Page 20 - ISAKOS 2018 Newsletter Volume 2
P. 20

The Stiff Elbow: Classification and Treatment Algorithm
Therefore, even mild or moderate loss of elbow motion is perceived as disabling (Fig. 2).
Morrey noted that most activities of daily living can be performed with an arc of 100° of elbow flexion (30° to 130°) and 100° of forearm rotation (50° of pronation and 50° of supination). However, greater motion may be required for personal hygiene, dressing, eating, holding the phone to the ear, and typing.
As a general rule, deficits of flexion and supination are harder to compensate for. For example, when reaching, grabbing, and manipulating an object, a pronation deficit can be partially compensated for with shoulder abduction and an extension deficit can be compensated for by bringing the object closer to the body. Without adequate flexion, however, it is difficult to bring the hand to the mouth or to perform to grooming or toileting activities. Similarly, without supination, it is difficult to receive coins and to lift objects.
A variety of elbow disorders can cause stiffness, with the most common being post-traumatic in origin; this category also includes burns, head injury, and elbow surgery. However, elbow stiffness also can be caused by atraumatic etiologies, such as osteoarthritis, inflammatory joint disease, infection, metabolic disease (e.g., hemophilia), and congenital conditions (arthrogryposis).
The typical etiology of joint stiffness involves an initial insult (such as trauma to the joint morphology1), followed by a healing response (soft-tissue contracture of the capsule, ligaments, and muscles), and then by the development of secondary changes (avascular necrosis and degeneration), all of which will affect the severity of stiffness when the patient presents for treatment. In addition, heterotopic ossification (HO) can restrict the joint or compress the ulnar nerve. It is important to recognize the notion of time spanning the initial insult, the healing response, and the secondary changes. The final common pathway is to develop degenerative arthritis of the joint.
Alessandro Marinelli, MD
Istituto Ortopedico Rizzoli Bologna, ITALY
Gregory Bain, MD, PhD
Flinders University Adelaide, AUSTRALIA
Elbow motion, which is essential for upper-extremity function and the ability to position the hand in space, is created by a cascade of anatomical zones that enable the “elbow machine” to be mobilized (Fig. 1). The normal physiological motion of the elbow is 140° to 150° of flexion-extension and 140° to 150° of pronation-supination.
Elbow stiffness is the most frequent presentation in the outpatient elbow clinic. The reason is that the elbow is prone to stiffness after injury or surgery and the adjacent joints provide only limited compensatory motion.

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