Elbow Stiffness After Injury

Orthopedic surgeons from the Mayo Clinic in Rochester, Minnesota review the concepts and molecular changes that occur with elbow stiffness after elbow trauma or injury.

There are many bone and soft tissue injuries that can contribute to posttraumatic elbow stiffness. It's not always clear what all the factors are leading to this condition. But animal studies have revealed some new and helpful information that may lead to improved treatment.

It appears there are two major areas of soft tissue damage linked with posttraumatic elbow stiffness. The first area of interest is the joint capsule. The capsule is a group of ligaments and connective tissue that surrounds the entire joint. The second factor that can result in elbow joint stiffness is the increase in number of myofibroblasts (protein in the muscle cells) after injury.

The exact chain of events at the cellular level that lead to capsular and myofibroblast changes are very complex. The author does a good job providing details of the chemical and mechanical signals that occur after elbow injury. Growth factors, collagen expression, and mast cell production are all important in the molecular and cellular events that occur after an injury.

In fact, the discovery that mast cells are released in response to trauma and pain was an important clue. There is some evidence that mast cells may be the missing link between an acute injury that becomes chronic. And that's where pharmaceutical (drug) treatments could be developed to help prevent posttraumatic stiffness.

There are other factors that might be part of the picture. Female sex hormones, prolonged immobilization right after the injury and genetic predisposition have been identified. Addressing these three risk factors might help physicians predict problems and prevent them. This concept is referred to as selective targeting.

Before treatment begins, imaging with X-rays and CT scans must be done. Imaging shows any fractures, loose fragments of bone or cartilage, or infection. If nothing shows up, loss of motion could be caused by the patient's apprehension and muscle tension more than a true mechanical problem. It may be necessary to examine the patient under anesthesia to find the true cause of loss of elbow motion.

Treatment is based on whether the stiffness is coming from inside or outside the joint and which specific structures are involved. Treatment ranges from conservative (nonoperative) care to surgery. Various treatment options include physical therapy, bracing, splinting, manipulation under anesthesia, and surgical release of the capsule. For patients who do not respond to any of these approaches, an elbow replacement may be advised.

The authors say there is a need for high-quality research to determine what works best to treat posttraumatic elbow stiffness. The new information presented comes from animal studies but may still help expand pharmaceutical treatment options in the near future. The focus now is on finding ways to prevent this problem from developing whenever possible.

References: Charalambos P. Charalambous, BSc, MBCHB, MSc, MD, FRCS (Tr&Ortho), and Bernard F. Morrey, MD. Current Concepts Review: Posttraumatic Elbow Stiffness. In The Journal of Bone and Joint Surgery. August 1, 2012. Vol. 94A. No. 15. Pp. 1428-1437.