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Operative Treatment of
Elbow Contracture in
Patients Twenty-one Years
of Age or Younger
BY ANTHONY A. STANS, MD, N.G.J. MARITZ, SHAWN W. O’DRISCOLL, MD, PHD, AND BERNARD F. MORREY, MD
Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Background: Elbow contracture is a recognized sequela of traumatic and developmental elbow disorders, but
little information is available regarding the surgical treatment of elbow stiffness in the pediatric population.
Methods: Thirty-seven patients who had had open surgical release of an elbow contracture at a mean age of
sixteen years (range, ten to twenty years) were retrospectively studied after a mean duration of follow-up of fif-
teen months (range, six to forty-four months). The elbow contracture was posttraumatic in twenty-eight patients.
The operation consisted of a capsular release with removal of osseous impediments to motion as necessary.
No patient had muscle or tendon-lengthening.
Results: The total arc of motion improved from a mean of 66° preoperatively to a mean of 94° postoperatively;
however, only twenty-eight patients (76%) had an improvement of ≥10° and only seventeen (46%) achieved a
functional arc of motion of 100° (from 30° to 130°). Two patients lost motion after surgery. These results are
less favorable than the results of previous studies of both pediatric and adult patients. Patients in whom the
contracture had been caused by a simple dislocation of the elbow or an extra-articular fracture tended to have
better results than those in whom the contracture was due to other causes.
Conclusions: The results of surgical treatment of elbow stiffness in pediatric patients are less favorable and
less predictable than those in adult patients.

E
lbow contracture is a well-recognized sequela of trau- the present study were to review the results of open surgical
matic and developmental pediatric elbow disorders. treatment of elbow stiffness in patients who were twenty-one
Stiffness has been reported in 3% to 6% of patients fol- years of age or younger and to test the hypothesis that the re-
lowing a fracture of the supracondylar aspect of the humerus sults of surgical treatment in such patients are less favorable
and in 33% to 100% of patients following surgical treatment than those in adult patients as reported in the literature.
of a fracture of the neck of the radius1,2. If instituted soon after
the contracture develops, nonoperative treatment such as Materials and Methods
physiotherapy and splinting often results in an improved etween January 1979 and January 1997, thirty-nine pa-
range of motion of the elbow3,4. An increasing body of data re-
garding the surgical treatment of elbow contracture in adults
B tients who were twenty-one years of age or younger under-
went surgical treatment of elbow contracture. A retrospective
suggests that good results can be expected in most patients5-11. review of charts and radiographs was performed after the study
Before undertaking this study, it was our impression that the had been approved by the institutional review board. Thirty-
results of surgical treatment of elbow contracture in children seven patients had available data collected at a minimum of
are less predictable than those in adults. Although literature is three time-points: immediately before surgery, during sur-
available to guide the surgical treatment of elbow contracture gery, and six months or more after surgery. The mean duration
in pediatric patients with neuromuscular disorders12, there is of follow-up was fifteen months (range, six to forty-four
little information regarding the treatment of elbow contrac- months). The follow-up period was greater than twenty-four
ture in other pediatric patients13. Therefore, the purposes of months for seven patients, thirteen to twenty-four months for
fifteen patients, and six to twelve months for fifteen patients.
A video supplement to this article is available from the Video Jour- The mean age at the time of surgery was sixteen years (range,
nal of Orthopaedics. A video clip is available at the JBJS web site,
www.jbjs.org. The Video Journal of Orthopaedics can be contacted
ten to twenty years). Surgery was performed at an average of
at (805) 962-3410, web site: www.vjortho.com. eighteen months (range, six to 108 months) following the on-
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eraged 118° (range, 71° to 150°), the total arc of motion aver-
TABLE I Surgical Procedures Performed for Pediatric
Elbow Stiffness
aged 66° (range, 15° to 135°), pronation averaged 61° (range,
5° to 80°), and supination averaged 63° (range, 0° to 100°).
No. of Surgery typically consisted of an anterior capsulectomy
Procedure Patients as described by Mansat and Morrey9, with additional proce-
Anterior capsulotomy 33 dures done at the discretion of the operating surgeon (Table
Posterior capsulotomy 17 I). When a tight posterior capsule was noted to restrict elbow
flexion, a posterior capsulotomy was performed. When os-
Excision of olecranon tip 11
seous impingement was found to limit motion, the offending
Excision of osteophytes 11 bone was removed, often by excising the tip of the olecranon
Excision of radial head 9 or by contouring the distal part of the humerus to try to recre-
ate the coronoid fossa or the olecranon fossa. No patient had
External fixation 6
muscle or tendon-lengthening. Marked degenerative changes
Removal of loose bodies 5 were treated with fascial interposition arthroplasty. External
Excision of coronoid tip 5 fixation was used in all three patients who were treated with
Humeral contouring 4
interposition arthroplasty and in three additional patients.
The surgical approach varied and evolved during the study
Removal of hardware 3 period. Initially, all elbows were exposed through an anterior
Fascial arthroplasty 3 approach, with a posterior approach added when necessary.
Excision of ectopic bone 2 Later, surgery was performed through a lateral and limited
medial approach as described by Mansat and Morrey9.
Because of the large number of previous operations that
set of symptoms. The indication for surgery in all patients was had been performed elsewhere and the variation in surgical
a persistent loss of elbow motion that had caused a limitation approach during the study period, it was not possible to use a
in the activities of daily living for at least six months despite single method for the management of the radial, ulnar, and
nonoperative therapy. Only five patients reported elbow dis- median nerves. However, several general principles were fol-
comfort. The elbow contracture was posttraumatic in twenty- lowed. These nerves were not routinely exposed if there was
eight patients and was associated with osteochondritis dissecans sufficient information indicating that they were localized away
in four, brachial plexopathy in three, arthrogryposis in one, from the region of surgical approach. For example, if there
and spondyloepiphyseal dysplasia in one. Twenty-one patients was a detailed operative report describing a previous anterior
had undergone one to three previous operations at other in- transposition of the ulnar nerve away from the area of a
stitutions. None of those operations had been performed with planned medial approach, the ulnar nerve was not exposed.
the primary goal of improving range of motion. When the location of a nerve was in doubt, the nerve was ex-
Because of a commitment to clinical elbow research, a posed and carefully protected.
standard methodology is routinely used to measure range of Postoperatively, after normal neurologic function was
motion in all patients undergoing elbow surgery at the Mayo documented in the recovery room, thirty-one patients under-
Clinic, including those in the present study. Flexion and ex- went placement of an indwelling axillary catheter. With the use
tension were measured by a resident or attending physician or of the catheter and an infusion pump, a brachial plexus block
by a physician assistant with use of a hand-held goniometer. was maintained for two to three days after the operation. Con-
Maximum pronation and supination were estimated visually tinuous passive motion was begun during the immediate post-
with the elbow at the patient’s side on the basis of the angle operative period for twenty-six patients and was typically
that was formed when an imaginary line passing through the continued at home for one month. Thirty-one patients were
radial and ulnar styloid processes intersected with a line paral- managed with patient-adjusted static extension and flexion
lel to the floor. Intraoperatively, elbow flexion and extension splints for approximately three months after surgery. Each pa-
were measured by the operating surgeon with a sterile goni- tient was instructed to wear the elbow splint for approximately
ometer or were estimated visually. Preoperatively, extension sixteen hours each day. During the hours out of the splint,
was limited by an average of 52° (range, 5° to 110°), flexion av- the patient used continuous passive motion, performed active

TABLE II Mean Preoperative and Postoperative Ranges of Motion of the Elbow

Total Arc of
Extension Flexion Flexion-Extension Pronation Supination
Preoperative –52° 118° 66° 61° 63°
Postoperative –32° 129° 94° 73° 69°
P value 0.0001 0.0057 0.0001 0.0042 0.3835
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TABLE III Improvement in Total Arc of Motion

arc of motion that measured at least 100° (from 30° to 130°). No
significant difference in the preoperative, intraoperative, or
No. of postoperative arc of motion was detected between the twenty-
Finding Patients
eight patients in whom the contracture was related to trauma
Improvement and the nine patients in whom it was not (Table IV). When all
>20° 20 (54%) patients were considered together, the intraoperative arc of mo-
10° to 19° 8 (22%) tion was significantly greater than the preoperative arc of mo-
0° to 9° 7 (19%) tion (Table V). Unfortunately, much of the improvement that
was measured intraoperatively was gradually lost by the time of
Loss of motion 2 (5%) the final follow-up examination. There was a trend, although
not a significant trend, for the degree of improvement and the
range-of-motion exercises, and/or applied ice to the elbow. final range of motion to increase with age (p = 0.30).
No patient received postoperative prophylaxis against hetero- To address the concern regarding the limited duration of
topic ossification. follow-up for some patients, we reviewed the results for patients
who had been followed for more than one year to determine if
Statistical Analysis range of motion changed over time. The twenty-two patients
Spearman’s rank correlation coefficient was used to assess who had been followed for more than twelve months showed an
whether continuous variables were significantly correlated average improvement of 7° (range, –6° to 11°) in the total arc of
with elbow motion. The Wilcoxon signed rank test was used motion between six months and twelve months after surgery.
to assess improvement in the range of motion. The Wilcoxon The seven patients who had been followed for more than two
rank-sum test or chi-square analysis was used to test the as- years lost an average of 3° (range, –13° to 8°) of motion between
sociation between discrete variables and the final range of the six-month evaluation and the final follow-up evaluation.
motion. Multiple linear regression analysis with a forward The improvement in motion after six months was minimal and
stepwise model selection procedure was performed for each was not significant, suggesting that clinical follow-up of more
outcome variable (postoperative flexion, extension, arc of than six months is not necessary to draw meaningful conclu-
motion, supination, and pronation) with use of the following sions regarding the efficacy of open surgical treatment for the
independent variables: the age of the patient at the time of restoration of motion in this patient population.
surgery, the duration of symptoms, previous surgery, anterior Patients in whom the contracture had been related to
capsulotomy, posterior capsulotomy, excision of the radial trauma were then subdivided into smaller groups on the basis
head, excision of osteophytes, contouring of the humerus, ex- of the type and severity of the injury (Table VI). Patients
cision of the olecranon, excision of the coronoid tip, removal who had sustained an intra-articular fracture or a fracture-
of hardware, removal of loose bodies, external fixation, intra- dislocation seemed to fare worse than those who had sustained
articular or extra-articular injury, use of a brace or a splint, an extra-articular fracture (Figs. 1-A through 1-D). Because
use of continuous passive motion, and posttraumatic injury. the number of patients in each group was relatively small,
The level of significance was p < 0.05. the results were not significant. Patients in whom the con-
tracture had been caused by simple dislocation of the elbow
Results or an extra-articular fracture had good final motion and the
he preoperative and final ranges of motion are shown in Ta- greatest improvement in motion after surgery. Final mo-
T ble II. Operative treatment resulted in a significant im-
provement in all ranges of motion except supination. However,
tion of the elbow was very good in patients in whom the
stiffness had been caused by contusion, but the actual im-
neither the magnitude nor the predictability of the improve- provement after surgery was marginal, consistent with the
ment was excellent. Only twenty-eight patients (76%) gained finding that those patients had had relatively good preoper-
≥10° in the total arc of motion (Table III). Two patients actually ative motion.
lost 10° and 30° of elbow motion. The final range of motion Significant relationships were identified between several
measured 30° to 79° in ten patients (27%) and 80° to 99° in ten factors and elbow motion. The identification and excision of
patients (27%); only seventeen patients (46%) had a functional loose bodies at the time of surgical release resulted in improved

TABLE IV Comparison of Mean Ranges of Motion Between Patients with Posttraumatic and Nontraumatic Contracture

Total Arc of Motion Final

No. of Improvement
Patients Preoperative Intraoperative Final in Arc of Motion
Posttraumatic contracture 28 56° 125° 81° 25°
Nontraumatic contracture 9 69° 100° 99° 30°
P value 0.35 0.18 0.29 0.41
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TABLE V Mean Total Arc of Elbow Motion Before, During,

obtain an arc of motion that is within 10° of the functional arc
and After Operative Release of Contracture of motion at each end (40° to 120°)14. Our own experience in
treating elbow contractures in adults has been consistent with
Total Arc those results9,10,15. However, the results of the present study of pa-
of Motion P Value*
tients who were twenty-one years of age or younger were not as
Preoperative 66° successful or as predictable as the results of our previous studies
Intraoperative 119° 0.0031 of adults, who had been treated by the same surgeons with use
Postoperative† 94° 0.0084 of the same protocol. The same held true when the results in the
subgroup of patients who had a posttraumatic contracture were
*Compared with the preoperative value. †At the time of the compared with the results of the studies of adults. We con-
most recent follow-up. cluded that something must be different in patients who are
twenty-one years of age or younger that causes them to respond
postoperative elbow extension (p = 0.03). Excision of the radial less well to this treatment protocol.
head at the time of surgical release was associated with poor While literature is available to guide the treatment of el-
postoperative pronation and supination (p = 0.002). Finally, bow contracture in pediatric patients with neuromuscular
patients who had undergone previous surgery were less likely to disorders12, there is a paucity of literature describing the surgi-
show a significant improvement in elbow flexion (p = 0.03). cal treatment of pediatric elbow stiffness due to other causes.
Additional factors that were analyzed but, with the In 1994, Mih and Wolf 13 reported on nine pediatric patients
numbers available, were not found to have a significant effect (average age, twelve years) who had been managed with a
on the range of motion included the age of the patient at the slight modification of a technique commonly used for adults
time of surgery, the date of surgery, the duration of follow-up, and observed a mean improvement in the total arc of elbow
the cause of stiffness, involvement of the dominant extremity, motion of approximately 100%. It is not clear why we ob-
the duration of symptoms, the presence of pain, the preopera- served less improvement in our series. Unlike the patients in
tive range of motion, the intraoperative range of motion, the the series of Mih and Wolf, our patients were not managed
use of an axillary catheter, the use of continuous passive mo- with muscle or tendon-lengthening, which may partially ex-
tion, and the use of postoperative immobilization. Numerous plain the less favorable results in our series. Boerboom et al.6
and varied previous operations had been performed in this reported improved results when surgical release was per-
group of patients, but no correlation was found between the formed within one year after the initial insult. The patients in
result of the index procedure and the number and type of pre- the study by Mih and Wolf had surgical release at an average of
vious operations that had been performed. ten months following the initial insult to the elbow, whereas
There were three complications in the present series. the patients in our series had surgical treatment at an average
One patient had a deep infection that required surgical débri- of eighteen months after the insult.
dement, another patient had a transient radial nerve palsy, Our analysis of the subgroups of patients who had had a
and a third patient had a hematoma in the early postoperative posttraumatic contracture revealed several interesting and im-
period that required surgical evacuation. portant points. Patients in whom the contracture was due to
an intra-articular injury tended to show less improvement
Discussion following surgery than did those in whom the contracture was
he increasing body of knowledge and experience regarding due to an extra-articular cause. This may have been because
T open surgical treatment of elbow stiffness in adults suggests
that good results can be expected in most patients5,7-11. An over-
it is more difficult to restore the complex shape of and the pre-
cise relationship between the bones of the elbow following
view of published reports in which data on individual patients malunion of an intra-articular fracture than it is to release ex-
were supplied suggested that 95% of adult patients gain motion, tra-articular soft tissues that have been contracted after pro-
80% obtain a functional arc of motion (30° to 130°), and 90% longed immobilization following dislocation of the elbow. Most

TABLE VI Mean Ranges of Motion Following Surgical Release According to Type of Injury

Improvement
No. of Total Arc in Total Arc
Patients Extension Flexion of Motion of Motion
Complex fracture-dislocation 8 –39° 133° 94° 25°

Intra-articular fracture 7 –42° 122° 80° 27°

Extra-articular fracture 4 –28° 121° 93° 41°

Dislocation 5 –15° 137° 122° 55°

No fracture, no dislocation 4 –30° 131° 101° 8°

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Fig. 1-B

Figs. 1-A through 1-D A male patient sustained an injury of the right elbow while
playing football at the age of sixteen years and ten months. The patient did not
seek medical attention at the time of the injury and presented two years later
with pain, locking, degenerative changes at the radiocapitellar joint, and a total
arc of motion of the elbow ranging from 40° to 130°. Despite excision of ectopic
bone and loose bodies, anterior capsulotomy, excision of the radial head, and
continuous passive motion, the arc of motion of the elbow ranged from 30° to
130° after six months of follow-up. Figs. 1-A and 1-B Radiographs made at the
time of presentation.
Fig. 1-A

disturbing was the finding that patients frequently demon- the groups with posttraumatic and nontraumatic stiffness.
strated near-complete recovery of motion intraoperatively (Ta- Our analysis of the results suggested that elbow motion
ble V) and in the first few days postoperatively but then lost that did not improve with longer follow-up. Because our message
motion over the subsequent weeks and months despite inten- is cautionary, longer follow-up is not essential to the validity
sive use of continuous passive motion and splinting for as much of our message.
as eighteen hours a day. Although it is difficult to measure pa- We believe that the present study represents the largest
tient compliance with postoperative therapy, it is our strong im- reported series of pediatric patients who have had surgical
pression that the loss of motion after the operation and the treatment of elbow contracture. Despite the retrospective col-
poor results compared with those seen in adult patients were lection of data, the relatively short period of follow-up, and
not due to poor compliance with postoperative therapy. the heterogeneity of our study population, we believe that sev-
The complications in this series were associated with the eral important conclusions can be made on the basis of our
severity and complexity of the presenting abnormality and the findings. Most importantly, the results of surgery were not
magnitude of the surgical procedure used to address it. Two of predictable. In addition, the magnitude of improvement was
the three complications occurred in patients who presented modest for many patients and was far less than what would
with a total arc of elbow motion of 15° and 20°, much less be expected in a similar series of adults. A final arc of motion
than the mean preoperative total arc of motion of 66° for the from 30° to 130° (the functional range necessary for activities
group as a whole. Both patients also had extensive degenera- of daily living) was achieved in only seventeen (46%) of the
tive changes in the elbow, and both were managed with inter- thirty-seven patients. These data confirm our hypothesis that
position arthroplasty and external fixation. pediatric patients derive less improvement from open surgical
We strongly considered excluding patients with nontrau- treatment of elbow contracture than adult patients do. To
matic stiffness from the present study, but we decided to in- avoid disappointment, patients and their parents should be
clude this group for a number of reasons: (1) patients with counseled that improved, but not normal, elbow motion can
nontraumatic etiologies comprised approximately 25% of all be expected in many but not all cases. The best results are
patients who were treated surgically for stiffness, thus substan- likely to be achieved when loose bodies are identified and ex-
tially increasing the size of the series; (2) the surgical proce- cised at the time of surgical release and when the stiffness is
dures performed for nontraumatic stiffness were not notably the result of a simple elbow dislocation or an extra-articular
different from those performed for posttraumatic stiffness; and fracture. Less improvement is to be anticipated when the con-
(3) the results of treatment did not differ significantly between tracture has been caused by an intra-articular fracture or
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Fig. 1-D

Figs. 1-C and 1-D Radiographs made six months after surgery.

Fig. 1-C

N.G.J. Maritz
when the patient has had previous surgery. The results of the Department of Orthopaedic Surgery, Pretoria Academic Hospital, Private
present study suggest that open surgical release, when neces- Bag X169, Pretoria 0001, South Africa
sary, results in improved (although rarely normal) elbow mo-
tion in approximately 75% of patients.
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive pay-
ments or other benefits or a commitment or agreement to provide such
Anthony A. Stans, MD benefits from a commercial entity. No commercial entity paid or
Shawn W. O’Driscoll, MD, PhD directed, or agreed to pay or direct, any benefits to any research fund,
Bernard F. Morrey, MD foundation, educational institution, or other charitable or nonprofit
Mayo Clinic, 200 First Street S.W., Rochester, MN 55905 organization with which the authors are affiliated or associated.

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