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Stiff elbow arthrolysis

66 citationsUpdated Sep 2026

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Overview

Elbow stiffness is a challenging clinical problem with no ideal management solution, though functional improvements can be achieved through both nonsurgical and surgical strategies [2]. While most cases of post-traumatic elbow stiffness improve with time and use [3], significant stiffness may persist despite this natural recovery [3]. A long duration of stiffness negatively influences functional outcomes and increases the risk of complications after arthrolysis [1]. Successful intervention depends on the quality of the joint and the extent of soft tissue damage [4], with restoration of motion serving as a difficult, time-consuming, and costly challenge [5]. The functional arc of motion serves as a frame of reference rather than an absolute goal for intervention [4].

Current treatment options for post-traumatic elbow stiffness range from conservative to surgical, with varying rates of success, invasiveness, and complications [7]. Surgical release can yield sustained improvement in range of motion and patient quality of life when nonsurgical treatment fails [6]. Arthroscopic arthrolysis leads to good clinical and functional results regarding range of motion, pain relief, functionality, and quality of life [13], with patients achieving satisfactory clinical outcomes very early postoperatively [9]. Open arthrolysis with hinged external fixation provides satisfactory medium-term results for severe posttraumatic stiffness [14], while arthroscopic circumferential release offers safe and effective restoration of motion regardless of preoperative severity [16].

Pre-operative evaluations must identify involved articular and periarticular tissues and determine whether articular surfaces and osteoarticular congruence are preserved [11]. Arthrolysis is typically performed by a combination of lateral and medial approaches [17], where routine hinged external fixation and anterior transposition of the ulnar nerve may improve postoperative recovery [17]. Additional peripheral nerve block combined with a postoperative nerve block catheter in arthroscopic arthrolysis may enhance postoperative outcomes by achieving better functional range of motion, perhaps through reduced postoperative pain [62]. Recent advancements in biology and pathology may lead to future breakthroughs in the prevention and treatment of elbow stiffness [2].

Anatomy & Pathophysiology

Bony Anatomy

The elbow is a highly constrained synovial hinge joint that frequently becomes stiff after injury [22]. It consists of three articulations: the ulnohumeral joint, the radiocapitellar joint, and the proximal radioulnar joint [22]. The ulnohumeral joint is the major force-bearing articulation for flexion-extension, formed between the humeral trochlea and the corresponding trochlear notch of the proximal ulna [22]. This hinged or trochoid portion features highly congruent anatomy through almost 180° of articular contact, with the exception of the bare area of the greater sigmoid notch of the ulna which is devoid of cartilage [66]. The trochlea possesses a 300-degree arc of cartilage [47]. The coronoid process, located anteriorly on the proximal ulna, has medial and lateral facets that buttress the trochlea anteriorly [47, 66]. The olecranon process is located posteriorly and allows for a broad attachment site of the triceps [47, 66]. The proximal ulna contains the sigmoid or semilunar notch [47]. The ulna medially bends approximately 8° at 8 cm from the tip of the olecranon and exhibits a slight anterior bow to the proximal ulna [66]. The articulation to the tip of the coronoid is approximately 30° from the long axis of the ulna in the sagittal plane [66].

The radiocapitellar joint, formed by the capitellum of the humerus and the radial head, is involved in both elbow flexion-extension and forearm supination-pronation rotation [22, 47]. The radial head is a concave elliptical structure covered with articular cartilage along the radiocapitellar joint and approximately 270° of the articular margin [66]. The radius is held in close approximation to the ulna at the proximal radioulnar joint by the annular ligament [66]. The area of the ulna which articulates with the margin of the radial head at this joint is known as the lesser sigmoid notch [66]. The distal humerus consists of medial and lateral columns [69]. The medial column diverges from the humeral shaft at a 45-degree angle, while the lateral column diverges at a 20-degree angle [47]. The articular surface of the distal humerus is angled 30 degrees anterior to the humeral shaft axis [69]. In full extension, 60% of axial load is transmitted through the radiocapitellar joint [69].

The distal humeral articulation is angled 30° from the longitudinal axis [66]. The anterior humeral line should pass through the center of the axis of rotation [66]. The axis of rotation is 5° to 7° angulated in the coronal plane to the epicondylar axis, with the medial side more distal than the lateral side [66]. This angulation accounts for the change in a valgus carrying angle to a more varus position as the elbow is flexed [66]. The medial epicondyle forms the attachment site for the origins of the flexor pronator mass and is larger and more posteriorly oriented than the lateral epicondyle [66]. The less prominent lateral epicondyle is the origin of the lateral extensor musculature [66]. The sublime tubercle is located just distal and medial to the coronoid and provides the attachment site of the anterior bundle of the medial ulnar collateral ligament [66].

Ligamentous Anatomy

Stability is conferred to the elbow by the bony articular anatomy, which is highly congruent, and the ligamentous structures on the medial and lateral sides [46]. The three primary stabilizers of the elbow are the ulnohumeral articulation, the medial ulnar collateral ligament (MUCL), and the lateral ulnar collateral ligament (LUCL) complex [46]. Secondary stabilizers include the radiocapitellar articulation, the common flexor tendon, the common extensor tendon, and the joint capsule [46]. The soft tissue boundary of the elbow joint is the articular capsule, which is weakest anteriorly [22].

The medial collateral ligament (MCL) complex comprises three ligaments: the anterior oblique, the posterior oblique, and the transverse [76]. The anterior oblique ligament is the strongest component of the MCL complex and is the primary stabilizer to valgus stress [76]. It originates on the anterior-inferior edge of the medial epicondyle and inserts on the sublime tubercle of the ulna [76]. The MCL also originates on the posterior medial epicondyle and inserts on the sublime tubercle of the medial coronoid process [69]. The anterior oblique ligament is composed of anterior and posterior bands that provide reciprocal function in resisting valgus stress through the range of flexion-extension motion [76]. The anterior band of the MCL is taut in extension, and the posterior band is tight in flexion [76]. The posterior bundle of the MCL is the primary restraint to valgus stress with the elbow in maximal flexion [69]. Stability in full extension is provided by the MCL, joint capsule, and ulnohumeral articulation [69]. The most important portion of the medial or ulnar collateral ligament is the anterior portion, which attaches to a small process on the medial surface of the coronoid [47]. The medial ulnar collateral ligaments are areas of capsular thickening which provide stability to the medial side of the elbow joint [66].

The lateral ulnar collateral ligament complex includes the radial collateral ligament and lateral ulnar collateral ligament on the lateral side of the elbow [66]. The origin of the lateral ulnar collateral ligamentous complex is located just distal to the lateral epicondyle at the geometric center of the radiocapitellar articulation [66]. The annular ligament attachment is located proximal and deep to the lateral ligamentous complex but is intimately associated with it [66]. The supinator-extensor muscle group attaches to the lateral epicondyle, which is slightly proximal and lateral to the capitellum [47].

Normal Range of Motion

The normal elbow has a range of motion from 0° to 140° from extension to flexion [46]. The normal range of elbow flexion/extension is 0 to 150 degrees [69]. A functional arc in each plane is 100° for flexion and extension and forearm rotation [46]. Functional range of motion is 30 to 130 degrees for flexion/extension and 50 degrees for pronosupination [69]. The normal elbow has a range of motion of 75° and 85° in pronation and supination respectively [46]. The normal forearm pronosupination (rotation) is 80 to 85 degrees in each direction [69]. The normal valgus carrying angle of the elbow is 5 to 10 degrees for men and 10 to 15 degrees for women [69].

Pathophysiology of Stiffness

Traumatic injury to the elbow is the most common cause of elbow stiffness [41]. Most cases of post-traumatic elbow stiffness improve with time and use, although significant stiffness may persist [3]. The true etiology of elbow stiffness can be categorized as extrinsic (extra-articular) or intrinsic (intra-articular) [41]. Intrinsic causes include articular damage or malunion, intraarticular hardware, and loose bodies [59]. Extrinsic causes include a contracted joint capsule and ligaments, heterotopic ossification, prominent hardware, and skin contracture [59].

Traumatic injury to the elbow often involves a combination of fracture and partial or complete dislocation with concordant ligamentous, neurologic, and muscular injury [41]. These injuries commonly result in hemarthrosis and subsequent scarring and contracture, along with the anatomic disruption caused by the initial trauma [41]. Initial surgical intervention, postoperative immobilization, and postoperative rehabilitation may worsen the initial soft-tissue injuries [41]. Long-term sequelae of elbow trauma include postoperative incisional scarring, bony malunions and nonunions, osteochondral defects or hypertrophic fracture callus, heterotopic ossification, ligamentous imbalances, compressive or scarring neuropathies, and muscular damage with associated scarring and loss of normal motion [41]. Any of these long-term complications may result in altered elbow mechanics, functional impairment, and prolonged pain [41]. Pain gives way to voluntary and involuntary guarding of the elbow, thereby exacerbating the already present capsular and muscular contracture [41]. This mechanism of pain generation is often the culprit leading to post-traumatic elbow stiffness, in some cases from relatively minor elbow trauma [41].

The posttraumatic or postsurgical contracture typically has a damaged, abnormally thickened joint capsule and the potential for altered anatomy [59]. The joint space is usually contracted and the capsule is scarred down to the bones in posttraumatic or postsurgical stiffness, making it difficult to enter the elbow joint [59]. The anatomy can be visually confusing once the joint is entered due to adhesions and scarring in posttraumatic or postsurgical stiffness [59]. As the anterior soft tissues are usually contracted, the locations of the median and radial nerves may be altered in posttraumatic or postsurgical stiffness [59].

Osteoarthritis of the elbow is characterized by osteophyte formation, capsular contracture, and loose bodies, often with relative preservation of the joint space [29]. Periarticular hypertrophic osteophytes act as a mechanical block at the end ranges of flexion and extension in elbow osteoarthritis [29]. Osteoarthritis typically involves the radiocapitellar joint articular cartilage preferentially, with relative preservation of the ulnohumeral articular surfaces [29]. Progression of elbow flexion contracture appears to level off after the age of 10 to 12 years, likely ending at skeletal maturity [27]. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with increased odds of dysfunctional elbow stiffness following operative fixation of distal humerus fractures [40]. Pre-operative evaluations in elbow stiffness should identify involved articular and periarticular tissues and determine whether articular surfaces and osteoarticular congruence are preserved [11]. The proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis [32]. Recent advancements in biology and pathology may lead to future breakthroughs in prevention and treatment of elbow stiffness [2].

Classification

Pathologic Classification: A proposed pathologic classification offers a new perspective on the understanding and standardization of elbow arthrolysis [32]. This system provides satisfactory clinical outcomes [32].

Other Considerations: Many classification systems have been developed for elbow stiffness [60]. No standardized, reproducible tools specifically designed for the self-assessment of elbow stiffness or comparative evaluation of treatment outcomes exist [106]. The Elbow Self-Assessment Score (ESAS) is a self-administered, valid and reliable tool to assess the most important aspects of the elbow function [44]. The Assessment through a Single Subjective Evaluation of Stiffness (ASSES) showed moderate correlations with SHEDS, SANE, OES, and DASH [106].

Clinical Presentation

Patients with elbow osteoarthritis typically present with loss of terminal extension and flexion, accompanied by painful catching, clicking, or locking of the elbow [29]. Pain is characteristically noted at the end ranges of motion rather than through the midrange [29]. Night pain is not typical for elbow osteoarthritis; if present, an inflammatory cause of the arthritis should be considered [29]. Ulnar neuropathy is present in up to 50% of patients with elbow osteoarthritis [29]. Forearm rotation remains relatively preserved until later in the disease process [29].

Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment, as isolated elbow injuries are rare and fractures should be interpreted as proxies for associated soft tissue injuries [39]. Successful intervention for stiff elbow depends on the quality of the joint and the extent of soft tissue damage, with the functional arc of motion serving as a frame of reference rather than an absolute goal [4]. Abnormal serum uric acid metabolism was a risk factor for poor performance and postoperative pain after arthrolysis in patients with post-traumatic elbow stiffness [102].

Investigations

History and Physical Examination

The history for elbow stiffness evaluation must include the duration of the elbow contracture, initial injury, previous surgical procedures, trials of splinting, therapy, or injections, complications of surgery, and the patient's work and life demands and goals [50]. Physical examination must assess the function of the entire upper extremity, including the shoulder, wrist, and hand [50]. The soft tissue surrounding the elbow should be examined for previous skin incisions, grafts, eschar, or infection [50].

Active and passive flexion, extension, supination, and pronation should be evaluated using a goniometer for accurate measurement [50]. The contralateral elbow should be examined for comparison during range of motion assessment [50]. Pain assessment during mid-arc or terminal motion is required, as mid-arc range of motion pain is more common with intrinsic disease and may not improve with contracture release alone [50]. The functional arc of motion serves as a frame of reference rather than an absolute goal for successful intervention [4].

The ulnar nerve is of utmost importance in the neurovascular examination due to its anatomic proximity to the elbow [50]. Electromyography and nerve conduction velocity studies should be performed if any question about neurologic dysfunction exists [50]. An assessment for ulnar nerve subluxation should be performed, as subluxation is a relative contraindication for an arthroscopic procedure secondary to possible iatrogenic nerve injury [50]. The examiner must verify if the ulnar nerve has been transposed if there is a history of prior surgical procedures [50]. If the elbow has less than 90° to 100° of flexion, the posterior bundle of the medial collateral ligament (MCL) is contracted and must be released to restore flexion [50].

Imaging

Plain radiography: Radiographs should always be obtained for the evaluation of elbow stiffness [50]. Standard radiographic views include AP, lateral, and oblique views [50]. Primary bony landmarks identified on radiographs include the ulnohumeral joint, coronoid process, radial head, capitellum, radiocapitellar joint, olecranon tip, coronoid and olecranon fossae, and trochlear ridge [50]. Serial radiography is used as follow-up when heterotopic ossification is present [50].

CT: CT is helpful when assessing for malunion architecture and the location and pattern of osteophytes and/or loose bodies [50]. Three-dimensional CT is used to check for heterotopic ossification [50]. CT is beneficial if any joint incongruity or abnormal bony anatomy is present [50]. CT is not necessary when the stiffness is entirely soft-tissue related [50].

MRI: MRI can be used to evaluate ligaments and tendons, but it is rarely indicated for elbow stiffness [50].

Other Considerations: 3D printing technology is a useful tool in surgery planning for treating complex cases of post-traumatic elbow stiffness, especially in the presence of joint deformity [42].

Treatment

Non-Operative

Nonsurgical treatment may be attempted in virtually all patients with elbow stiffness, provided the intervention will not worsen the condition [85]. This conservative regimen includes physical therapy with active and passive range of motion (ROM) exercises, NSAIDs for 6 to 12 weeks, and intra-articular corticosteroid injections [85]. Splinting and ROM regimens are also standard, encompassing dynamic splinting, progressive static stretch, and turnbuckle orthosis [85]. Static progressive and dynamic splinting are mainstays of nonsurgical treatment for posttraumatic elbow stiffness, with no statistically significant difference in outcomes between the two methods [30]. Both dynamic orthoses and static progressive splinting demonstrate good results for elbow stiffness regardless of etiology [36]. Hold-relax interventions may be used for early post-traumatic stiffness, while weaker evidence supports bracing in persistent cases [54]. Static-progressive bracing appears safe and associated with early ROM improvement in post-traumatic or post-operative stiffness, although increasing age may reduce its efficacy in patients with extension deficits [57]. For heterotopic ossification (HO), conservative treatment is indicated when the condition has been present for less than six months [55]. Current non-surgical measures for HO include physical therapy and manipulation under anesthesia to restore ROM, though these options have limited effects and are mainly useful for HO causing small limitations of ROM [55].

Operative

Indications: Surgical treatment is indicated when a course of nonsurgical treatment has failed and the patient will be compliant with postoperative therapy [85]. In the setting of failed nonsurgical treatment, surgical release can yield sustained improvement of ROM and patient quality of life [6]. Surgical release is ideally indicated for extrinsic contractures when the joint surface is congruous and normal joint architecture is maintained [85]. It can also be helpful for some intrinsic contractures, such as osteoarthritis [85]. However, results are much less predictable once the joint surface is altered or incongruous, especially if the patient reports mid-arc pain [85]. Surgical release is rarely indicated for mild contractures (<40°) or cases with severe articular incongruity [85]. For HO, surgical options are necessary if nonoperative management fails to restore elbow function and ROM after 6 months [55]. Heterotopic ossification can be resected once it is mature, evidenced by well-corticalized margins of the new bone and a lack of changes on serial radiographs [85].

Contraindications: Intra-articular ankylosed elbow, neurologic elbow disorder, Charcot elbow, and posttraumatic arthritis are contraindications for surgical release [85]. A deficient skin envelope, which may require a rotational flap, is also a contraindication [85].

Surgical Approach / Technique: Arthroscopic capsular release or osteocapsular arthroplasty is indicated for patients with osteoarthritis or extrinsic capsular contractures [85]. This procedure is technically demanding due to the small joint space and close proximity of neurovascular structures [85]. In the posterior compartment, olecranon tip/fossa osteophytes and loose bodies are débrided, and posterior capsular release is performed [85]. Débridement and suction are avoided medially to protect the ulnar nerve [85]. A mini-open incision may be used to release the posterior bundle of the medial collateral ligament (MCL) to gain flexion and protect the ulnar nerve [85]. In the anterior compartment, coronoid tip/fossa and radial fossa osteophytes are débrided, loose bodies are removed, and anterior capsulotomy or capsulectomy is performed [85]. Accessory portals and retractors should be used judiciously to improve visualization and protect neurovascular structures [85]. The radial nerve is at greatest risk during arthroscopic release, followed by the ulnar and median nerves [85]. Strategies to protect neurovascular structures include insufflating the joint before establishing portals, using proximally positioned medial and lateral portals in the anterior compartment, keeping the elbow flexed when establishing anterior portals, using retractors during débridement and capsulotomy, releasing the anterior capsule proximally, and avoiding cautery and shavers in the posterior medial gutter [85].

The open lateral column (Morrey) approach is indicated for extrinsic and/or intrinsic contracture that has failed nonsurgical treatment [85]. This approach can be performed through a posterior or lateral skin incision [85]. The extensor carpi radialis longus/brachioradialis muscles are elevated anteriorly, and the triceps muscle is elevated posteriorly [85]. The brachialis muscle is mobilized off the anterior capsule, which is then released and excised [85]. The coronoid tip/fossae are débrided, the olecranon tip/fossae are decompressed, the radiocapitellar joint is débrided, and the posterior capsule is released or excised [85]. The open lateral column approach must be combined with a medial release when severe loss of flexion is noted [85].

The open medial “over the top” (Hotchkiss) approach is indicated for patients with extrinsic contractures, associated medial side heterotopic ossification, ulnar neuropathy, and/or preoperative flexion limited to 90° to 100° [85]. In this approach, the ulnar nerve is decompressed or transposed [85]. The posterior band of the MCL and/or the capsule is released to increase flexion [85]. The surgeon works anterior to the flexor/pronator mass and may need to release proximally to assess the anterior capsule, which is then excised [85]. The coronoid tip/fossae are débrided [85].

A combined approach is indicated for cases of significant elbow stiffness where a unilateral approach is inadequate, when previous hardware removal is necessary, or in select cases with medial and lateral heterotopic ossification [85]. A posterior skin incision with medial and lateral skin flaps is made, or a dual incision approach medially and laterally can be considered [85]. If the elbow has less than 90° to 100° of flexion, the posteromedial band of the MCL and the posterior capsule are released to restore flexion [85]. Ulnar nerve decompression or transposition should be considered if the elbow has less than 90° to 100° of flexion during a combined approach [85]. The dual mediolateral mini-open technique allows for a safe and effective release of stiff elbows through small incisions of 3–5 cm in length [101].

Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life [13]. Arthroscopic circumferential release provides safe and effective restoration of ROM, pain relief, and functional improvement in patients with posttraumatic elbow stiffness, regardless of preoperative severity [16]. Arthroscopic elbow contracture release can improve function and range of motion; however, outcomes may vary based on preoperative patient characteristics [33]. Arthroscopic management of the stiff elbow after subacute trauma or postsurgery should be reserved for the highly experienced elbow arthroscopist [59]. The major disadvantage of arthroscopic release is damage to adjacent neurologic structures and/or articular cartilage [59]. The major advantage, if conducted safely by an experienced arthroscopist, is effective contracture release without exposure-related complications such as hematoma, seroma, and skin flap issues [59]. Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release [26].

Satisfactory medium-term results were found for open arthrolysis with hinged external fixation in patients with severe posttraumatic elbow stiffness [14]. This could be an option for treating ankylosed, severely or very severely stiff elbows using ligament repair with suture anchors and a hinged external fixator [23]. Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture [21]. The use of a hinged external fixator in open arthrolysis is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs [24]. The most common indications for hinged external fixation are acute or chronic instability of the elbow after trauma, distraction interposition arthroplasty, or use after contracture release or excision of heterotopic ossification [61].

Implant Selection: Interposition arthroplasty is a procedure in which the distal humerus is resurfaced with biologic material [85]. An external fixator is often used to distract the joint and provide stability in the immediate postoperative period [85]. Interposition arthroplasty is considered for intrinsic contractures in young patients (20 to 50 years) with articular cartilage destruction in whom the anatomic architecture of the distal humerus and proximal ulna are relatively preserved [85]. A hinged external fixator is used for distraction and to maintain stability during interposition arthroplasty [85]. The procedure is worthy of consideration for stiff, painful arthritic elbows despite the potential for instability [8].

Total elbow arthroplasty is rarely indicated, and it is not indicated for patients younger than 65 years or physically active patients because of concerns about implant longevity [29]. Bony or fibrous ankylosis with the elbow in a poorly functioning position is another indication for elbow arthroplasty [87]. The primary indications for total elbow arthroplasty are pain and/or instability [87]. Deformity and dysfunction without pain are not indications for surgery [87]. Infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints are contraindications to total elbow arthroplasty [87]. Extensive bone loss on either side of the joint and poorly functioning flexor and extensor mechanisms were contraindications to total elbow arthroplasty [87]. A history of previous elbow sepsis is an absolute contraindication to prosthetic elbow implant arthroplasty [87]. A previous fascial or other interpositional arthroplasty and previous hinged arthroplasty are absolute contraindications to the use of the capitellocondylar device [87]. Excessive bone loss, as in giant rheumatoid cysts, deficiency of the trochlear notch of the ulna, and posttraumatic or degenerative arthritis are relative contraindications to the use of an unconstrained resurfacing arthroplasty [87]. Total elbow arthroplasty may be required to manage posttraumatic arthritis that involves the ulnohumeral joint [88]. Open or arthroscopic débridement may be effective in the treatment of early arthritis, whereas interposition arthroplasty or total elbow arthroplasty is best reserved for more advanced cases [94]. Total elbow arthroplasty is best reserved for low demand, elderly patients who will be able to comply with the 5-lb weightlifting restriction imposed postoperatively to protect the implants from bearing wear, hardware loosening, or failure [94].

Other Considerations: The treatment of heterotopic ossification of the elbow following burn injury resulted in significant gains in elbow motion and upper extremity function with few complications [37]. Overall, patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function after operative management of elbow stiffness secondary to heterotopic ossification [19]. Operative management of pediatric elbow contractures is effective [45].

Outcomes and Complications: Elbow stiffness is a challenging problem with no ideal management solution; however, functional improvements can be achieved with both nonsurgical and surgical strategies [2]. Current treatment options for post-traumatic elbow stiffness range from conservative to surgical, with varying rates of success, invasiveness, and complications [7]. The gain in range of motion was 51° for open arthrolysis, 40° for arthroscopic arthrolysis, 88° for open arthrolysis with external fixation, and 56° for open arthrolysis with distraction arthroplasty [38]. The average percentage of complications was 23% for open arthrolysis, 5% for arthroscopic arthrolysis, 73% for open arthrolysis with external fixation, and 58% for open arthrolysis with distraction arthroplasty [38].

Infection can manifest as superficial (minor wound complications) or deep [29]. Deep infections in the elbow are more common than other joints treated arthroscopically (0.8% to 2.2%) [29]. Transient nerve palsies complicate 1% to 3% of cases, with radial and ulnar nerves being the most common [29]. Hematoma formation is a complication of elbow surgery [29]. Synovial ganglion formation is a complication of elbow surgery [29]. Stiffness (heterotopic ossification) is a complication of elbow surgery [29].

During arthroscopic surgery, joint distention moves the capsule away from bone, but the distance between the neurovascular structures and the capsule remain unchanged; therefore, the nerves remain at risk with capsular work [29]. Neurovascular structures at risk during portal placement, débridement, and capsular release include the median nerve (anteromedial), the ulnar nerve (posteromedial), and the radial nerve (lies adjacent to the anterolateral capsule) [29]. The brachialis muscle protects the median nerve and brachial artery during capsular procedures [29]. The olecranon fossa is an oval structure that is wider in the medial to lateral dimension [29]. Olecranon osteophytosis extends medially and laterally and not just at the tip [29]. Resection of olecranon osteophytes needs to be extended along the medial and lateral aspects of the olecranon to allow maximal extension and prevent impingement [29].

Complications

Infection: A history of prior procedures in the post-traumatic elbow and the complexity of the operative technique are clinically associated with an increased risk of deep infection following hinged external fixation [107].

Instability: Interposition arthroplasty of the elbow with hinged external fixation carries a potential for instability [8].

Nerve palsy: It is unclear which patients who have surgery for elbow stiffness will develop new ulnar nerve dysfunction [34].

Operative Morbidity: The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs [24].

Other Considerations: A long duration of elbow stiffness may increase the risk of complications after arthrolysis [1]. Current treatment options for post-traumatic elbow stiffness have varying rates of complications [7]. Long-term sequelae of traumatic elbow injury that can result in altered elbow mechanics include postoperative incisional scarring, bony malunions and nonunions, osteochondral defects or hypertrophic fracture callus, heterotopic ossification, ligamentous imbalances, compressive or scarring neuropathies, and muscular damage with associated scarring and loss of normal motion [41].

Recovery

Light activity (weeks): The evidence does not specify a typical week range for desk work, driving, or light activities of daily living.

Full activity (months): The evidence does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence does not specify a month range for the stabilization of pain, strength, or final functional outcomes.

Rehabilitation protocol: Static progressive and dynamic splinting are mainstays of nonsurgical treatment for posttraumatic elbow stiffness, with no statistically significant difference in outcomes between the two methods [30]. In appropriately selected patients, early surgical excision combined with structured rehabilitation may restore functional elbow motion effectively [28]. The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness may result in short-term improvements in flexion-extension range of motion but is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs [24].

Functional milestones: Patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function after operative management of elbow stiffness secondary to heterotopic ossification [19]. Patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release [26]. Open arthrolysis with radial head arthroplasty yielded satisfactory short-term outcomes for post-traumatic elbow stiffness at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years) [63]. Treatment for bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes [64].

Other Considerations: In appropriately selected patients, early surgical excision combined with structured rehabilitation may restore functional elbow motion effectively, with no clinical or radiographic recurrence observed at 1-year follow-up [28]. At 43 months mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation [35]. There is sound evidence that ulnar neuropathy has a negative effect on symptoms and disability, but it is unclear which patients who have surgery for elbow stiffness will develop new ulnar nerve dysfunction [34]. Delayed-onset anterior interosseous nerve palsy can develop one week after open elbow contracture release, likely due to a stretch injury [109]. One patient had full range of movement at the elbow with no obvious deformity at 6 weeks and no weakness in the limb [31].

Key Evidence

• [L3] A long duration of elbow stiffness may negatively influence functional outcomes and increase the risk of complications after arthrolysis. [1] (10.1016/j.jse.2017.11.012)
• [L4] Elbow stiffness is a challenging problem with no ideal management solution; however, functional improvements can be achieved with both nonsurgical and surgical strategies, and recent advancements in biology and pathology may lead to future breakthroughs in prevention and treatment. [2] (10.1016/j.jhsa.2013.06.007)
• [L5] Most cases of post-traumatic elbow stiffness improve with time and use, although significant stiffness may persist. [3] (10.1177/1758573216633065)
• [L5] Successful intervention for stiff elbow depends on the quality of the joint and the extent of soft tissue damage, with the functional arc of motion serving as a frame of reference rather than an absolute goal. [4] (10.1016/j.jisako.2023.09.002)
• [L4] Restoration of joint motion in the posttraumatic stiff elbow can be a difficult, time-consuming, and costly challenge. [5] (10.1016/j.jhsa.2007.09.015)
• [L5] In the setting of failed nonsurgical treatment of the stiff elbow, surgical release can yield sustained improvement of ROM and patient quality of life. [6] (10.5435/jaaos-d-14-00051)
• [L5] Current treatment options for post-traumatic elbow stiffness range from conservative to surgical, with varying rates of success, invasiveness, and complications. [7] (10.1177/1758573218793903)
• [L4] The procedure is worthy of consideration for stiff, painful arthritic elbows despite the potential for instability. [8] (10.1016/j.jse.2007.11.008)
• [L1] Patients with stiff elbows who underwent arthroscopic arthrolysis achieved satisfactory clinical outcomes very early postoperatively. [9] (10.1016/j.jse.2024.06.009)
• [L5] Pre-operative evaluations in elbow stiffness should identify involved articular and periarticular tissues and determine whether articular surfaces and osteoarticular congruence are preserved. [11] (10.1016/j.jisako.2023.10.009)
• [L4] Arthroscopic arthrolysis leads to good clinical and functional results in post-traumatic elbow stiffness regarding ROM, pain relief, functionality, and quality of life. [13] (10.1016/j.jse.2020.01.099)
• [L4] Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. [14] (10.1097/corr.0000000000000726)
• [L3] Arthroscopic circumferential release provides safe and effective restoration of ROM, pain relief, and functional improvement in patients with posttraumatic elbow stiffness, regardless of preoperative severity. [16] (10.1177/23259671261450556)
• [L4] Arthrolysis should be performed by a combination of lateral and medial approaches, and routine hinged external fixation and anterior transposition of the ulnar nerve may improve the postoperative recovery of elbow stiffness. [17] (10.1007/s00402-012-1659-4)
• [L5] Arthroscopic capsular release of the elbow is effective for restoring a functional arc of motion in the short term in most patients with extrinsic contractures. [18] (10.5435/00124635-201105000-00004)
• [L4] Overall, patients maintained substantial reductions in pain, improvement in elbow range of motion, and increased overall elbow function. [19] (10.1016/j.jse.2024.11.019)
• [L5] Endoscopic capsulectomy is an effective procedure for adhesiolysis in severe elbow stiffness. [20] (10.1016/j.jisako.2024.02.003)
• [L4] Arthrolysis, late internal fixation, and use of a hinged external fixator can solve problems associated with stiff elbow after delayed diagnosis of capitellum fracture. [21] (10.1016/j.jse.2015.01.019)
• [L5] [22] (10.1016/j.jhsa.2009.02.020)
• [L4] This could be an option for treating ankylosed, severely or very severely stiff elbows. [23] (10.1016/j.jse.2014.03.013)
• [L3] The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness may result in short-term improvements in flexion-extension range of motion but is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs. [24] (10.1186/s12891-024-08167-6)
• [L4] A subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release. [25] (10.1016/j.jhsg.2023.07.002)
• [L4] Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release. [26] (10.1177/23259671231190381)
• [L4] Progression of elbow flexion contracture appears to level off after the age of 10 to 12 years, likely ending at skeletal maturity. [27] (10.1177/17531934231178121)
• [L5] This case illustrates that, in appropriately selected patients, early surgical excision combined with structured rehabilitation may restore functional elbow motion effectively, with no clinical or radiographic recurrence observed at 1-year follow-up. [28] (10.1016/j.xrrt.2026.100805)
• [L4] Static progressive and dynamic splinting are mainstays of nonsurgical treatment for posttraumatic elbow stiffness, with no statistically significant difference in outcomes between the two methods. [30] (10.1016/j.jhsa.2013.06.009)
• [L5] The patient had full range of movement at the elbow with no obvious deformity at 6 weeks and no weakness in the limb. [31] (10.1016/s0020-1383(98)00141-7)
• [L4] This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes. [32] (10.1016/j.jse.2019.08.001)
• [L4] Arthroscopic elbow contracture release can improve function and range of motion; however, outcomes may vary based on preoperative patient characteristics. [33] (10.1016/j.jseint.2026.101621)
• [L5] There is sound evidence that ulnar neuropathy has a negative effect on symptoms and disability, but it is unclear which patients who have surgery for elbow stiffness will develop new ulnar nerve dysfunction. [34] (10.1016/j.jhsa.2014.04.009)
• [L4] At 43 months mean follow-up, none of the patients had significant postoperative contracture, and none had any clinically apparent signs of instability or suffered subluxation or re-dislocation. [35] (10.1016/j.jseint.2024.08.043)
• [L2] Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. [36] (10.1007/s00402-015-2199-5)
• [L4] The treatment resulted in significant gains in elbow motion and upper extremity function with few complications. [37] (10.1016/j.jse.2010.05.029)
• [L4] [38] (10.1016/j.jse.2012.11.010)
• [L5] Adequate elbow assessment is essential for accurate diagnosis and initiating proper treatment, as isolated elbow injuries are rare and fractures should be interpreted as proxies for associated soft tissue injuries. [39] (10.1016/j.jhsa.2014.04.028)
• [L3] Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with increased odds of dysfunctional elbow stiffness. [40] (10.1016/j.jse.2024.06.010)
• [L5] [41] (10.1016/j.jse.2010.11.029)
• [L4] 3D printing technology is a useful tool in surgery planning for treating complex cases of post traumatic elbow stiffness, especially in the presence of joint deformity. [42] (10.1016/j.jisako.2024.03.013)
• [L3] The Elbow Self-Assessment Score (ESAS) is a self-administered, valid and reliable tool to assess the most important aspects of the elbow function. [44] (10.1007/s00167-015-3647-z)
• [L1] Operative management of pediatric elbow contractures is effective. [45] (10.1016/j.jhsa.2024.01.010)
• [L4] Hold-relax interventions may be used for early post-traumatic elbow stiffness, with weaker evidence supporting bracing in persistent elbow stiffness. [54] (10.1016/j.jseint.2025.06.015)
• [L4] [55] (10.3390/life13122358)
• [L4] While increasing age may reduce efficacy in patients with extension deficits, static-progressive bracing appeared safe and was associated with early improvement in ROM in patients with post-traumatic or post-operative elbow stiffness and should be considered in all patients. [57] (10.1177/17585732251389182)
• [L5] [60] (10.1016/j.jisako.2023.10.011)
• [L5] The most common indications are acute or chronic instability of the elbow after trauma, distraction interposition arthroplasty, or use after contracture release or excision of heterotopic ossification. [61] (10.1016/j.hcl.2010.04.004)
• [L3] Additional peripheral nerve block combined with a postoperative nerve block catheter in arthroscopic arthrolysis in cases of elbow stiffness may be an opportunity to enhance postoperative outcomes by achieving better functional ROM, perhaps through reduced postoperative pain. [62] (10.1016/j.jseint.2024.10.009)
• [L4] OEA with RHA yielded satisfactory short-term outcomes for PTES at 3 years, with substantial improvements in elbow mobility and function, and the results were durable over the long term (8 years). [63] (10.1016/j.jse.2021.10.028)
• [L4] This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes. [64] (10.1016/j.jse.2023.12.003)
• [L4] The dual mediolateral mini-open technique allows for a safe and effective release of stiff elbows through small incisions of 3–5 cm in length. [101] (10.1186/s13018-025-06288-9)
• [L3] Abnormal serum uric acid metabolism was a risk factor for poor performance and postoperative pain after arthrolysis in patients with post-traumatic elbow stiffness. [102] (10.1016/j.jse.2020.02.021)
• [L4] Arthroscopic arthrolysis of a stiff elbow using a purely posterior approach with anterior capsulectomy via the Outerbridge-Kashiwagi procedure was safe and effective. [105] (10.1016/j.asmr.2024.101029)
• [L4] [106] (10.1016/j.jseint.2025.101587)
• [L4] Factors clinically associated with an increased risk of deep infection include a history of prior procedures in the post-traumatic elbow and the complexity of the operative technique. [107] (10.1016/j.jse.2007.10.006)
• [Case_report] The authors describe a case of delayed-onset anterior interosseous nerve palsy developing one week after open elbow contracture release, likely due to a stretch injury. [109] (10.5397/cise.2022.00899)

See Also

• Neuropathies
• Elbow Osteoarthritis
• Elbow Arthroplasty
• Radial head arthroplasty

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