Posttraumatic Elbow Contracture

Gregory Rafijah

Disclosures

Curr Orthop Pract. 2014;25(3):213-216. 

In This Article

Prevention

Prevention of posttraumatic elbow contracture may yield the best results. In the acute setting, prevention of edema formation and fluid collection and controlling inflammation are critical to avoid excessive scarring and stiffness. This is accomplished with elevation, compressive dressings, ice or cold therapy, and antiinflammatory medications. Early controlled motion should be instituted when possible. Motion helps to control edema formation and pump out fluid collections. Early use of constant passive motion may be beneficial but may not result in long-term benefit.[6] Prevention of ectopic bone formation after surgery or trauma may be beneficial in preventing contracture formation. Several modalities have been recommended to prevent heterotopic bone formation including nonsteroidal antiinflammatory drugs (NSAIDS), radiation, and bisphosphonates. Strauss et al.[7] evaluated 44 patients who received both indomethacin (10 days) and radiation perioperatively to prevent heterotopic ossification. Forty-eight percent of patients had heterotopic ossification at final follow-up, but no patient required further surgery, and the combination of radiation and indomethacin was found to be safe. Although radiation may prevent recurrence, there is some risk for sarcoma formation and an increased risk of fracture nonunion when used in the acute setting.[8] Therefore, radiation therapy is best used to prevent recurrence after reconstructive procedures such as extensive heterotopic ossification excision for contracture release. A single perioperative dose of 700 cGy within 48 h after surgery has been reported to be an effective modality to prevent recurrence of heterotopic ossification after excision.[9]

Botulinum A toxin has been used to prevent elbow stiffness caused by myostatic contracture.[6] Botox has been injected into elbow flexors, resulting in reports of improved range of motion, especially when combined with corrective splinting.Ketotifen, a mast cell stabilizer used in the treatment of asthma, has been proposed as a potential preventive treatment of joint contracture and has been shown to be effective in a rabbit model.[3] Theoretically, elbow trauma results in pain that stimulates neuronal secretion of Substance P, a neuropeptide,[3] that stimulates mast cells to produce profibrotic bioactive mediators that activate myofibroblasts.[10]

Ketotifen may prevent mast cell stimulation of myofibroblasts and prevent or limit contracture development. Efficacy of ketotifen in humans has not yet been demonstrated.

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