Arch Orthop Trauma Surg DOI 10.1007/s00402-015-2199-5
ORTHOPAEDIC SURGERY
Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients Ewout S. Veltman1 • Job N. Doornberg2 • Denise Eygendaal3 Michel P. J. van den Bekerom4
•
Received: 28 December 2014 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction The elbow is prone to stiffness after trauma. To regain functional elbow motion, several conservative and surgical treatment options are available. Nonoperative treatment includes physical therapy, intra-articular injections with corticosteroids, and a static progressive or dynamic splinting program. The objective of this study was to perform a comprehensive review of the literature to evaluate the best current evidence for nonoperative treatment options for posttraumatic elbow stiffness. Methods We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients and with the functional outcome reported were included in this study. Results Eight studies (including 232 patients) met our eligibility criteria and were included for data analysis and pooling. These studies included one randomized controlled trial and seven retrospective cohort studies. Static progressive splinting was evaluated in 160 patients. The
& Ewout S. Veltman [email protected] 1
Department of Orthopaedic Surgery, Spaarne hospital, Hoofddorp, The Netherlands
2
University of Amsterdam Orthopaedic Residency Program, Orthotrauma Research Center, Academic Medical Center, Amsterdam, The Netherlands
3
Department of Orthopaedic Surgery, Amphia hospital, Breda, The Netherlands
4
Department of Orthopaedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, The Netherlands
average pre-splinting range of motion of all elbows was 72°, which improved by 36° after splinting to an average post-splinting arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an average pre-splinting range of motion of 63°. The average improvement was 37° to an average post-splinting arc of motion of 100°. Conclusions Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion. Keywords Elbow stiffness Conservative treatment Static splint Dynamic splint
Introduction The elbow is prone to stiffness after trauma [1–4], up to twelve percent of all posttraumatic elbows end up with a flexion contracture requiring surgical intervention [5]. Etiopathogenesis remains largely unknown [3, 6, 7]. According to Morrey and colleagues, most of the activities of daily living can be accomplished with 100° of elbow flexion (30–130) and 100° of forearm rotation (50–50). More recently, Sardelli and colleagues [8] concluded that functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks [8].
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To regain functional elbow motion, several nonoperative and surgical treatment options are available [1, 3, 8–10]. Surgical treatment can be performed open or arthroscopic depending on the type of deformity of the posttraumatic elbow and the surgeons’ preference. The results of both techniques are more or less comparable [1]. Recurrence of elbow stiffness remains a point of concern and is unrelated to the technique used [2, 11–13]. Another disadvantage of operative treatment is the risk of complications [12, 13]. According to Kodde and colleagues [12], arthroscopic and open arthrolysis have similar results in terms of functional outcome; however, the amount of complications seems to rise with the extent of the surgical procedure. Nonoperative treatment includes physiotherapy, intraarticular injections with corticosteroids, or a static progressive or dynamic splinting program [2]. Static bracing provides stretch in the position requiring most improvement in range of motion. As the elbow is fixed in one position, elbow movement is impossible and the splint can only be used several hours per day, and preferably at night. Static bracing is recommended at least three times half an hour a day [14, 15]. Dynamic bracing provides a constant pressure in the direction of the flexion or extension contracture, while enabling functional elbow movement and is recommended to be worn 8 h a day [15, 16]. Which treatment modality provides the best long-term outcome in range of elbow motion remains open to debate [9, 10, 17]. Objective of the current study was to perform a comprehensive overview of the literature to evaluate the best nonoperative treatment option for posttraumatic elbow stiffness.
Materials and methods This review was performed and reported following the principles of the PRISMA guidelines. We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults using the search term: (therapy OR physiotherapy OR conservative* OR treatment) AND (stiff*[All Fields] AND (‘‘elbow’’[MeSH Terms] OR ‘‘elbow’’[All Fields])) AND (elbow). Two databases (Pubmed/Medline and EMBASE) were searched covering the period from 1978 to 2014. The references of retrieved publications were manually checked for additional studies that would potentially meet the eligibility criteria and that had not been found by the electronic search. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients, and with the functional outcome reported were included in this study. Exclusion criteria were case reports
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with less than five patients per paper and studies describing surgical treatment for elbow stiffness. Abstracts of all articles that were found in the initial search were reviewed independently by two of the authors (XX and XX) for agreement with the eligibility criteria. Then, full texts of selected articles and of those articles with an incomprehensive abstract were read before final inclusion in our review. From each study, we recorded available data regarding baseline patient characteristics, number of patients, cause of elbow stiffness, pre- and posttreatment range of elbow motion, treatment protocols, duration of follow-up and complications. The data were extracted by one author (XX) and verified by the second (XX). Improvements in motion are reported for the overall cohort of all studies with a comparison of the different nonoperative treatment modalities. All reported averages are sample-size weighted.
Results Eight studies [14–16, 18–22] met our eligibility criteria and were included for data analysis (flow diagram). These studies consisted of one randomized controlled trial and seven retrospective cohort studies. The patients were analyzed based on the two groups: (1) including patients treated with static progressive splinting and (2) patients treated with dynamic splinting. General information A total of 232 patients (232 elbows) with elbow stiffness in eight studies were included in the review. Etiology of elbow stiffness was posttraumatic in 231 patients and burn injury in one patient. The latter patient could not be excluded due to reporting error of the original study. Stiffness involved the right arm in fifty-four percent of patients and the dominant limb was involved in fifty percent of patients. The average age was 38 years (range 32–45) and fiftytwo percent of patients were male. The average time from injury until surgery was 9 months (range 1–65 months). The average follow-up of all patients was 15 months (range 12–23 months). Treatment protocols varied greatly between studies in both cohorts. In four studies in the static progressive splinting cohort, patients used the splint during 30 min four times daily for a period of 1–4 months, depending on the progress in range of elbow motion. In the other two studies in the static progressive splinting, cohort patients used the splint between 15 and 20 h a day for 5 months. In the dynamic splinting cohort, all treatment protocols dictated patients to use the orthosis 8 h a day, but the frequency of
Arch Orthop Trauma Surg
use varied from 1 to 4 times daily and duration of use from 2 to 8 h. The orthosis was used for 2 months. Cohort 1: static progressive splinting A total of 160 patients (160 elbows) with elbow stiffness described in six studies [14, 15, 18–20, 22] were included. Etiology of elbow stiffness was trauma in 159 patients (99 %), and burn injury in one patient. The average pre-splinting range of motion of all elbows was 72° (range 54°–89°) with an average 112° of flexion (range 101°–118°) and an average 39° of extension deficit (range 23°–59°). The average improvement was 36° to an average post-splinting arc of motion of 108° (range 100°– 112°) with 128° of flexion (range 125°–130°) and 22° of extension deficit (range 17°–28°) (Fig. 1). Cohort 2: dynamic orthosis A total of 72 patients (72 elbows) in three studies [15, 16, 21] with elbow stiffness were treated with dynamic splinting. Etiology of elbow stiffness was trauma in all patients. Mean time between trauma and start of static or dynamic splinting was 9 months. The average pre-splinting range of motion of all elbows was 63° (range 52°–68°) with an average 111° of flexion (range 100°–124°) and an average 48° of flexion contracture (range 41°–58°). The average improvement was 37° to an average post-splinting arc of motion of 100° (range 92°– 105°) with 127° of flexion (range 126–129°) and 28° of extension deficit (range 21–37°) (Fig. 1). Complications Heterotopic ossification of the elbow requiring surgery developed in nine out of 160 patients (6 %) treated with static progressive splinting and in three out of 72 patients
Fig. 1 Improvement in range of motion after static and dynamic splinting
(4 %) treated with a dynamic orthotic device. Ulnar neuropathy developed in seven patients of group 1 (4 %), requiring surgical therapy in two patients (1 %). In group 2, ulnar neuropathy was present in 2 patients (3 %), requiring surgical decompression in both patients. No improvement in range of motion was noted in 5 out of 160 patients (3 %) treated with static progressive splinting and in three out of 72 patients (4 %) treated with a dynamic orthosis. Two patients in the study of Bhat and colleagues [18] developed a mild cutaneous allergy for the Turnbuckle material which resolved spontaneously after using a cloth fabric.
Discussion In this study, the results of nonoperative treatment for post traumatic elbow stiffness were analyzed with a focus on comparison of static and dynamic treatment for elbow stiffness. The authors realize that differences in trauma mechanism and posttraumatic deformity as well as the time elapsed between the trauma and onset of nonoperative treatment can influence the outcome after nonoperative treatment of elbow stiffness. It seems that there was no difference (36° and 37° of improvement) between dynamic and static treatment. Due to reporting errors in the original data, true statistical analysis of the results was not possible. The reported complications can also be interpreted as late sequelae of the initial trauma, resulting in a low incidence of complications. A weakness of current review is the lack of available level I evidence, as only one randomized controlled trial [15] is available. A RCT provides a higher level of evidence; this literature review provides a very large sample size and might emphasize difference in outcome between the two treatment modalities. The risk of selection or reporting bias is higher in a literature review. In another
120 100 80 60 40 20 0
pre-splint arc
post-splint arc Stac
Dynamic
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Arch Orthop Trauma Surg
review concerning the operative treatment of elbow stiffness, almost 800 patients were included and in current review concerning the nonoperative treatment, only 232 patients could be included. This is remarkable because in most patients, the nonoperative treatment is the first choice and this most probably is a result of publication bias [23]. A pearl of this study is that we created a comprehensive upto-date overview of the available literature on nonoperative treatment for elbow stiffness of any etiology. Our conclusion is line with the findings of the only randomized controlled trial available, by Lindenhovius and colleagues [15]. The authors concluded no difference in outcome between treatment with dynamic orthoses or static progressive splinting. Average DASH [24] (Disabilities of the Arm, Shoulder and Hand) score was 28 versus 26 points at 12 months follow-up for dynamic versus static splinting, respectively. Patients from both groups achieved valuable improvement (average 47° in dynamic splinting group, average 49° in static group) until the final follow-up 12 months postoperatively. Most improvement in range of motion is noted in the first months of treatment. Persistence in physical therapy and splinting is rewarding, as patients gained in range of elbow motion until 12 months after the start of treatment. Eight patients (16 %) in their prospective cohort required subsequent surgical release, despite nonoperative measurements. Only one of the included studies, by Lindenhovius and colleagues [15], described the results of static progressive and dynamic splinting on pronation and supination. After static progressive splinting, the arc of forearm rotation improved with 25°; in the dynamic splinting group, the arc of forearm rotation improved with 34°. In this study, splinting was applied to regain flexion and extension, although pronation–supination-specific devices exist. Araghi and colleagues [25] studied results of manipulation under anesthesia on elbow stiffness in a group of 51 patients. Patients were manipulated under anesthesia a mean of 40 days after previous surgery. Improvement in range of elbow motion was 36° after manipulation. For future research, we advise a large prospective randomized trial comparing the results of nonoperative treatment with progressive static splinting or dynamic orthoses versus operative treatment for elbow stiffness should be performed. Patient satisfaction following static versus dynamic splinting, or duration of splint use per day are other outcome factors which have not been studied yet. We believe that the duration of elbow stiffness is an important prognostic factor for the result after nonoperative treatment for elbow stiffness, which is supported by the results of Lindenhovius and colleagues [15].
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Conclusions Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion. Improvement in elbow range of motion of almost 50° seems possible. The risk of complications of nonoperative treatment for elbow stiffness is small. Acknowledgments The author has no acknowledgements to mention. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest All named authors hereby declare that they have no conflict of interest to disclose.
References 1. Charalambous CP, Morrey BF (2012) Posttraumatic elbow stiffness. J Bone Joint Surg Am 94:1428–1437 2. Lindenhovius AL, Jupiter JB (2007) The posttraumatic stiff elbow: a review of the literature. J Hand Surg Am 32:1605–1623 3. Morrey BF (2005) The posttraumatic stiff elbow. Clin Orthop Relat Res 431:26–35 4. Muller AM, Sadoghi P, Lucas R, Audige L, Delaney R, Klein M, Valderrabano V, Vavken P (2013) Effectiveness of bracing in the treatment of nonosseous restriction of elbow mobility: a systematic review and meta-analysis of 13 studies. J Shoulder Elbow Surg 22:1146–1152 5. Myden C, Hildebrand K (2011) Elbow joint contracture after traumatic injury. J Shoulder Elbow Surg 20:39–44 6. Doornberg JN, Bosse T, Cohen MS, Jupiter JB, Ring D, Kloen P (2014) Temporary presence of myofibroblasts in human elbow capsule after trauma. J Bone Joint Surg Am 96:e36 7. Hildebrand KA (2013) Posttraumatic elbow joint contractures: defining pathologic capsular mechanisms and potential future treatment paradigms. J Hand Surg Am 38:2227–2233 8. Sardelli M, Tashjian RZ, MacWilliams BA (2011) Functional elbow range of motion for contemporary tasks. J Bone Joint Surg Am 93:471–477 9. Davila SA, Johnston-Jones K (2006) Managing the stiff elbow: operative, nonoperative, and postoperative techniques. J Hand Ther 19:268–281 10. Everding NG, Maschke SD, Hoyen HA, Evans PJ (2013) Prevention and treatment of elbow stiffness: a 5-year update. J Hand Surg Am 38:2496–2507 11. Lindenhovius AL, Doornberg JN, Ring D, Jupiter JB (2010) Health status after open elbow contracture release. J Bone Joint Surg Am 92:2187–2195 12. Kodde IF, van Rijn J, van den Bekerom MP, Eygendaal D (2013) Surgical treatment of post-traumatic elbow stiffness: a systematic review. J Shoulder Elbow Surg 22:574–580 13. Veltman ES, Lindenhovius AL, Kloen P (2014) Improvements in elbow motion after resection of heterotopic bone: a systematic review. Strategies Trauma Limb Reconstr 9:65–71
Arch Orthop Trauma Surg 14. Doornberg JN, Ring D, Jupiter JB (2006) Static progressive splinting for posttraumatic elbow stiffness. J Orthop Trauma 20:400–404 15. Lindenhovius AL, Doornberg JN, Brouwer KM, Jupiter JB, Mudgal CS, Ring D (2012) A prospective randomized controlled trial of dynamic versus static progressive elbow splinting for posttraumatic elbow stiffness. J Bone Joint Surg Am 94:694–700 16. Gallucci GL, Boretto JG, Davalos MA, Alfie VA, Donndorff A, De CP (2014) The use of dynamic orthoses in the treatment of the stiff elbow. Eur J Orthop Surg Traumatol 24:1395–1400 17. Evans PJ, Nandi S, Maschke S, Hoyen HA, Lawton JN (2009) Prevention and treatment of elbow stiffness. J Hand Surg Am 34:769–778 18. Bhat AK, Bhaskaranand K, Nair SG (2010) Static progressive stretching using a turnbuckle orthosis for elbow stiffness: a prospective study. J Orthop Surg (Hong Kong) 18:76–79 19. Bonutti PM, Windau JE, Ables BA, Miller BG (1994) Static progressive stretch to reestablish elbow range of motion. Clin Orthop Relat Res 303:128–134 20. Gelinas JJ, Faber KJ, Patterson SD, King GJ (2000) The effectiveness of turnbuckle splinting for elbow contractures. J Bone Joint Surg Br 82:74–78
21. Shewring DJ, Beaudet M, Carvell JE (1991) Reversed dynamic slings: results of use in the treatment of post-traumatic flexion contractures of the elbow. Injury 22:400–402 22. Ulrich SD, Bonutti PM, Seyler TM, Marker DR, Morrey BF, Mont MA (2010) Restoring range of motion via stress relaxation and static progressive stretch in posttraumatic elbow contractures. J Shoulder Elbow Surg 19:196–201 23. Okike K, Kocher MS, Mehlman CT, Heckman JD, Bhandari M (2008) Publication bias in orthopaedic research: an analysis of scientific factors associated with publication in the Journal of Bone and Joint Surgery (American Volume). J Bone Joint Surg Am 90:595–601 24. Hudak PL, Amadio PC, Bombardier C (1996) Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 29:602–608 25. Araghi A, Celli A, Adams R, Morrey B (2010) The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release. J Shoulder Elbow Surg 19:202–208
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ORTHOPAEDIC SURGERY
Static progressive versus dynamic splinting for posttraumatic elbow stiffness: a systematic review of 232 patients Ewout S. Veltman1 • Job N. Doornberg2 • Denise Eygendaal3 Michel P. J. van den Bekerom4
•
Received: 28 December 2014 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Introduction The elbow is prone to stiffness after trauma. To regain functional elbow motion, several conservative and surgical treatment options are available. Nonoperative treatment includes physical therapy, intra-articular injections with corticosteroids, and a static progressive or dynamic splinting program. The objective of this study was to perform a comprehensive review of the literature to evaluate the best current evidence for nonoperative treatment options for posttraumatic elbow stiffness. Methods We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients and with the functional outcome reported were included in this study. Results Eight studies (including 232 patients) met our eligibility criteria and were included for data analysis and pooling. These studies included one randomized controlled trial and seven retrospective cohort studies. Static progressive splinting was evaluated in 160 patients. The
& Ewout S. Veltman [email protected] 1
Department of Orthopaedic Surgery, Spaarne hospital, Hoofddorp, The Netherlands
2
University of Amsterdam Orthopaedic Residency Program, Orthotrauma Research Center, Academic Medical Center, Amsterdam, The Netherlands
3
Department of Orthopaedic Surgery, Amphia hospital, Breda, The Netherlands
4
Department of Orthopaedic Surgery, Shoulder and Elbow Unit, OLVG, Amsterdam, The Netherlands
average pre-splinting range of motion of all elbows was 72°, which improved by 36° after splinting to an average post-splinting arc of motion of 108°. Dynamic splinting was evaluated in 72 patients with an average pre-splinting range of motion of 63°. The average improvement was 37° to an average post-splinting arc of motion of 100°. Conclusions Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion. Keywords Elbow stiffness Conservative treatment Static splint Dynamic splint
Introduction The elbow is prone to stiffness after trauma [1–4], up to twelve percent of all posttraumatic elbows end up with a flexion contracture requiring surgical intervention [5]. Etiopathogenesis remains largely unknown [3, 6, 7]. According to Morrey and colleagues, most of the activities of daily living can be accomplished with 100° of elbow flexion (30–130) and 100° of forearm rotation (50–50). More recently, Sardelli and colleagues [8] concluded that functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks [8].
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Arch Orthop Trauma Surg
To regain functional elbow motion, several nonoperative and surgical treatment options are available [1, 3, 8–10]. Surgical treatment can be performed open or arthroscopic depending on the type of deformity of the posttraumatic elbow and the surgeons’ preference. The results of both techniques are more or less comparable [1]. Recurrence of elbow stiffness remains a point of concern and is unrelated to the technique used [2, 11–13]. Another disadvantage of operative treatment is the risk of complications [12, 13]. According to Kodde and colleagues [12], arthroscopic and open arthrolysis have similar results in terms of functional outcome; however, the amount of complications seems to rise with the extent of the surgical procedure. Nonoperative treatment includes physiotherapy, intraarticular injections with corticosteroids, or a static progressive or dynamic splinting program [2]. Static bracing provides stretch in the position requiring most improvement in range of motion. As the elbow is fixed in one position, elbow movement is impossible and the splint can only be used several hours per day, and preferably at night. Static bracing is recommended at least three times half an hour a day [14, 15]. Dynamic bracing provides a constant pressure in the direction of the flexion or extension contracture, while enabling functional elbow movement and is recommended to be worn 8 h a day [15, 16]. Which treatment modality provides the best long-term outcome in range of elbow motion remains open to debate [9, 10, 17]. Objective of the current study was to perform a comprehensive overview of the literature to evaluate the best nonoperative treatment option for posttraumatic elbow stiffness.
Materials and methods This review was performed and reported following the principles of the PRISMA guidelines. We performed a search of all studies on nonoperative treatment for elbow stiffness in human adults using the search term: (therapy OR physiotherapy OR conservative* OR treatment) AND (stiff*[All Fields] AND (‘‘elbow’’[MeSH Terms] OR ‘‘elbow’’[All Fields])) AND (elbow). Two databases (Pubmed/Medline and EMBASE) were searched covering the period from 1978 to 2014. The references of retrieved publications were manually checked for additional studies that would potentially meet the eligibility criteria and that had not been found by the electronic search. All articles describing nonoperative treatment of elbow stiffness, written in the English, German, French or Dutch language, including human adult patients, and with the functional outcome reported were included in this study. Exclusion criteria were case reports
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with less than five patients per paper and studies describing surgical treatment for elbow stiffness. Abstracts of all articles that were found in the initial search were reviewed independently by two of the authors (XX and XX) for agreement with the eligibility criteria. Then, full texts of selected articles and of those articles with an incomprehensive abstract were read before final inclusion in our review. From each study, we recorded available data regarding baseline patient characteristics, number of patients, cause of elbow stiffness, pre- and posttreatment range of elbow motion, treatment protocols, duration of follow-up and complications. The data were extracted by one author (XX) and verified by the second (XX). Improvements in motion are reported for the overall cohort of all studies with a comparison of the different nonoperative treatment modalities. All reported averages are sample-size weighted.
Results Eight studies [14–16, 18–22] met our eligibility criteria and were included for data analysis (flow diagram). These studies consisted of one randomized controlled trial and seven retrospective cohort studies. The patients were analyzed based on the two groups: (1) including patients treated with static progressive splinting and (2) patients treated with dynamic splinting. General information A total of 232 patients (232 elbows) with elbow stiffness in eight studies were included in the review. Etiology of elbow stiffness was posttraumatic in 231 patients and burn injury in one patient. The latter patient could not be excluded due to reporting error of the original study. Stiffness involved the right arm in fifty-four percent of patients and the dominant limb was involved in fifty percent of patients. The average age was 38 years (range 32–45) and fiftytwo percent of patients were male. The average time from injury until surgery was 9 months (range 1–65 months). The average follow-up of all patients was 15 months (range 12–23 months). Treatment protocols varied greatly between studies in both cohorts. In four studies in the static progressive splinting cohort, patients used the splint during 30 min four times daily for a period of 1–4 months, depending on the progress in range of elbow motion. In the other two studies in the static progressive splinting, cohort patients used the splint between 15 and 20 h a day for 5 months. In the dynamic splinting cohort, all treatment protocols dictated patients to use the orthosis 8 h a day, but the frequency of
Arch Orthop Trauma Surg
use varied from 1 to 4 times daily and duration of use from 2 to 8 h. The orthosis was used for 2 months. Cohort 1: static progressive splinting A total of 160 patients (160 elbows) with elbow stiffness described in six studies [14, 15, 18–20, 22] were included. Etiology of elbow stiffness was trauma in 159 patients (99 %), and burn injury in one patient. The average pre-splinting range of motion of all elbows was 72° (range 54°–89°) with an average 112° of flexion (range 101°–118°) and an average 39° of extension deficit (range 23°–59°). The average improvement was 36° to an average post-splinting arc of motion of 108° (range 100°– 112°) with 128° of flexion (range 125°–130°) and 22° of extension deficit (range 17°–28°) (Fig. 1). Cohort 2: dynamic orthosis A total of 72 patients (72 elbows) in three studies [15, 16, 21] with elbow stiffness were treated with dynamic splinting. Etiology of elbow stiffness was trauma in all patients. Mean time between trauma and start of static or dynamic splinting was 9 months. The average pre-splinting range of motion of all elbows was 63° (range 52°–68°) with an average 111° of flexion (range 100°–124°) and an average 48° of flexion contracture (range 41°–58°). The average improvement was 37° to an average post-splinting arc of motion of 100° (range 92°– 105°) with 127° of flexion (range 126–129°) and 28° of extension deficit (range 21–37°) (Fig. 1). Complications Heterotopic ossification of the elbow requiring surgery developed in nine out of 160 patients (6 %) treated with static progressive splinting and in three out of 72 patients
Fig. 1 Improvement in range of motion after static and dynamic splinting
(4 %) treated with a dynamic orthotic device. Ulnar neuropathy developed in seven patients of group 1 (4 %), requiring surgical therapy in two patients (1 %). In group 2, ulnar neuropathy was present in 2 patients (3 %), requiring surgical decompression in both patients. No improvement in range of motion was noted in 5 out of 160 patients (3 %) treated with static progressive splinting and in three out of 72 patients (4 %) treated with a dynamic orthosis. Two patients in the study of Bhat and colleagues [18] developed a mild cutaneous allergy for the Turnbuckle material which resolved spontaneously after using a cloth fabric.
Discussion In this study, the results of nonoperative treatment for post traumatic elbow stiffness were analyzed with a focus on comparison of static and dynamic treatment for elbow stiffness. The authors realize that differences in trauma mechanism and posttraumatic deformity as well as the time elapsed between the trauma and onset of nonoperative treatment can influence the outcome after nonoperative treatment of elbow stiffness. It seems that there was no difference (36° and 37° of improvement) between dynamic and static treatment. Due to reporting errors in the original data, true statistical analysis of the results was not possible. The reported complications can also be interpreted as late sequelae of the initial trauma, resulting in a low incidence of complications. A weakness of current review is the lack of available level I evidence, as only one randomized controlled trial [15] is available. A RCT provides a higher level of evidence; this literature review provides a very large sample size and might emphasize difference in outcome between the two treatment modalities. The risk of selection or reporting bias is higher in a literature review. In another
120 100 80 60 40 20 0
pre-splint arc
post-splint arc Stac
Dynamic
123
Arch Orthop Trauma Surg
review concerning the operative treatment of elbow stiffness, almost 800 patients were included and in current review concerning the nonoperative treatment, only 232 patients could be included. This is remarkable because in most patients, the nonoperative treatment is the first choice and this most probably is a result of publication bias [23]. A pearl of this study is that we created a comprehensive upto-date overview of the available literature on nonoperative treatment for elbow stiffness of any etiology. Our conclusion is line with the findings of the only randomized controlled trial available, by Lindenhovius and colleagues [15]. The authors concluded no difference in outcome between treatment with dynamic orthoses or static progressive splinting. Average DASH [24] (Disabilities of the Arm, Shoulder and Hand) score was 28 versus 26 points at 12 months follow-up for dynamic versus static splinting, respectively. Patients from both groups achieved valuable improvement (average 47° in dynamic splinting group, average 49° in static group) until the final follow-up 12 months postoperatively. Most improvement in range of motion is noted in the first months of treatment. Persistence in physical therapy and splinting is rewarding, as patients gained in range of elbow motion until 12 months after the start of treatment. Eight patients (16 %) in their prospective cohort required subsequent surgical release, despite nonoperative measurements. Only one of the included studies, by Lindenhovius and colleagues [15], described the results of static progressive and dynamic splinting on pronation and supination. After static progressive splinting, the arc of forearm rotation improved with 25°; in the dynamic splinting group, the arc of forearm rotation improved with 34°. In this study, splinting was applied to regain flexion and extension, although pronation–supination-specific devices exist. Araghi and colleagues [25] studied results of manipulation under anesthesia on elbow stiffness in a group of 51 patients. Patients were manipulated under anesthesia a mean of 40 days after previous surgery. Improvement in range of elbow motion was 36° after manipulation. For future research, we advise a large prospective randomized trial comparing the results of nonoperative treatment with progressive static splinting or dynamic orthoses versus operative treatment for elbow stiffness should be performed. Patient satisfaction following static versus dynamic splinting, or duration of splint use per day are other outcome factors which have not been studied yet. We believe that the duration of elbow stiffness is an important prognostic factor for the result after nonoperative treatment for elbow stiffness, which is supported by the results of Lindenhovius and colleagues [15].
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Conclusions Both dynamic orthoses and static progressive splinting show good results for the treatment of elbow stiffness, regardless of etiology. The choice for one treatment over the other is based on the preference of the surgeon and patient. We recommend to continue nonoperative treatment with dynamic or static bracing for 12 months or until patients stop making progression in range of elbow motion. Improvement in elbow range of motion of almost 50° seems possible. The risk of complications of nonoperative treatment for elbow stiffness is small. Acknowledgments The author has no acknowledgements to mention. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest All named authors hereby declare that they have no conflict of interest to disclose.
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