Aim:. To investigate the clinical outcomes of elbows with post-traumatic stiffness treated by open surgical release. Methods:. A retrospective review was completed on thirty-five consecutively managed patients who underwent an open elbow release for post-traumatic stiffness between 2007 and 2012. Pre-operative and post-operative range of motion (ROM), pain scores and functional outcomes were recorded. Results:. Mean follow-up was 31 months (6–84). The cohort consisted of 20 male and 15 female patients with an average age at time of surgery of 34 years (17–59). The interval from injury to time of release was 26 months (6–180). An improvement in mean ROM from 49° (0°–105°) to 102° (55°–150°) was obtained. The improvement in ROM in patients with pre-operative heterotopic bone was 61° compared to 45° in patients without heterotopic bone. The mean Mayo Elbow Performance Score improved from 44 pre-operatively to 82 at most recent follow-up. Mean VAS scores improved from 5.9 pre-operatively to 2.8 at most recent follow-up. Patients rated the affected elbow a mean of 73% as compared to the contralateral/normal side (50–100%). Apart from a 10% incidence of transient ulnar nerve neurapraxia in patients who had a medial or combined approach, complication rates and functional outcomes were comparable between medial, lateral and combined approaches. Conclusion:. Open release for post-traumatic elbow stiffness results in satisfactory functional outcomes in the majority of cases, with no significant differences between medial, lateral or combined approaches

Successful ORIF of proximal humeral fractures requires a careful assessment of the patient factors (age/osteoporosis/functional expectations), accurate identification the fracture segments (head/shaft/tuberosities) and accessory factors which are of vascular and surgical relevance (length of posteromedial metaphyseal head extension, integrity of medial soft tissue hinge, head split segments, tuberosity/head segments impacted to-gether or distracted apart). Fixation of the fracture can be achieved by a number of techniques because of the multiple factors that often apply—numerous techniques are usually required of the surgeon. The principles of fixation require accurate restoration of the head and tuberosity orientation, fixation of the metaphyseal segments (tuberosities) results in a stable circular platform on which the head segment rests. Thus, the fixation of choice acts as a load sharing device not a load bearing device. This fixation is often augmented with tension band and circlage suture fixation. These concepts are especially applicable to the osteoporotic patient. The order of fixation requires that the medial hinge not be disrupted. If it is disrupted in the younger patient it requires fixation first. All tuberosity segments are tagged with ethibond sutures. The head and the largest tuberosity segment are reduced and held with k-wire or canulated scews, avoiding the central medullary canal entry point. If the head tuberosity segment is unstable in relation to the shaft, the fixation implant of choice (plate/intramedullary) is chosen and the head/tuberosity complex is reduced to the shaft. Depending on the fracture segments and the degree of comminution this may require compression of distraction. Post-op the patient is immobilised in external rotation to balance the cuff forces. If very rigid fixation is achieved then early mobilisation is undertaken to minimise the adhesions due to opening of the subdeltoid space. If fixation is tenuous movement is commenced a 3–4 weeks. AVN of the humeral head with good tuberosity head architecure can be salvaged. The diagnosis of AVN is determned at three months with a MRI and consideration given to Zolidronate therapy. Post-traumatic stiffness with good architecture can be salvaged with an arthroscopic capsular release

The causes of a stiff elbow are numerous including: post-traumatic elbow, burns, head injury, osteoarthritis, inflammatory joint disease and congenital. Types of stiffness include: loss of elbow flexion, loss of elbow extension and loss of forearm rotation. All three have different prognoses in terms of the timing of surgery and the likelihood of restoration of function. Contractures can be classified into extrinsic and intrinsic (all intrinsic develop some extrinsic component). Functional impairment can be assessed medicolegally; however, in clinical practice the patient puts an individual value on the arc of motion. Objectively most functions can be undertaken with an arc of 30 to 130 degrees. The commonest cause of a Post-traumatic Stiff elbow is a radial head fracture or a complex fracture dislocation. Risk factors for stiffness include length of immobilisation, associated fracture with dislocation, intra-articular derangement, delayed surgical treatment, associated head injury, heterotopic ossification. Early restoration of bony columns and joint stability to allow early mobilisation reduces incidence of joint stiffness. Heterotopic ossification (HO) is common in fracture dislocation of the elbow. Neural Axis trauma alone causes HO in elbows in 5%. However, combined neural trauma and elbow trauma the incidence is 89%. Stiffness due to thermal injury is usually related to the degree rather than the site. The majority of patients have greater than 20% total body area involved. Extrinsic contractures are usually managed with a sequential release of soft tissues commencing with a capsular excision (retaining LCL/MCL), posterior bundle of the MCL +/− ulna nerve decompression (if there is loss of flexion to 100 degrees). This reliably achieved via a posterior incision, a lateral column exposure +/− ulna nerve mobilisation. A medial column exposure is a viable alternative. Arthroscopic capsular release although associated with a quicker easier rehabilitation is associated with increased neural injury. Timing of release is specific to the type of contracture, i.e. flexion contractures after approx. six months, extension contractures ASAP but after four months, loss of forearm rotation less 6 to 24 months. The use of Hinged Elbow Fixators is increasing. The indications include reconstructions that require protection whilst allowing early movement, persistent instability or recurrent/late instability or interposition arthroplasty. Post-operative rehabilitation requires good analgesia, joint stability and early movement. The role of CPM is often helpful but still being evaluated

Aim. Over the last 15 years there has been a series of publications reporting the beneficial effects of elbow arthrolysis, with considerable variation in operative technique and post-operative management. Many advocate the use of passive stretching techniques in the early post-operative period if range of motion fails to improve satisfactorily. The purpose of this study was to assess our results of open elbow arthrolysis in patients who did not receive any passive stretching after discharge from hospital. Methods. Prospectively collected data of 55 patients with a minimum follow-up of 1 year after arthrolysis were analysed. All procedures were performed by the same surgeon (LR), achieving as much improvement in elbow motion as possible at operation. All patients had continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively but none received any passive stretching after discharge. At review, a senior physiotherapist (BD) formally assessed all the patients. Results. All patients' arc of movement improved from 68 degrees to 104 degrees (flexion 18 degrees/extension 23 degrees). Upper limb function (Disabilities of the Arm, Shoulder and Hand score) improved by 50%. Pain decreased from 20 to 9, measured with a Visual Analogue Score. The greatest improvement in motion was obtained in the stiffest elbows - 7 patients with an arc of 30 degrees or less pre-operatively achieved an arc of 100 degrees by the time of the last review. Conclusions. Good results of open arthrolysis for post-traumatic elbow stiffness can be achieved with continuous brachial plexus blocks and continual passive motion for 2-3 days post-operatively. There appears to be little evidence to support treatment with passive stretching techniques after discharge from hospital, as our results are similar to other reported series