Stiff elbow and fffd elbow managememt

STIFF ELBOW

FUNTIONAL ARC OF ELBOW

MOVEMENT NEEDED FOR ACTIVITIES OF DAILY LIFE:

30 TO 130 DEGREES OF FLEXION50 DEGREE EACH OF PRONATION &

SUPINATION

LOSS OF EXTENSION IS COMMON.LOSS OF FLEXION IS LESS TOLERATED.

FFD 45*

ROM 45-115*

KEY TO TREATMENTBASE TREATMENT ON FUNCTIONAL &

OCCUPATIONAL IMPAIRMENT.

NOT ON ABSOLUTE LOSS OF MOVEMENT.

COMPENSATORY BIOMECHANICAL FUNCTION IS ABSENT IN ELBOW.(unlike in shoulder)

ANATOMY & STIFF ELBOWTHREE JOINTS WITHIN SINGLE CAVITY.CRUCIATE ORIENTATION OF FIBRES OF

ANTERIOR CAPSULE.(contracture easy)CLOSE PROXIMITY OF CAPSULE TO

MUSCLES & LIGAMENTS.

80* FLEXION – ALLOWS 25 ml CAPACITY, & DROPS TO 6ml IN STIFF ELBOW.(contracture of capsule)

PATHOGENESIS of STIFF ELBOW

MULTIFACTORIAL & OBSCURE.

MYOFIBROBLASTS IN ANTERIOR CAPSULE.

MATRIX METALLO PROTEINASES INCREASED IN CONTRACTED CAPSULE.

COMPLEX CHAIN OF EVENTS IN HEAD TRAUMA.

EVENTS IN CAPSULEANTERIOR CAPSULE THICKENS (2 mm

normal)

COLLAGEN CROSS LINKING INCREASE.WATER CONTENT DECREASE.PROTEOGLYCAN CONTENT DECREASE.

COLLAGEN HYPERTROPHY.

STIFF ELBOW-CLASSIFICATION

INTRINSICEXTRINSICPERIPHERAL - MORREYSTATICDYNAMIC

INTRINSIC CAUSES OF STIFF ELBOWARTICULAR INCONGRUITY.

DEGENERATIVE CHANGES.INTRA ARTICULAR ADHESIONS.

LOOSEBODIES.SYNOVITIS.INFECTIONS.

EXTRINSIC CAUSES OF STIFF ELBOWSOFT TISSUE&CAPSULAR CONTRACTURE.MUSCLE FIBROSIS.

COLLATERAL LIGAMENT TIGHTNESS.

HETEROTOPIC OSSIFICATION.

SKIN CONTRACTURE.

PERIPHERAL CAUSES OF STIFF ELBOW FACTORS ANATOMICALLY SEPARATE

FROM ELBOW:

NEUROLOGICAL PROBLEMS

HEAD INJURY, STROKE, PERIPHERAL NERVE DISORDERS, CEREBRAL PALSY etc.

STATIC & DYNAMIC causesSTATIC: PATHOLOGY OF TISSUES IN &

AROUND ELBOW JOINT.

DYNAMIC: DEFECTIVE FUNCTION OF

MUSCLES AROUND THE JOINT

CLINICAL ASSESSMENT

DEGREE OF FUNCTIONAL IMPAIRMENT-ROM, ulnohumeral- affects flexion&extension,

superior radio ulnar- affects rotations, radio capitullar – both flexion-extension

&rotation

PRIOR TREATMENT-SURGICAL SCARS,

INFECTION,SOFT TISSUE COMPROMISE

PHYSICAL EXAMINATION:

ELBOW STABILITYELBOW RANGE OF MOVEMENTULNAR NERVE INTEGRITY

FUNCTION OF SHOULDERFUNCTION OF CERVICAL SPINEFUNCTION OF CONTRALATERAL LIMB

PHYSICAL EXAM- ROM

INVESTIGATIONSPLAIN RADIOGRAPHS VISUALISE THE BONE, JOINT CONGRUITY, HETEROTOPIC OSSIFICATION (status) OSTEOPHYTES, STATUS OF FRACTURE, etc

CT SCAN WITH IMAGE REFORMATION IN SAGITAL & CORONAL PLANES

ANTERIOR BLOCK TO MOVEMENT

WRIST X RAY - NEEDED

DIFFERENTIAL DIAGNOSIS

DYSPLASTIC RADIAL HEAD (congenital)ELBOW FRACTURE DISLOCATIONHETEROTOPIC OSSIFICATION

HEAD INJURYBURNSMUSCULAR HYPOTONIASTROKE

DYSPLASTIC ELBOW

NON OPERATIVE MANAGEMENTUPTO 6 MONTHS AFTER ONSET OF

CONTRACTURE

END POINT IF SOFT & SPONGY

ACTIVE ASSISTED ROM EXERCISESSTATIC / DYNAMIC SPLINTS (progressive)10-50 DEGREES OF MOVEMENT GAIN

ELBOW RELEASE (timing)AFTER 6 MONTHS OF INJURY:

SOFT TISSUE INFLAMMATION SETTLE DOWN

(ESR,CRP,S.ALKALINE PHOSPHATASE)

SUFFICIENT REHABILITATION PROGRAMME IS DONE

PRE OP-PLANNINGIDENTIFY THE ANATOMICAL

IMPEDIMENTS TO MOVEMENT

RECOGNISE ASSOCIATED PATHOLOGY WHICH CAN BE ADDRESSED AT THE TIME OF SURGERY

DECIDE ON THE TYPE OF OPERATION & APPROACH

IDENTIFY BARRIER TO MOTION

TIGHT STRUCTURE ON ONE SIDE contracted capsule

IMPINGEMENT ON THE OTHER bony spur, heterotopic

ossification,hardwares etc

CONTRA INDICATIONS OF ARTHROLYSIS

GROSS DISTORTION OF ARTICULAR COUNTOUR

> 50% LOSS OF ARTICULAR CARTILAGE

IF COLLATERAL LIGAMENT SACRIFICE IS REQUIRED

MOTOR DEFICIENCY/SPASTICITY

AIM OF ELBOW RELEASEREMOVE OFFENDING STRUCTURES

MAINTAIN STABILITY OF ELBOW

MAINTAIN INTEGRITY OF NEUROVASCULAR STRUCTURES

APPROACH (incision)MEDIAL/ LATERAL/ ANTERIOR/

POSTERIOR

DEPENDS ON EVALUATION OF EACH CASELOCATION & ANATOMY OF OFFENDING

STRUCTURES & CONCOMITANT PROBLEMS eg-ULNAR NERVE INVOLVEMENT,

NON UNION, HETEROTOPIC OSSIFICATION etc

GOAL OF TECHNIQUEWIDE EXPOSURE OF CAPSULE & OFFENDING

STRUCTURES.

MAINTAIN ELBOW STABILITY- retain lateral ulno- humeral ligament &

anterior band of MCL

PROTECT NEUROVASCULAR STRUCTURES ULNAR NERVE- EXPOSE & PROTECT RADIAL NERVE,MEDIAN NERVE & VESSELS- BY KEEPING SOFT TISSUE BARRIER

STEPS OF ARTHROLYSISULNAR NEUROLYSIS

RELEASE OF CONTRACTED SOFT TISSUES-remove contracted capsule both anterior& posterior ,+

subperiosteal elevation of muscles.

REMOVAL OF BONY IMPINGEMENT –DEBRIDEMENT ARTHROPLASTY(OUTERBRIGE-KASHIWAGI PROCEDURE)

DEEP LATERAL TECHNIQUELATERAL INCISION-bony land mark- lateral

supracondylar ridge

PRESERVE LCLBR & ECRL,ECRB elevated anteriorlyLATERAL TRICEPS & ANCONEUS elevated

posteriorly

VISUALISE anterior & posterior capsules,olecranon & coronoid fossae & processes

LATERAL INCISION

LATERAL COLUMNBONY LANDMARK INCISION

ANTERIOR CAPSULE

ANTERIOR CAPSULECTOMY

DEEP MEDIAL TECHNIQUEMEDIAL INCISION

ISOLATE ULNAR NERVEPRESERVE MCLELEVATE FLEXOR PRONATORS anteriorly

& TRICEPS posteriorly

VISUALISE anterior & posterior capsules & fossae & bony land marks.

POSTERIOR APROACHINCISION – LONGITUDINAL & MIDLINE

POSTERIORFLAPS RAISED BOTH MEDIALY & LATERALY to

point anterior to the epicondyles

CUTANEOUS NERVES ARE LEAST DAMAGEDALLOWS EXPOSURE OF CAPSULE BOTH

ANTERIORLY & POSTERIORLY ULNAR NEUROLYSIS EASIERESPECIALLY USEFUL IN FRACTURE NON UNION

INTRA OPERATIVE ASSESSMENT

GAINED RANGE OF MOTION – SOFT TISSUE CONTRACTURES GENTLY

STRETCHED OUT

STABILITY - ULNO HUMERAL SUBLUXATION WITH GRAVITY FORCE EXTENSION OF ELBOW

GENTLE STRETCHING

INTRA OP - ROMextension flexion

WOUND CLOSUREMUSCLES RE ATTACHED – DRILL HOLES,

SUTURE ANCHORS

METICULOUS HAEMOSTASIS – RELEASE TOURNIQUET

STRONG SKIN CLOSURE TO ALLOW EARLY EXERCISE

SKIN CLIPS TO ALLOW EXERCISE

POST OP MANAGEMENTBULKY DRESSING & SPLINT IN EXTENSION

SECOND DAY - REMOVE DRAIN, START ACTIVE ROM EXERCISE

NIGHT SPLINT IN EXTENSIONCPM IF AVAILABLE

VISITS – AFTER 2 WKS & THEN EVERY 4 WKS

POST OP - EXERCISEEXTENSION FLEXION

POST OP - EXERCISESUPINATION PRONATION

ELBOW ARTHROLYSIS- FUTURE ??