WHAT YOU SHOULD KNOW
The word contracture simply means that full movement of a joint is prevented by the soft tissues surrounding the joint. This differs from movement being prevented by the bones of the joint. The main soft tissue associated with a joint is the membrane that surrounds the joint and contains its fluid. This membrane is called the joint capsule.
MEDICAL HISTORY
An elbow contracture typically occurs following previous elbow trauma: fracture or ligament injury. The timing of the original injury relative to the loss of motion is very important to understanding why the motion was lost. All the details of the previous treatment including prior surgery and therapy efforts should be reviewed.
EXAMINATION
The most important part of the examination is trying to determine if the underlying joint is stable and properly shaped with healthy cartilage. A joint that does not have healthy cartilage or that is already unstable will not fare well during contracture treatment. The elbow joint is measured in its four directions of movement: flexion, extension, supination, and pronation. The joint is checked for stability of its two main ligament groups (medial and lateral). Adjacent nerve compression (particularly the ulnar nerve going to the ring and small fingers) must be sought out prior to treatment as it will only get worse if not included in the plan.
ADDITIONAL TESTS
The main additional test needed is simply a basic x-ray. Rarely should expensive imaging studies such as a CT scan or MRI be needed in the work-up. If there is any question regarding ulnar nerve compression, a nerve conduction test should be performed to measure the exact nerve conduction velocities.
TREATMENT OPTIONS
| NON-OPERATIVE | CAPSULECTOMY | |
| CONSISTS OF | Outpatient and home motion exercises and splinting | Surgically removing the scarred capsule tissue that limits elbow motion |
| FEATURES | Static progressive splint adjusts to push motion to the limits | Must preserve the medial and lateral collateral ligaments; transpose the ulnar nerve if compressed |
| ADVANTAGES | Avoids surgery | Most powerful treatment to restore motion |
| DISADVANTAGES | Only effective while post-traumatic scar tissue is still maturing (less than 4 months after the original trauma) | Very painful and requires intense therapy commitment on the patient’s part |
RECOVERY
The capsulectomy surgery removes all the previous motion limiting scarred capsular tissue. At the conclusion of the procedure, the patient will have full motion. The body immediately begins forming new scar to limit motion. If the patient is not able to maintain daily full range of motion right after the procedure, a new contracture will gradually develop. Keeping up with full range elbow motion on a daily basis is both time consuming and very painful. Patients must be mentally prepared to handle this challenge before proceeding with treatment. Post-capsulectomy therapy continues as an outpatient for 2-3 months and at home for up to 6 months. Patients routinely use specialized splints (static progressive splints) to maintain maximum range of motion.
