Posttraumatic Elbow Contracture
Elbow stiffness can occur after both traumatic and atraumatic causes, including fractures, dislocations, crush injuries, burns, and head injury. Anatomically, elbow stiffness can be viewed as caused by extrinsic and intrinsic contributions. Intrinsic joint contracture includes malunited articular surfaces, loose bodies, osteophytes, synovitis, and hypertrophic joint capsule. Anterior capsule hypertrophy is a frequent cause of intrinsic contracture that typically demonstrates increased levels of disorganized collagen.
Extrinsic sources of elbow stiffness include muscle, tendon, and skin. Injury to muscles around the elbow, especially the brachialis muscle, may result in myostatic contracture and scarring. The skin may be deficient after extensive trauma or burns and may require release and reconstruction with grafts or flaps to restore motion. Posttraumatic elbow contracture may be complicated by ectopic bone formation. Heterotopic ossification may limit motion in 3% of simple elbow dislocations and in up to 89% of patients with elbow trauma and head injury. Heterotopic bone formation can occur anywhere in the elbow, but it has a predilection for formation posterior to the elbow joint and in the proximal forearm resulting in radioulnar synostosis.
The pathogenesis of elbow contracture is not fully understood but may result from a complex cascade of events after trauma that activates myofibroblasts. Myofibroblasts proliferate under influence of transforming growth factor (TGF) beta 1 that may be influenced by female sex hormones and genetic predisposition.
Etiology
Elbow stiffness can occur after both traumatic and atraumatic causes, including fractures, dislocations, crush injuries, burns, and head injury. Anatomically, elbow stiffness can be viewed as caused by extrinsic and intrinsic contributions. Intrinsic joint contracture includes malunited articular surfaces, loose bodies, osteophytes, synovitis, and hypertrophic joint capsule. Anterior capsule hypertrophy is a frequent cause of intrinsic contracture that typically demonstrates increased levels of disorganized collagen.
Extrinsic sources of elbow stiffness include muscle, tendon, and skin. Injury to muscles around the elbow, especially the brachialis muscle, may result in myostatic contracture and scarring. The skin may be deficient after extensive trauma or burns and may require release and reconstruction with grafts or flaps to restore motion. Posttraumatic elbow contracture may be complicated by ectopic bone formation. Heterotopic ossification may limit motion in 3% of simple elbow dislocations and in up to 89% of patients with elbow trauma and head injury. Heterotopic bone formation can occur anywhere in the elbow, but it has a predilection for formation posterior to the elbow joint and in the proximal forearm resulting in radioulnar synostosis.
The pathogenesis of elbow contracture is not fully understood but may result from a complex cascade of events after trauma that activates myofibroblasts. Myofibroblasts proliferate under influence of transforming growth factor (TGF) beta 1 that may be influenced by female sex hormones and genetic predisposition.
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