The use of combined lateral and medial releases
in the treatment of post-traumatic contracture
of the elbow
Bilgehan Tosun & Hakan Gundes & Levent Buluc &
Ahmet Y. Sarlak
Received: 27 July 2006 /Revised: 4 August 2006 /Accepted: 5 August 2006 / Published online: 12 October 2006
# Springer-Verlag 2006
Abstract Elbow stiffness is a common disorder, which
restricts daily activities. Between 30° and 130° of elbow
movement is usually enough to perform most daily
activities. However, a 10° to 15° loss of elbow extension
may be a problem when the patient is an athlete. From 1996
to 2004, 20 elbows of 20 patients (who were available for
follow-up examination) were treated by lateral and medial
release at Kocaeli University, for post-traumatic elbow
contracture. Preoperative and the postoperative 12-month
follow-up measurements were performed. The mean pre-
operative arc of motion was 35° and this value improved to
86.2°. The maximum improvement at the arc of motion was
105°. In an effort to understand the pathophysiology of the
condition, surgical approaches may be used safely. The
purpose of this study was to assess the functional outcome
of the elbow joint after using a combination of lateral and
medial approaches to treat elbow stiffness.
Résumé La raideur du coude est une pathologie fréquente
qui restreint les activités quotidiennes. Pour celles-ci une
mobilité de 30° à 130° est largement suffisante. Cependant
un flessum de 10° à 15° peut être un problème quand le
patient est un athlète. Revue d’une série de 20 patients (20
coudes) opérés de 1996 à 2004 par libération interne et
externe pour une raideur post-traumatique. Les mesures
étaient faites avant l’opération et 12 mois après. L’amp-
litude articulaire pré-opératoire moyenne était de 35° et
était augmenté à 86,2°. Le maximum de gain était 105°.
Capsular contracture of the elbow joint has been known as
the main pathological feature of the stiff elbow for a long
Morrey classified elbow stiffness as either extrinsic or
intrinsic . Jupiter et al.  described six subgroups of
simple elbow stiffness, which may be treated successfully
by soft tissue releases alone. However, most of those
patients had both extrinsic and intrinsic causes.
An appropriate approach to the stiff elbow should
expose the elbow joint and the pathological structures fully.
Nevertheless, the chosen approach must be able to restore
Urbaniak et al.  and Gates et al.  reported good
results for anterior capsulectomy performed through an
anterior approach. Nevertheless, two separate skin inci-
sions, postero-medial or medial and anterior, were used
successfully by Itoh et al. . In view of the more simple
and safe approaches available, the anterior approach may
not be the best option.
The posterior approach has gained wide acceptance for
elbow arthroplasty over the years . Although most parts
of the joint may be in view with this approach, the anterior
capsule is far away, and haematoma and wound healing
International Orthopaedics (SICOT) (2007) 31:635–638
This study was done at the Department of Orthopaedic Surgery and
Traumatology, Kocaeli University.
B. Tosun (*)
Clinic of Orthopaedics and Traumatology,
Tatvan Military Hospital,
Department of Orthopaedics, Maltepe University,
Faculty of Medicine,
L. Buluc:A. Y. Sarlak
Department of Orthopaedics and Traumatology,
Kocaeli University, Faculty of Medicine,
problems are seen frequently. This is a useful approach
when the posterior compartment needs to be debrided.
Husband and Hastings  and Mansat and Morrey 
reported successful outcomes with the lateral approach. Wada
et al.  reported the superiority of the medial approach in
respect to both the anterior and lateral approaches.
Materials and methods
From 1996 to 2004, 20 elbows of 20 patients (who were
available for follow-up examination) were treated by lateral
and medial release at Kocaeli University, for post-traumatic
contracture. The patients had an average age of 30 (range
8–77) years. There were nine female and 11 male patients;
11 left and nine right elbows. The aetiology was trauma; 11
had fallen from a height, six were traffic accidents, two
machine compressions and one burn sequelae (Table 1).
Six of our patients had an associated injury.
The average time between the traumatic event and
release was 6.8 (range 1–18) months. According to the
classification of Kay, two of them were Type I, three were
Type III and 15 Type IV. Eight patients had extrinsic, 12
had intrinsic causes.
During the operation, lateral release alone was sufficient
to give a full range of motion in three patients. However, a
medial release was added to the surgical procedure in the
remaining patients. Anterior capsulectomy was performed in
Four patients suffered from recurrent stiffness and
required a further operation. The mean interval from the
time of the first operation to reoperation was 4.5 months.
Although no haemorrhage, haematoma or wound healing
problems were encountered, three patients developed a
postoperative infection which required debridement.
Passive range of motion (ROM) exercises were started on
the first postoperative day. On the third postoperative day,
continuous passive motion (CPM) exercises were added to
the passive ROM exercises. During the hospital stay, both
passive ROM and CPM exercises were maintained. When
the patient was discharged from hospital, a home exercise
program was used to prevent reccurrent stiffness.
We measured both preoperative and postoperative elbow
movements manually with a goniometer. All patients used a
custom-made splint in the postoperative period.
Preoperative and the postoperative 12-month follow-up
measurements were performed. The mean preoperative arc
of motion was 35° and this value improved to 86.2°. The
maximum improvement at the arc of motion was 105°.
Three of the 20 elbows treated with a lateral release
alone showed full ROM in the operating room. However,
the remaining 17 patients required combined lateral and
Four patients modified their jobs because of the
insufficient elbow movements.
Postoperatively, the main complaint was periodical pain
during daily activities, and cold intolerance was the next
most common complaint. Additional complaints were
transient paresthesia and restricted elbow motion. Three
out of 20 patients had a transient ulnar paresthesia.
Although seven patients had no complaint, other patients
reported dissatisfaction when asked about postoperative
A stiff elbow is usually defined as an elbow having a
reduction of more than 30° in extension, or flexion less than
130° . If the elbow has an arc of motion of 100°, from
30° to 130° of flexion, most activities of daily living are
possible [11, 13].
Stiffness is a common problem after trauma to the elbow.
Some conditions such as trauma to the elbow, burns, or
coma may lead to impaired elbow functions. On the other
hand, spinal cord injury, cerebral trauma, transplantation or
prolonged artifical ventilation can lead to stiffness in an
uninjured elbow . Contracture of the elbow joint may be
due to the intrinsic, extrinsic or combined pathology. More
restriction at the joint and the necessity for difficult
treatment modalities arise when the appropriate treatment
is delayed. Boerboom et al.  reported that operative
release within a year of the injury is twice as effective as
the operation after a longer period. Early postoperative
passive ROM exercises, followed by active ROM exercises,
have a key role in the treatment.
Three articulations in a single joint capsule and the close
relation of the joint surfaces may collude in the mechanism
of the elbow stiffness.
Many techniques have been described for the operative
release of a post-traumatic stiff elbow. Advocates of a
lateral approach claim some advantages, such as less risk of
nerve damage and wound problems . This incision also
permits evaluation and treatment of both the anterior and
posterior trochlear and the radiohumeral joint. Ulnar
paresthesia is the main complication seen after the release
by lateral incision . Because of this complication,
anterior transposition of the ulnar nerve is suggested when
Wada et al.  stated the benefits of the medial
exposure and they found several advantages over the lateral
approach. According to Wada et al. , pathological
636International Orthopaedics (SICOT) (2007) 31:635–638
changes in the posterior oblique bundle of the medial
collateral ligament, and anterior and posterior aspects of the
elbow joint, can be seen via one medial incision. This
incision allows a complete soft-tissue release and excision
of loose bodies at the olecranon and coronoid fossae.
Preservation of the lateral collateral and annular liga-
ments is advocated by some authors to prevent elbow
instability [6, 7, 16]. Although protection of the lateral
collateral ligament was not attempted in our patients,
instability at the elbow joint did not occur.
Table 1 Characteristics of elbow stiffness patients (frx fracture)
Olecranon frx70/100(−40)/070 Cold
3 50/90(−50)/(−60)30 Infection/
6Tibia frx 80/140(−80)/(−40)100
International Orthopaedics (SICOT) (2007) 31:635–638637
The arc of motion which was obtained at operation
decreased rapidly in the early postoperative period. Elbow
movements were reduced dramatically with the persistent
postoperative rehabilitation. At the 1-year follow-up, the
arc of motion was reduced near to the peroperative values,
but not more.
Some patients may have a life-style which requires full
elbow ROM which explains why our 17 patients stated
dissatisfaction in the postoperative period, even though
they had improved elbow ROM. The postoperative
evaluation criterion should be the restoration of the daily
activities, not patient satisfaction or reduction of elbow
Various modalities are available for the treatment of the
stiff elbow. However, there is no consensus as to which one
is the most useful. We have used the combination of lateral
and medial exposures to explore the whole circumference
of the elbow for the resection of contracted structures. We
have found similar results to those in the literature, but note
that the best approach to the elbow joint is via the
combined lateral and medial approach, which permits
observation of all the contracted structures.
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