The elbow joint is a very harmonious and stable joint on human body, but it is also very vulnerable. With the development of transportation and industry, complex elbow joint injuries are constantly emerging. As clinicians are focusing more on all kinds of operative research, postoperative functional deficiency and stiffness of different levels come as the problems that are awaited to be solved. In recent years, posttraumatic elbow joint stiffness has been paid with more attention. Although conservative and surgical methods are numerous, the curative effects are inconsistent. Therefore, the selection of appropriate treatment method is the prerequisite for good recovery of elbow function.

(1) General information. From January 2012 to December 2014, 13 patients (8 males and 5 females) with posttraumatic elbow joint stiffness were treated in our hospital with extensive arthrolysis and hinged external fixator. The age ranged from 35 to 77 years with an average of 40.3 years. Causes of injury: 7 cases of traffic accident, 4 cases of fall damage and 2 cases of high fall. Types of elbow injury: 3 cases of comminuted distal humeral fracture, 5 cases of terrible triad of elbow, 1 case of radial head fracture combined with ulna coronoid process fracture, 1 case of radial head fracture combined with olecranal fracture, 1 cases of radial head fracture combined with capitellum fracture, 2 cases of trans olecranon fracture-dislocation (1 case combined with lumbar transverse process fracture, and 1 case combined with rib fracture) . All the fractures were closed, and the initialinjuries were performed with internal fixation. According to Morrey classification (extreme severity for ≤30°, severity for 31-60°, moderation for 61-90° and mildness for >90°) , there were 8 cases of moderate, 4 cases of severe and 1 case of extremely severe. The mean preoperative extension angle, mean flexion angle and mean range of motion were (31.5±2.7) °, (93.0±10.1) ° and (61.5±12.4) ° respectively. The level of heterotopic ossification was categorized by Hastings and Graham classification, and there were 6 cases of type Ⅱ A, 6 cases of type ⅡC and 1 case of type Ⅲ. After 3-6 months of conservative treatment such as regular rehabilitation and physiotherapy, the results were unsatisfied. Thus, arthrolysis was performed at the same time of internal fixator removal. Preoperative imaging examination confirmed that all the fractures were healed, and CT examination was used to further investigate heterotopic ossification, osteophyte distribution, free bone fragments, etc. (2) Operative methods. After conventional brachial plexus anesthesia or general anesthesia, the patient was in supine or lateral position of the unaffected side. The surgical approaches include medial approach, lateral Kocher approach, posterior median approach, etc. The original incision should be applied when possible, while another approach is made for cooperative operation. Medial approach: the incision extended 3-5 cm from medial epicondylar towards both distal and proximal sides, and the skin and subcutaneous were cut open layer by layer with the ulnar nerve isolated and protected properly. The thickened scare tissue of medial muscle fiber and contracted soft tissue were carefully released and properly cleaned, and attention should be paid to the identification and protection of the anterior bundle of medial collateral ligament. To expose anterior joint, part of the insertion of flexors was cut off with the joint capsule opened up. The posterior joint was exposed from the deep surface of triceps brachii. Afterward, rigid blocking structures such as heterotopic ossification and osteophyte around medial column and at both the anterior and posterior sides of joint were removed. Lateral Kocher approach: the incision extended 3-5 cm from medial epicondylar towards both distal and proximal sides, and part of the insertion of flexors was cut off to expose anterior joint capsule. To expose posterior joint, the anconeus and triceps brachii were peeled backward together through the gap between anconeus and extensor carpi ulnaris. Attention should be paid to the identification and protection of the ulnar bundle of lateral collateral ligament. Rigid blocking structures such as heterotopic ossification and osteophyte around lateral column and at both the anterior and posterior sides of joint were removed as well.Posterior median approach: the skin was incised layer by layer, and the flap was pulled to both sides with the ulnar nerve protected. The medial and lateral columns were exposed through medial and lateral gaps. Alternatively, the posterior block structures were exposed and removed under direct vision after the distal triceps branchii was split. The internal fixator was removed initially, and the soft tissue around four columns was extensively released via each of the incision. The joint extension was paid with attention to increase the compliance of soft tissue. The medial and lateral epicondylars were drilled, and the insertions of flexors and extensors were sutured in situ. Once damaged, the anterior bundle of medial collateral ligament and the ulnar bundle of lateral collateral ligament were fixed with suture anchor. With conventional subcutaneous anterior transposition of ulnar nerve, the negative pressure drainage tube was placed inside the incision after complete hemostasis. The hinged external fixator (Tianjin Wyman company) was applied postoperatively. The rotational axis of elbow joint was identified as the line that crosses the lateral center of capitulum humeri and the anterior part of condylus medialis humeri. As the location was accurate, the axial hole of external fixator was inserted with Kirschner wire. The proximal movable arm was fixed at the lateral humerus, while the distal arm was fixed at the ulnar crest. The external fixator was adjusted after drilling and screw placement. (3) Postoperative treatment and evaluation. After operation, oral celecoxib was given 200 mg per time and 2 times per day to prevent heterotopic ossification (an initial dose of 400 mg was given 6 hours after operation with an addition of 200 mg 4 hours later) . Flexion and extension exercises were conducted under analgesia. Namely, the range of extension and flexion around the rotational center of elbow joint was increased gradually with practice of 2 times per day (practice range>100°) . The elbow joint was locked with external fixator in either full extension or full flexion position alternately at night. After surgery, celecoxib was normally taken for 4 weeks. Gastric mucosal protective agents could be given if there was gastrointestinal discomfort. The external fixator was used for approximately 4 weeks. As there was still bleeding from the incision, the removal of negative pressure drainage tube could be delayed to 1 week after operation. After the patients were discharged from hospital, they were instructed to continue to strengthen trainings such as flexion, extension, rotation, etc. The patients were reexamined each month, and the Broberg and Morrey score was used for elbow joint evaluation. (4) Statistical analysis. SPSS 13.0 statistical software was used for statistical analysis. The measurement data was presented as statistically significant.

The postoperative follow-up time ranged from 18 to 24 months with an average of 20.8 months. Complications such as incision infection, hematoma, or nerve injury did not occur after operation. The mean postoperative extension angle, mean flexion angle and range of motion of elbow joint were (10.5±2.4) °, (117.5±4.2) ° and (107.0±6.1) ° respectively, which were statistically significant compared with those before operation (P <0.05) . The curative effect was evaluated based on Broberg and Morrey elbow joint function score, and there were 2 cases of excellent, 8 cases of good and 3 cases of moderate. The good and excellent rate was 76.9%.

To treat complex posttraumatic elbow stiffness, extensive arthrolysis, adjustable external fixation and regular rehabilitation should be adopted as the curative effects of these strategies have been clearly affirmed. However, the mechanism of elbow stiffness is still worth of long-term exploration.