions between the annular ligament and the radial head following trauma and immobilization (Figure 3). The condition can be caused by a range of pathologies. Furthermore. Note rheumatoid induced changes in the humeroulnar and radiohumeral articulations. Mal-united or non-united supra or intercondylar fractures are rare causes (Figure 5). release and radial head resection. However. surgery for distal biceps tendon rupture (Figure 6). ORTHOPAEDICS AND TRAUMA 26:6 398 Ó 2012 Elsevier Ltd. . inflammatory change or fracture. Figure 4 Preoperative AP radiograph of a 23 years old female with juvenile rheumatoid arthritis. In other situations surgical release of forearm rotation is difficult.

We use the system defined by Morrey. since capsular stiffness is almost always part of the condition. Finally. In the later stages. significant joint destruction can be observed. The clinically relevant systems relate to both pathophysiology and treatment. The synostosis was operatively resected with the application of a fascia lata graft. All rights reserved. ORTHOPAEDICS AND TRAUMA 26:6 399 Ó 2012 Elsevier Ltd. no ulnar nerve transposition. Classification There are different classification systems. Sometimes there are ossifications around the joint.ELBOW Figure 5 Preoperative lateral radiograph of a 23 years old male with malunion 2 years after a supracondylar humeral fracture.8 Figure 6 Preoperative lateral radiograph of a 52 years old male with synostosis 1 year after treatment for a traumatic distal biceps tendon rupture. capsule or muscles.10 Clinical presentation Patients present with stiffness in the flexion axis and/or in the forearm rotation axis. In posttraumatic cases pain. adhesions between the joint surfaces can cause lack of motion. the anterior capsule is involved and is found to be stiff and thick. intrinsic and mixed causes for the elbow joint stiffness. intra-articular loose bodies can block movement and osteophytes can cause impingement. Intrinsic causes Intrinsic causes include articular mal. leading to contracture formation.as well as extra-articular structures are the most frequent of elbow contractures. . Furthermore. when present. classify the contractures as either simple or complex. no prior surgery. Often. Extrinsic causes Capsular contractures may result from prolonged immobilization or lack of use due to pain. or by extra-articular painful bony malor non-unions. Jupiter et al. This patient was treated with osteotomy and arthrolysis. Furthermore. situated in either the ligaments. Simple contractures have mild to moderate contracture. no heterotopic ossification and preserved anatomy. whereas in cases of degeneration or inflammatory joint disease the condition is characterized by periodic painful joint effusions and generalized elbow joint pain. the intrinsic causes inside the joint space and the mixed causes affect both locations.9 This classification system deals with extrinsic. The extrinsic causes are located outside the joint space. elbow contractures can be caused by the skin. as in severe burns.and non-unions or joint side destruction due to elbow arthritis. Mixed contractures Contractures with involvement of intra. is reported in the extremes of motion.

Diagnostic approach In all cases of elbow joint stiffness we perform anteroposterior and lateral plain radiographs (Figures 3 and 4). occupation. We often wait at least 6 months. in select cases. should be evaluated in a similar fashion to the evaluation of other upper extremity nerves. described manipulation as an adjunct to surgical release and as a possible remedy in the early postoperative period after a surgical elbow joint release when persistent or recurrent stiffness is problematic. Mehlhoff et al. are comparable to results seen following surgical release of the elbow joint.17.11. we always examine the stability of the elbow joint although instability is rarely present in cases of elbow stiffness. stable internal fixation is the aim.17 Splinting techniques Splints and bandaging can be used as both treatment and prevention in elbow joint stiffness. to allow early mobilization. night-pain etc. when considering posttraumatic contractures.19 This paper. documents the use of both dynamic and static splinting with results that.15 ORTHOPAEDICS AND TRAUMA 26:6 400 Ó 2012 Elsevier Ltd. Figure 7 Preoperative CT-scan of anterior joint side changes in an arthritic elbow joint in a middle-aged male. Araghi et al. With ulnar neuropathy and ulnar nerve pain we occasionally request neurophysiological testing (EMG) in order to evaluate the status of the nerve. it is important to wait until a final ROM has been reached. Physiotherapy Guided exercises following elbow trauma are generally recommended but poorly documented. age.20 In 2012 a publication has advocated early manipulation in posttraumatic cases.16 Several authors discuss the use of CPM (Continuous Passive Motion) devices in the postoperative phase with the aim of preventing recurrent elbow joint stiffness.20 Treatment and clinical outcome Prevention Measures should be taken to avoid the development of posttraumatic elbow joint stiffness after injury.12.14 Other authors have advocated mobilization even earlier than 3 weeks. trauma. Certain elbow scores exists.21 Closed elbow manipulation under anaesthesia This was previously used as a treatment in its own right and e referred to as “Brissemnt of the elbow”. reported worse results in patients following conservative treatment of acute elbow dislocation who had immobilization for more than 3 weeks.19 Other recent publications recommend the use of splints combined with closed manipulation.21 Caution in cases with ulnar nerve paresthesiae has been recommended.ELBOW The history elicited from the patient is important.8 If traumatic articular cartilage defects are suspected a magnetic resonance imaging (MRI) scan can be helpful.14 Reports increasingly advocate early mobilization following dislocation or fracture. however. Several reports document success with immobilization as short as 8e10 days. by Lindenhovius et al. focussing on the onset of symptoms. Following elbow joint fracture.19e21 A recent study documents the use of splinting for elbow joint stiffness. with stable ROM at more consultations before decision on release surgery is drawn.18 The majority of reports on the surgical treatment of stiff elbows using open techniques advocate it’s use in the immediate postoperative period. In cases of heterotopic bone formation. but better validated scores exists as the DASH and the Oxford Elbow Score and it has been recommended to use those.8. Palpation for pain and crepitus is important and ulnar nerve symptoms. In selected cases we perform computed tomography (Figure 7) in order to define the bony pathology that needs resection or correction during surgery: this is particularly the case in distal humeral mal. This allows examination of the joint architecture and identifies bony causes for contracture of the joint. maturation of the bone formation is important prior to surgery.12 Finally. including mobility of the nerve during ROM.. specified for active and passive motion.12 The majority of reports on the surgical release of stiff elbows recommend the early onset of guided training in order to avoid recurrence of stiffness.or non-union. combined with splinting. In cases with inflammatory disease or suspected infection blood counts and microbiological examination of articular fluid are performed. . Improvements in elbow ROM during training or splinting can appear late following trauma or surgery.20. hand dominance. All rights reserved. We use an elbow modified Constant score: the so called Functional Elbow Score. followed by measurements of the exact elbow ROM in flexion and rotation.16. Finally. We always perform a visual analogue scale (VAS) related to pain at activity and at rest. Furthermore we always observe the spontaneous use of the elbow during undressing and in the consultation in general. which facilitate clinical evaluation as well as measuring outcome after treatment. Currently the use of active or passive stretching of the elbow is debated.13.

Finally this set-up allows easy conversion to an open procedure. even in complex patients. Note the landmarks.26 Mansat reported the limited lateral approach. We place the patients in the lateral position. Figure 9 Arthroscopic surgery in the posterior compartment of the elbow joint. a ROM >80 . In our practice the exact measured restriction is less important than the resulting handicap reported by the patient. a good range of elbow flexion of a mean 80 has been achieved. All rights reserved. we enter the joint from the anterolateral portal and we create an anteromedial portal using an inside-out technique. and multiple portals can be employed.22.17.26 Other authors reported their results with the extensive open approach using a range of different surgical techniques and observed increases in elbow flexion between 23 and up to 86 .20 In a few small series distraction arthroplasty with external fixation was also noted to be successful. and reported increases in flexion of a mean 45 with only few complications. named the column procedure. Generally we avoid immobilization of the elbow joint as much as possible and rarely would any elbow be totally immobilized for more than 3 weeks. The authors approach to surgical treatment for stiffness of the elbow joint In posttraumatic or degenerative cases a stable degree of elbow stiffness with significant disability has to be present.25 Current reports show significant increases in the flexion range of up to 34 .23 In the more recent literature the incidence of reported complications is lower.14 In the case of minor motion deficits with no significant bone lesions to be removed.8e10.12.25 Open release This is the traditional surgical approach to the posttraumatic or degenerative stiff elbow. The procedure is technically demanding and initially severe complications were reported.12 Total elbow arthroplasty (TEA) TEA has been reported as a salvage procedure in selected cases of ankylosed or fused elbow joints. and support the mid portion of the humerus on a padded rest (Figure 8). In cases where osseous resection is needed we also use a burr (Figure 9).24 In the extension range significant improvements were also reported. especially in cases with no other possible surgical treatment options in the old and less active patient. Normally.13. After acute elbow trauma we introduce guided elbow mobilization and physiotherapy as soon as possible in order to avoid or minimize the elbow stiffness induced by immobilization. usually the most lateral. Complication rates of 15% are reported. with reoperations in more than 50% of the patients.ELBOW Arthroscopic release Arthroscopic release is increasingly being used for the treatment of elbow joint stiffness. We draw landmarks. We use a standard 45 4 mm arthroscope and a radiofrequency ablation device or shaver.8.22. completing the anterior compartment release before approaching the posterior part of the joint.24 The outcome following arthroscopic management is comparable to the outcome obtained with open surgery. Ulnar neuritis and residual stiffness are the most common complications described. apply a tourniquet. we carry out an arthroscopic joint release and synovectomy. With this set-up the surgery can be performed with only a nurse assistant and the joint can be moved during the surgery.12. . extension deficit <40 and where a radial head resection is not indicated. If severe swelling occurs or if there is loss of the view of the posterior compartment we occasionally proceed to a mini-open posterior release through a direct posterior approach by extending one of the posterior portals.22.22.22. Note the padded rest under the mid-portion of the humerus. However. This allows easy access to the front as well as the posterior part of the joint.27 Figure 8 Patient positioning for elbow arthroscopy. with ultimate deficits in extension of 6 and 7 . marking the ulnar nerve and the portals.12. the majority being minor. and insufflate the joint with 20 ml marcaine with adrenalin. ORTHOPAEDICS AND TRAUMA 26:6 401 Ó 2012 Elsevier Ltd.27 Significant complications have been reported. We normally then use two portals centred on the olecranon fossa to facilitate posterior compartment release and debridement.12 The largest improvements following open elbow release were seen in the stiffest elbow joints.24.

12 In major releases where the radial head is resected and/or the anterior band in the MCL released and reinserted. In the case of major motion deficits and in situations where bony release. We then resect the posterolateral capsule. we reinsert the ligament using a bone anchor applied in the origin of the MCL at the medial humeral epicondyle. since the LCL is reinserted at the end of the procedure as described above (Figure 11). Occasionally we perform a capsular release and trim or resect bony osteophytes at or around the radial head but preserve it. Therefore the ulnar nerve is released and protected and the joint is prepared for a full triceps split. The ulnar nerve is release then protected throughout. ORTHOPAEDICS AND TRAUMA 26:6 402 Ó 2012 Elsevier Ltd. We try to spare the anterior band of the MCL in order to preserve elbow joint stability. We then identify the medial collateral ligament (MCL) and resect its posterior band and then try to release the anterior capsule near the preserved anterior band of the collateral ligament. All rights reserved. Radial head resection is reserved for special indications where joint stiffness in flexion or rotation is mediated by the radial head. In this situation the surgeon has to consider if the anterior band MCL release is necessary or if a minor extension deficit can be accepted by the patient. We always use a tourniquet. In this. We position the patient is as described above. except that placement of the padded rest is beneath the distal part of the humerus. Figure 10 The direct posterior approach for open elbow joint release. in our hands. In those cases we consider applying a temporary external fixator. the LCL is reinserted using another bone anchor inserted in the origin of the LCL. Only in very rare cases is it necessary to release the anterior band at its humeral insertion in order to obtain a full ROM. at the undersurface of the lateral humeral epicondyle (Figure 11).12 After posterolateral release alone elbow joint instability is rarely a problem. radial head resection or ulnar nerve release or transposition is needed. but we do not normally transpose it at the end. Then. This is. If the anterior band in the MCL is released. If this alone is not sufficient to give free elbow motion on the table we continue to the second stage. elbow joint instability might be a problem. When needed we resect the tip of the coronoid process. the ulnar nerve is released and protected before resection of the posteromedial capsule (Figure 10).ELBOW Occasionally a posterior or lateral portal directly overlying the radiocapitellar joint line is used for evaluating and handling radiohumeral pathology. Only rarely do we preserve the lateral collateral ligament as described by Mansat in the column procedure26 and rarely do we resect the capsular tissue. A midline posterior incision is made with subcutaneous dissection (Figure 10). . a debridement of the olecranon fossa with resection of impinging olecranon and removal of loose bodies. showing radial head resection and reinsertion of the LCL using a bone anchor at the undersurface of the lateral epicondyle. we tend to do an open procedure. identify the lateral collateral ligament (LCL) and normally release this ligament from its humeral insertion in order to give easy and secure access to the anterior compartment through posterolateral joint subluxation. Figure 11 A postoperative AP radiograph of the patient seen in figure 2 following an open elbow joint release. The anterior capsule is then released from inside out and the coronoid fossa is debrided of calcifications and loose bodies. Normally we carry out a staged procedure and the first stage is a posterolateral release. This is the situation where both stages of the procedure are needed.

One patient had two arthroscopic procedures before the end result was achieved. We observed a general decrease in pain scores and one case of ulnar nerve paraesthesiae at follow-up. 5th edn. One patient needed another open operation before the end result was reached. Pathogenesis and classification of elbow stiffness. only two patients reported any residual pain at follow-up. is that more procedures are performed arthroscopically. A biomechanical study of normal functional elbow motion. Sneppen O. Askew LJ. Conclusion Treatment of the stiff elbow is a discipline with many possible approaches. Dalstra M. 3 Kapandji IA. REFERENCES 1 Morrey BF. the mean postoperative extension loss was 15 (Range 0 e40 ) and the mean maximum flexion was 128 (Range 110 e135 ). After a minimum of 3 months follow-up the mean postoperative extension deficit was 7 (Range 0 e30 ) and the mean maximal flexion was 130 (Range 120 e135 ). Usually pain is prominent in the first few postoperative days. 4 Olsen BS. early mobilization and pain management are probably the most important components of the postoperative regime. No patient had any decrease in forearm rotation before or after surgery.ELBOW Postoperative treatment Multiple postoperative rehabilitation programmes to follow elbow joint release have been published. There was a mean gain in the flexion arc of 23 (Range 15e40  ). CPM use beyond 48 h is debated. Churchill Livingstone. This allows continuous infusion of ropivacain at up to 20 mg/h. The physiology of the joints.8. The physiotherapist carries out regular visual analogue pain scores and if intolerable pain that prevents adequate rehabilitation the pain management regime is changed. We have tried to review the current status. As an illustration of the application of the principles described. Rehabilitation sessions continue until elbow joint motion has stabilized. 2 Jawa A. In: Stanley David. and our indications for which kind of procedure we chose are slowly changing. There were 12 males. Physiotherapy is initiated with the block effect still present. and in the rest the indications were degenerative joint disease (Figures 2 and 4). J Bone Joint Surg (Am) 1981.17. We use a combination of active assisted exercises and passive elbow stretching. In our department the current trend. . Edinburgh: Churchill Livingstone. All rights reserved. We inform the patient that the surgery restore up to 50% of the preoperative ROM deficit and in the majority of cases pain is decreased locking is cured. In order to facilitate this. A Our results In 2011 we performed 26 surgical procedures for chronic elbow joint stiffness. Chao EY. Recommended further reading The reader is directed to references 2. We did 17 open elbow joint release procedures and nine arthroscopic procedures. I have described our philosophy at Herlev Hospital and the early results that we expect. Trail Ian. This block is used for 24e48 h postoperatively to allow early application of a CPM device. 63: 872e7. 1982.28 In minor arthroscopic releases physiotherapy is initiated immediately after surgery. The mean age at surgery was 37 years (Range 14e57 years).18 We tend to avoid “at home” CPM treatment. It is important to give the patient a realistic expectation of what he or she can achieve after surgery. We also use non-steroidal anti-inflammatory medications to prevent heterotopic bone formation when needed. The mean preoperative loss of extension was 37 (Range  15 e60 ) and flexion was possible up to 105 (Range 80 e125 ).24. Operative elbow surgery. It is helpful in this process to always retain the possibility of conversion from arthroscopic to an open procedure in order to minimize the risk of serious complications and to secure the best postoperative result for the patient.26 for much further useful information on this topic. After a minimum of 3 months follow up. the patients are closely followed up in our physiotherapy department to ensure maintenance of the range of movement. eds. Elsevier. Arthroscopic procedures These were performed in seven cases for degenerative joint disease or arthritis.12 Generally the publications agree that early mobilization is important. The ROM arc was 113 (Range 70 e135 ) after surgery. Following the block we normally prescribe oral tramadol 50e100 mg and paracetamol 1 g four times per day. There was a mean gain in flexion of 45 (Range 25 e65 ). One was unchanged at follow-up. The ROM arc was a mean of 100 (Range 65 e120 ) before surgery. There were five females. At discharge from our department at day 2. Søjbjerg JO. At follow-up none had locking and all experienced pain relief. Jupiter JB. Most of our arthroscopic releases are done as day-case surgery and the patient attends rehabilitation sessions from day one. ORTHOPAEDICS AND TRAUMA 26:6 403 Ó 2012 Elsevier Ltd. 409e16. Three were normalized and two had improved forearm rotation at follow-up. with increasing experience with arthroscopic elbow joint release and debridement. The mean age at surgery was 48 years (Range 27e73 years). Surgery is performed under an ultrasound guided infraclavicular one-shot block. The mean preoperative extension loss was 19 (Range 0 e40 ) and maximal flexion was 119 (Range 100 e135 ). 5: 333e41.12. Kinematics of the lateral ligamentous constraints of the elbow joint. Open procedures These were performed in 13 cases due to sequelae of trauma (Figure 3).10.12. In major open releases we use an infraclavicular low brachial plexus block applied through an ultrasound guided indwelling catheter. 2012. The ROM arc was 123 (Range 100 e135 ) after surgery. Ring D. J Shoulder Elbow Surg 1996. The ROM arc before surgery was a mean 68 (Range 30 e110 ). presenting the different surgical and non-surgical approaches.12. which are comparable to other studies reported in the literature. Six patients had preoperative deficits of forearm rotation. All patients had preoperative pain and four patients experienced locking. Only two cases had posttraumatic elbow joint stiffness.

Sanchez-Sotelo J. The elbow and its disorders. Adolfsson L. Olsen BS. Olsen BS. Nicoletti S. eds. In: Stanley David. Søjbjerg JO. All rights reserved. In: Stanley David. 7 Safran MR. 437e52. Tullos HS. Simple dislocation of the elbow in the adult. In: Morrey BF. Churchill Livingstone. Saunders: Elsevier. 21 Charalambous CP. 14: 179se85. Morrey B. J Bone Joint Surg (Am) 1990. Eygendaal D. O’Driscoll SW. Churchill Livingstone. Saunders: Elsevier. 20 Araghi A. 6: 15e23. 2012. Rymaszewski L. Fractures of the distal humerus: plating techniques. Instr Course Lect 2003. 13 Cohen MS. J Bone Joint Surg (Am) 1998. 23 Haapaniemi T. Nunn T. 6 Jensen SL. Trail Ian. 12 Murray O. 8 Lindenhovius AL. Bennett JB. Baillargeon D. 18 Lindenhovius AL. Total elbow replacement for the management of the ankylosed or fused elbow. 70: 244e9. Operative elbow surgery. Outcomes of open arthrolysis of the elbow without post-operative passive stretching. Lee GC. 267e77. General and regional anesthesia and postoperative pain control. Posttraumatic elbow stiffness. Treatment by open surgical techniques. Elsevier. Ring D. O’Driscoll SW. 19 Lindenhovius AL. The elbow and its disorders. 38: 2509e15. (Elbow stiffness) treatment by arthroscopy. Elsevier. Mudgal CS. The posttraumatic stiff elbow: a review of the literature. J Shoulder Elbow Surg 2002. 160e3. Jupiter JB. 15: 784e7. J Bone Joint Surg (Am) 1988. Complete transection of the median and radial nerves during arthroscopic release of posttraumatic elbow contracture. J Bone Joint Surg (Am) 2012. 32: 1605e23. J Shoulder Elbow Surg 1998. Sneppen O. Anatomy and kinematics. Lennon RL. 143e51. J Bone Joint Surg (Br) 2008. Dalstra M. J Hand Surg Am 2007. 15 O’Driscoll SW. J Shoulder Elbow Surg 2011. 2012. 20: 813e8. eds. 417e35. Johannsen HV. Sojbjerg JO. Acute elbow dislocation: evaluation and management. . J Shoulder Elbow Surg 2005. McEhan J. 90: 1198e204. Trail Ian. Arthroscopic restoration of terminal elbow extension in high-level athletes. Jupiter JB. The medial collateral ligament of the elbow joint. 72: 601e18. Hastings H. vand de Luijtgaarden K. 16 Higgs ZCJ. Am J Sports Med 2010. eds. J Hand Surg Am 2009. SanchezSotelo J.ELBOW 5 Floris S. 26 Mansat P. Berggren M. In: Morrey BF. 25 Blonna D. J Shoulder Elbow Surg 2010. Operative elbow surgery. 17 O’Driscoll S. Open elbow contracture release: postoperative management with and without continuous passive motion. Celli A. Morrey BF. 4th edn. 52: 93e111. Jupiter J. Elsevier. 2012. 10 Jupiter JB. Sibinski M. Rymaszewski LA. Ring D. Morrey BF. 94: 1428e37. Olsen BS. Brouwer KM. Seki A. J Shoulder Elbow Surg 2011. 9 Morrey BF. Churchill Livingstone. Soft-tissue stabilizers of the elbow. 94: 694e700. 22 Cefo I. Adams R. 11: 158e65. eds. Arthroscopic arthrolysis for posttraumatic elbow stiffness. 2009. The clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum of young athletes. 14 Mehlhoff TL. Cohen MS. Danks BA. Noble PC. The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release. 80: 1603e15. J Bone Joint Surg (Am) 2012. Kopp SL. ORTHOPAEDICS AND TRAUMA 26:6 404 Ó 2012 Elsevier Ltd. eds. 19: 202e8. The assessment and management of the stiff elbow. 20: 334e9. 94: 348e52. 27 Peden JP. Post-traumatic contracture of the elbow. J Bone Joint Surg (Br) 2012. J Am Acad Orthop Surg 1998. Doornberg JN. Sneppen O. Radiohumeral stability to forced translation: an experimental analysis of the bony constraint. A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. In: Stanley David. 11 Ovesen J. 2009. 34: 858e65. 4th edn. 7: 345e51. Morrey BF. Operative elbow surgery. 24 Funk L. 28 Horlocker TT. The column procedure: a limited lateral approach for extrinsic contracture of the elbow. Arthroscopy 1999. Trail Ian. Continuous passive motion.

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