The most common complication around the elbow following any type of trauma or surgery is stiffness.
It is not fully understood why the elbow becomes stiff and this stiffness often involves the soft tissues rather than the joint itself. Nowadays we have the technology to release the soft tissue contractures and this has shown us that most of the elbow range of motion can be restored if the joint surface itself is not damaged.
There are two basic types of elbow splints: The first is called a static splint which does not allow the elbow to move. This is typically used for short periods of time after surgery to immobilise the elbow. It can also be used after a fracture.
The second type is a dynamic splint and this can take many forms. Typically there is a hinge at the elbow which allows bending and straightening of the joint but it can also be locked in a bent or straight position.
There are also splints such as turnbuckle splints which allow the hand to be twisted upwards or downwards.
Appropriate use of splints can sometimes avoid the need for further surgery by stretching out the soft tissue around the elbow rather than having to cut out scar tissue.
Morning – out of splint on waking.
8am – 10am splints to bend the elbow.
10am – 12 noon splints to straighten the elbow.
12 noon – 1pm lunch with no splint.
1pm – 3pm splint to bend the elbow.
3pm – 5pm splint to straighten the elbow.
5pm – 6pm dinner with no splints.
6pm – 9pm splints to bend the elbow.
9pm – morning splints to straighten the elbow.
It is important to note that the splinting protocol is not rigid and will be tailored to your needs.
In most instances, physiotherapy for stiff elbows is in the form of exercises and instructions rather than the therapist physically stretching the elbow. If the stretch is done by anyone other than the patient it can cause irritation of the soft tissues around the elbow and further shortening (contractures) of the tissue (and stiffness in itself). You should never experience pain when performing an elbow stretch because the joint will become more inflamed and you will lose motion a few hours later. A feeling of discomfort is permitted and will allow a gradual increase in range of motion over several days. It is best not to let the therapist stretch you because they cannot feel the pain and do not know exactly when to stop.
Splints can be dynamic or static. Dynamic splints usually have some sort of elastic mechanism built into them to allow some movement of the elbow while being stretched the rest of the time.
In my practice I tend to use static adjustable splints or splints which you control yourself to gently “force” the elbow in one direction at a time for an extended period of time.
The patient controls the amount of force applied and the length of time that it is applied, avoiding pain. It will depend on whether the goal is to gain more straightening or more bending of the elbow as to which direction more time is spent in the splint. It takes quite a period of time to get used to the splints and their appropriate use. It will almost certainly require several visits to either the doctor or physiotherapist to check that you are using your splint correctly.
Several Important Points Should be Noted…
- If the splint hurts you, it is probably applied too tightly.
- If the splint is causing pain it will probably not be used.
- A small amount of discomfort is appropriate but extreme pain is not.
- When applying the splint, place it to the point where it does hurt you and then ease the tension off to feel mild discomfort only.
- The splint should be tight enough so that you feel some stretch but you are unlikely to see any effect until you have worn the splint for at least one to two weeks.
- The splint is reapplied (or alternate direction splinting used) repetitively through the day until night time.
- Do not adjust the tension after the first few minutes to allow “stress relaxation” or gentle stretching of the tissues to take place (the engineering term for this is ‘creep’).
- Typically the splint is removed after three to four hours and the elbow moved and used for one hour. During this time it is useful to soak the elbow in warm water to loosen it up after removal of the splint. Ice can be used when initially going back into the splint after having moved it for one hour.
- The brace is worn for a total of eighteen to twenty hours per day if the stiffness is severe.
- Splinting is continued until no improvement in motion is noted over approximately six weeks. This stops a “rebound effect” in which motion loss can take place if the splinting is stopped too rapidly.
It is possible to lose motion in one direction if excessive splinting in the opposite direction takes place. Other problems include but are not limited to: nerve irritation or compression, skin problems from the brace and loss of motion from overzealous use of the splints.
If there is no anatomical problem with the joint and the contracture has been present for less than three months a “functional” range of motion will almost certainly be returned. This is not necessarily full straightening or full bending of the arm but allows full usage of the limb. The results are less reliable if the contracture has been present for three to six months. If the contracture has been present for more than six months the improvements are marginal (If only 10 to 30 degrees of motion is required splinting may be worthwhile but, in most instances, it is not) and surgery is usually required.