ORIGINAL ARTICLE
Combination of Arthrolysis by Lateral and Medial Approaches and
Hinged External Fixation in the Treatment of Stiff Elbow
Shen Liu, MD, Cun-Yi Fan, MD, PhD, Hong-Jiang Ruan, MD, Feng-Feng Li, MD, and Jian Tian, MD
Background: Various methods are available to treat the stiff elbow. How-
ever, there is no consensus on which one is most useful. This study involves
the effects of combination of arthrolysis by lateral and medial approaches
and hinged external fixation in the treatment of stiff elbow.
Patients: We treated 12 patients with stiff elbows using a combination of
arthrolysis by lateral and medial approaches and hinged external fixation.
The arthrolysis was applied to the elbow for complete soft-tissue release, and
the hinged external fixation mainly for rehabilitation and stability of the
elbow after arthrolysis. With the help of the hinged external fixation,
nonsurgical treatment including exercises was effectively performed to
maintain the stability and the results of arthrolysis. Before surgery, the mean
extension was ⫺35 degrees and the mean flexion 70 degrees. One patient had
a loss of 70 degrees in pronation.
Results: Satisfactory follow-up was given to 11 patients with the mean
length of 15 month. The mean postoperative extension was ⫺8 degrees
whereas flexion 122 degrees. Two of 11 patients had a transient ulnar
paresthesia and returned to normal after 8-month follow-up. The loss of
pronation in one patient reduced to 30 degrees afterward. There were no
complicating infections. All patients reported satisfactory effect.
Conclusion: The combination of arthrolysis by lateral and medial ap-
proaches and hinged external fixation in the treatment of stiff elbow is safe
and effective.
Key Words: Stiff elbow, Approach, Hinged external fixation.
(J Trauma. 2011;70: 373–376)
T he stiff elbow is a common problem that can be associated
with significant morbidity.1 This has been caused by
fibrosis and thickening of the capsule and periarticular soft
tissues.2– 4 Different methods have been used.5–9 Most have
mainly focused on either arthrolysis or rehabilitation rather
than using them both. However, it is advisable that a hinged
external fixation is helpful for rehabilitation for the range of
motion (ROM) after elbow arthrolysis, especially when there
is an instability of the joints.
Submitted for publication November 1, 2009.
Accepted for publication April 27, 2010.
Copyright © 2011 by Lippincott Williams & Wilkins
From the Department of Orthopaedics, The Sixth Affiliated People’s Hospital,
Shanghai Jiaotong University School of Medicine, Shanghai, People’s Re-
public of China.
Address for reprints: Cun-Yi Fan, Department of Orthopaedics, The Sixth Affil-
iated People’s Hospital, Shanghai Jiaotong University School of Medicine,
600 Yishan Road, Shanghai, People’s Republic of China 200233; email:
fancunyi888@hotmail.com.
DOI: 10.1097/TA.0b013e3181e4f5e3
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 70, Number 2, February 2011
MATERIALS AND METHODS
Within September 2005 and July 2008, we treated 12
stiff elbows using a combination of arthrolysis by lateral and
medial approaches and hinged external fixation. Eleven pa-
tients were given satisfactory follow-up (Table 1 ). There
were four women and seven men with a mean age of 34 years
(16 – 62 years) when performed arthrolysis. Eleven elbows
were followed up for a mean of 15 month (12–24 months).
The mean interval from the time of the initial injury was 9
months (3–24 months). The mean extension before operation
was ⫺35 degrees (0 to ⫺85 degrees), and the mean flexion
was 70 degrees (30 –110 degrees). The mean active ROM of
all 11 elbows before operation was 35 degrees (0 –95 de-
grees). One patient had a loss of 70 degrees in pronation.
All patients had undergone the combination of arthrol-
ysis by lateral and medial approaches and hinged external
fixation in the treatment of stiff elbow. In one case, an
anterior transposition of the ulnar nerve was performed ac-
cording to the ulnar neurapraxia before operation.
The lateral incision was performed as the extended
Kocher approach. The extensor origins of brachioradialis and
extensor carpi radialis longus were reflected anteriorly for
releasing the anterior aspect of the joint. After excising the
anterior part of capsule and removing the whole marginal
osteophytes, we also released the humeroradial joints. The
radial bundle of lateral collateral ligament could be excised,
but the ulnar one should be left to prevent subsequent insta-
bility.10 A medial incision was performed, beginning distally,
curving along the ulnar nerve, and continuing proximally to
the posterior aspect of the upper arm. The ulnar nerve was
exposed and released and could be transposed anteriorly if
necessary. Triceps were reflected posteriorly and the poste-
rior part of the capsule was exposed. Posterior capsule and
marginal osteophytes on the olecranon could be easily ex-
cised. To increase the extension angle, the tip of the olecra-
non could be shortened from 0.5 cm to 1 cm when the
extension of the elbow was felt to be blocked by it. The
olecranon fossa was also released or reconstructed to locate
the olecranon. Triceps were reflected laterally from the me-
dial side of the distal humerus to expose the olecranon fossa
and the posterior aspect of the humerus for debridment. A
part of flexor and pronator origins was detached from the
medial epicondyle to expose the anterior capsule for release.
The posterior and transverse bundle of the medial collateral
ligament (MCL), heterotopic ossification, and the capsule
should be excised. But the anterior part of the MCL was left
for elbow stability.10
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Liu et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 70, Number 2, February 2011

TABLE 1. Details of 11 Patients (11 Elbows) With Stiff Elbow

Age Time From Preoperation Extension/
Case Sex (Years) Side Initial Pathology Injury (Months) Initial Previous Treatment Flexion (Degrees)
1 M 45 L Dislocation and coronoid process 4 ORIF 0/30
fracture
2 M 35 L Monteggia fracture 24 ORIF and radial head ⫺40/60
resection
3 F 40 L Distal humeral intra-articular 9 Open reduction and K-wire ⫺50/95
fracture fixation
4 M 31 R Distal humeral intra-articular 7 ORIF ⫺20/60
fracture
5 M 62 L Distal humeral intra-articular 6 ORIF ⫺40/70
fracture
6 M 43 L Distal humeral intra-articular 8 ORIF ⫺85/90
fracture
7 M 16 R Distal humeral fracture 6 Close reduction ⫺30/70
8 M 23 R Distal humeral intra-articular 3 Close reduction ⫺10/90
fracture
9 F 31 R Radial head fracture 13 Radial head resection ⫺50/50
10 F 21 R Distal humeral intra-articular 6 Close reduction ⫺15/110
fracture
11 F 27 L Dislocation 16 Open reduction and K-wire ⫺40/40
fixation
ORIF, open reduction with internal fixation.

TABLE 2. Details of 11 Patients (11 Elbows) With Stiff Elbow

Postoperative Extension/ Follow-Up
Case Previous Pathology Surgical Approach Flexion (Degrees) Complication (Months)
1 Old dislocation Medial and lateral ⫺5/110 Transient pain 21
2 Instability Medial and lateral ⫺20/110 Transient pain and instability 13
3 None Medial and lateral 0/140 Transient pain 13
4 HO Medial and lateral ⫺25/80 Transient ulnar paresthesia 15
5 None Medial and lateral ⫺15/120 Transient pain 17
6 None Medial and lateral ⫺15/115 Transient pain 24
7 None Medial and lateral 0/130 Transient pain 13
8 Old fracture Medial and lateral 0/140 Transient pain 14
9 HO Medial and lateral 0/145 Transient pain 12
10 None Medial and lateral ⫺5/130 Transient pain 14
11 HO Medial and lateral 0/125 Transient ulnar paresthesia 12
HO, heterotopic ossification.

After getting a satisfactory ROM, a hinged external
fixation was applied to the elbow. The important step of using
a hinged external fixation was to identify elbow rotational
axis, after which a 2.0 mm Kirschner wire was drilled along
the axis. The middle part of the fixation was placed through
the Kirschner wire. The upper and the lower parts of the
fixation were placed on the bones of each side of the elbow.
Then, after checking and documenting the satisfactory ROM,
the muscle was reattached with atraumatic sutures and the
wound is closed in layers.
Indomethacin (25 mg) was given three times a day over
a period of 4 weeks to prevent heterotopic ossification.
During the first week after operation, the patient should gain
at least 90% of the ROM, which has been documented during
operation. They were instructed to perform cycle exercises of
flexion and extension gradually including active and passive
exercises twice a day for half an hour each time and sleep
with the elbow alternately as much flexion or extension as
possible. During the following weeks, the time of rehabilita-
tion gradually increased to 1 hour each time. Six or 8 weeks
after arthrolysis, the hinged external fixation was removed
without anesthesia as an outpatient procedure.
RESULTS
The mean preoperative limitation of extension reduced
from ⫺35 degrees to ⫺8 degrees, and the mean preoperative
flexion of the elbow improved from 70 degrees to 122
degrees (Table 2 ). The mean gains in extension and flexion
movement were 27 degrees and 53 degrees, respectively. The

374 © 2011 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 70, Number 2, February 2011Combination of Arthrolysis by Lateral and Medial
Figure 1. (A) and (B), Preoperative flexion and extension. (C) and (D), Postoperative flexion and extension (1 week). (E) and
(F), Postoperative flexion and extension.
total ROM of the elbow improved from a preoperative mean
of 35 degrees to a postoperative mean of 115 degrees. Thus,
the mean ROM increased by 80 degrees. Subsequently, there
was no significant loss of ROM during follow-up time. The
loss of pronation in one patient reduced to 30 degrees after-
ward. Two out of 11 patients had a transient ulnar paresthesia
which returned to normal after 8-month follow-up. All pa-
tients had pains for less than 1 month and no pain at the last
follow-up. One patient who suffered from preoperative insta-
bility had an improvement and was satisfied with the result.
There were no complicating infections. All patients reported
satisfaction of postoperative effect (Fig. 1).
DISCUSSION
A stiff elbow is usually defined as an elbow having a
reduction of more than 30 degrees in extension or flexion less
than 130 degrees.11 Ninety percent of normal daily activities
need an extension-flexion angle from 30 degrees to 130
degrees.12 Many techniques have been described to treat the
stiff elbow. However, if nonsurgical treatment fails, the
patient may be a surgical candidate.
Several approaches have been used for the surgical
treatment of stiff elbow. The aim of a surgical approach to the
elbow is to provide an adequate exposure with preservation of
the neurovascular structures. Moreover, this technique allows
a complete soft-tissue release, a removement of loose bodies
in the coronoid fossae, a prevention of subsequent instability
by preserving the important bundle of lateral collateral liga-
ment and MCL, early postoperative exercises and less wound
problems.6,11,13–15
Tosun et al.6 reported the outcome of 20 posttraumatic
elbow contracture of 20 patients. Twelve-month follow-up
measurements were performed. The mean preoperative ROM
was 35 degrees and this value improved to 86 degrees. In our
series, the lateral incision was performed mainly to release
© 2011 Lippincott Williams & Wilkins
Approaches
the anterior aspect of the joint and the medial one mainly to
release the posterior aspect. By this way, all our patients
gained completely release with minimal trauma. Our value
improves from a preoperative mean of 35 degrees to a
postoperative mean of 115 degrees. To a great extent, we can
learn that the addition of hinged external fixation may be
helpful to increase ROM.
The use of hinged external fixation increases the ROM
after arthrolysis and enhances elbow stability. Distraction
arthroplasty, which may aid cartilage healing, can be another
advantage. Ayoub et al.16 reported their results of using an
elbow hinge device. They approached full surgical release to
five elbows. All patients showed a mean improvement in
extension of 21 degrees and in flexion of 12 degrees, whereas
three patients developed superficial simple pin-track infec-
tions and one patient developed a transient ulnar neurapraxia.
In our series, the mean gains in extension and flexion move-
ment were 27 degrees and 53 degrees. Two of our patients
had a transient ulnar paresthesia but no complicating infec-
tions according to the care for pin-track.
Early postoperative passive exercises have a key role in
the treatment and should be followed by active exercises. The
use of continuous passive motion is controversial and may
have a limited role in treating the stiff elbow.1 However, a
hinged external fixation cannot only meet the needs of the
early exercises but also maintain stability for the elbow after
arthrolysis, which is reported to be safe and effective.16 –18
That is the reason why a hinged external fixation is widely
used. From our latest follow-up, we think that the excellent
results attribute mainly to the patients’ compliance to reha-
bilitation and their tolerance to pain during exercises.
Our results show, to some extent, that a combination of
arthrolysis by the lateral and medial approaches and hinged
external fixation in the treatment of stiff elbow has advan-
tages of them both. Therefore, our indications of using the
375
Liu et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 70, Number 2, February 2011
hinged external fixation include not only the traditional one
but also the need of rehabilitation.
Above all, various methods are available to treat the
stiff elbow. However, there is no consensus on which one is
most useful. We have used not only lateral and medial
approaches to release the stiff elbow completely but also
hinged external fixation for a successful rehabilitation. Ex-
cellent results of our treatments suggest that the combination
of arthrolysis by lateral and medial approaches and hinged
external fixation for stiff elbow is safe and effective.
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