Sunday, May 24, 2009

Stiff elbow & static progressive splinting for it- A mini Review

Elbow is a highly constrained synovial hinge joint (3). A 50% reduction of elbow motion can reduce the upper extremity function by almost 80% (1). Elbow motion is essential for upper extremity function to position the hand in space (2). Stiffness of the elbow impairs hand function, because this is highly dependent on elbow extension and flexion and forearm rotation (1).

Elbow joint is prone to stiffness following a multitude of traumatic and atraumatic etiologies. Diagnosis depends on a complete history and physical exam, supplemented with appropriate imaging studies (2).

Søjbjerg JO defined stiff elbow as reduction in extension greater than 30 degrees, and/or a flexion less than 120 degrees. According to him supination and pronation are also often reduced as well but this author says contracture of the elbow is not related to forearm rotation. However, it seems this description matches the capsular restriction.

General guideline of treatment (1, 2 & 3):

1. Elbow contracture is challenging to treat, and therefore prevention is of paramount importance (2, 3).
2. When preventive approach fails, non-operative followed by operative treatment modalities should be pursued (2). The non-operative treatments are as follows:
3. Upon initial presentation in those who have minimal contractures of 6-month duration or less, static and dynamic splinting, serial casting, continuous passive motion, occupational/physical therapy, and manipulation are non-operative treatment modalities that may be attempted (2).
4. Surgery of the posttraumatic stiff elbow is a challenging and demanding procedure (1). A stiff elbow that is refractory to non-operative management can be treated surgically, either arthroscopically or open, to eliminate soft tissue or bony blocks to motion (2). Advanced postoperative rehabilitation can improve the final outcome (1).

Results of a retrospective study on static progressive splinting for posttraumatic elbow stiffness:

Doornberg JN et al evaluated a retrospective case series to examine the effect of static progressive splinting in helping patients with posttraumatic elbow stiffness regain functional motion and avoid operative treatment for stiffness. 29 patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. In this study, Doornberg & colleagues found static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most these 29 patients (4).

References:

1. Søjbjerg JO; Acta Orthop Scand. 1996 Dec;67(6):626-31.
2. Nandi S et al; Hand (N Y). 2009 Apr 7. [Epub ahead of print]
3. Evans PJ et al; 2009 Apr;34(4):769-78.
4. Doornberg JN et al; 2006 Jul;20(6):400-4.



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