Musculoskeletal Imaging • Original Research

Zubler et al.
Osseous Causes of Elbow Stiffness

Musculoskeletal Imaging
Original Research
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Elbow Stiffness: Effectiveness of

Conventional Radiography and CT
to Explain Osseous Causes
Veronika Zubler 1 OBJECTIVE. The purpose of our study was to evaluate the effectiveness of conventional
Nadja Saupe1 radiography and CT for explaining the osseous causes of elbow stiffness.
Bernhard Jost 2 MATERIALS AND METHODS. Two independent readers analyzed loose bodies and
Christian W. A. Pfirrmann1 osteophytes on conventional radiography and CT (or CT arthrography) of the elbow in 94 con-
Juerg Hodler 1 secutive patients (71 men, 23 women; mean age, 41 years; range, 18–68 years). Arthroscopic
or surgical correlation was available in 58 (62%) patients. In all 94 patients, the expected re-
Marco Zanetti1
striction of motion was measured on images and correlated (Pearson’s correlation) with the
Zubler V, Saupe N, Jost B, Pfirrmann CWA, Hodler clinical restriction of motion. Kappa statistics were performed for interobserver agreement.
J, Zanetti M RESULTS. Accuracy for detecting loose bodies was 67% with conventional radiography
and 79% with CT. Differences in accuracy were most pronounced for detecting loose bodies
in the posterior joint space (64% for conventional radiography vs 79% for CT). Accuracy for
detecting osteophytes was 69% with conventional radiography and 76% with CT. Expected
restriction of motion on conventional radiography correlated significantly with clinical re-
striction for only one reader for flexion (R = 0.21, p = 0.04). Expected restriction of extension
on CT correlated significantly with clinical restriction of motion by both readers (R = 0.34
and 0.33, p = 0.001 and 0.001, respectively). Expected restriction of flexion on CT correlated
significantly by one reader (R = 0.24, p = 0.02). Interobserver agreement with regard to de-
tection of both loose bodies and osteophytes was higher for CT (κ = 0.83 and 0.76) than for
conventional radiography (0.64 and 0.60).
CONCLUSION. CT is more effective than conventional radiography in explaining the
osseous causes of elbow stiffness.

Keywords: conventional radiography, CT, elbow
stiffness, restriction of motion
DOI:10.2214/AJR.09.3741
Received September 30, 2009; accepted after revision
December 14, 2009.
1
Department of Radiology, Orthopedic University
Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich,
Switzerland. Address correspondence to V. Zubler
(veronika.zubler@balgrist.ch).
2
Department of Orthopedic Surgery, Orthopedic
University Hospital Balgrist, Zurich, Switzerland.
WEB
This is a Web exclusive article.
AJR 2010; 194:W515–W520
0361–803X/10/1946–W515
© American Roentgen Ray Society
E
lbow stiffness can be caused by
osseous or soft-tissue abnormali-
ties that may be located either
within the joint or outside of the
joint. Intraarticular causes include posttrau-
matic arthritis, joint incongruity, ankylosis of
articular surfaces, articular adhesions, loose
bodies, and osteoarthritis with bone spurs and
proliferative synovitis. Extraarticular causes
include heterotopic bone formation, capsular
thickening, and musculotendinous contrac-
ture [1]. Soft-tissue abnormalities (e.g., syno-
vitis, insertion tendinopathies, and collateral
ligament lesions) are preferably evaluated by
ultrasound or MRI [2]. Soft-tissue abnormali-
ties frequently can be treated conservatively,
whereas osseous abnormalities, such as loose
bodies, osteophytes, or joint incongruity, are
more commonly treated by arthroscopy or
open surgery [3–5]. Osseous abnormalities in
elbow stiffness are most commonly clarified
by radiography and CT.
Conventional radiography is still the pri-
mary step in the evaluation of elbow stiffness
[6]. CT or CT arthrography is generally con-
sidered by radiologists to be more accurate
for evaluation of loose bodies than conven-
tional radiography. However, controversy ex-
ists [7–9]. Canadian orthopedic surgeons
concluded in 2005 that neither CT arthrogra-
phy nor MRI is reliable or more accurate than
conventional radiography alone to detect
loose bodies in patients with elbow stiffness
[10]. To our knowledge, even less evidence
exists as to whether CT is at all more effec-
tive than conventional radiography in evalu-
ating the osseous causes of elbow stiffness.
The technologic advance of MDCT in the
last decade with the possibility of excellent
secondary reformations caused the assump-
tion that CT may be superior to conventional
radiography in explaining osseous causes of
elbow stiffness. Thus, the purpose of this in-
vestigation was to evaluate the effectiveness

AJR:194, June 2010 W515

 Zubler et al.

of conventional radiography and CT for ex- views of the elbow (sitting patient, arm 90° elevat- matrix, 150; thickness, 0.67; increment, 0.33; win-
plaining the osseous causes of elbow stiffness. ed, elbow flexion 90° [if possible], beam orientation dow center, 450; and window width, 2,000. Trans-
from radial to ulnar). Intraarticular contrast medi- versal, coronal, and sagittal reformations were per-
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Material and Methods um was injected in a standardized fashion. CT was formed (thickness, 2.0; increment, 2.0). Patients
Patient Population performed on a Somatom Plus 4 scanner (Siemens were examined in the prone position with the arm
Two hundred seven consecutive patients re- Healthcare) (57 of 94, 61%) and on a Brilliance CT extend if possible over the head and the forearm as
ferred for CT or CT arthrography of the elbow be- 40 scanner (Philips Healthcare) (37 of 94, 39%) extended as far as possible. Thirty-seven patients
tween September 2004 and September 2008 were The imaging parameters were ultra high resolu- (37/94, 39%) underwent standard CT and 57 pa-
identified in our PACS system. Patients older than tion; 120 kV; 150 mAs; collimation, 20 × 0.625; tients (57/94, 60%) underwent CT arthrography.
18 years were included in the study when conven-
tional radiography was performed within 100 days
before or after CT without any elbow surgery in
between. Patients were excluded when image qual-
ity was nondiagnostic (motion artifact, absence of
secondary reformation, n = 3), in the presence of
a tumor (n = 12), after a recent fracture or dislo-
cation (within 6 months before CT) (n = 13), pres-
ence of an elbow prosthesis (n = 6), hemophiliac
arthropathy (n = 2), posttraumatic pseudoarticula-
tion of the humerus (n = 2), severe posttraumatic
deformity of the joint (n = 4), extensive osteosyn-
thesis material (n = 2), ankylosis of the joint (n =
2), and spasm of the triceps muscle caused by a
birth defect (brachial plexus damage) (n = 1).
The final study group consisted of 94 patients
(71 men and 23 women [mean age, 41 years; range,
18–68 years]). Thirty-seven patients (37/94, 39%)
underwent standard CT, and 57 patients (57/94,
61%) underwent CT arthrography. Fifty-eight of
the 94 patients (62%) underwent surgery within A B
190 days (mean, 43.4 days; range 0–190 days) af-
ter CT. Twenty-eight of these 58 (48%) underwent
open surgery; 27 of 58 (47%), arthroscopy; and
three of 58 (5%), implantation of a prosthesis. Sur-
gery and arthroscopy included débridement, re-
section of osteophytes, removal of loose bodies,
releasing of fibrosis, resection of plicae, neurolysis
of the ulnar nerve, and the Outerbridge-Kashiwa-
gi procedure. In each patient, only one elbow was
evaluated (34 left elbows, 60 right elbows). The
mean interval between conventional radiography
of the elbow and CT or CT arthrography was 32
days (range, 0–98 days). Our institutional review
board does not require approval or informed con-
sent for the retrospective review of patient records
or images. However, patients’ rights are protected
by a law that requires that they must be informed
that their charts and images might be reviewed for
scientific purposes and that grants patients the op-
portunity to forbid such use of their data. All pa-
tients agreed to the use of their data. C D
Fig. 1—26-year-old man with clinically 20° restriction of extension and 25° restriction of flexion.
Conventional Radiography, CT, and A, Lateral conventional radiograph obtained anteriorly in fossa coronoidea shows apparent small osteophyte
CT Arthrography (arrow). Not clearly visible are osteophytes in fossa olecrani and loose body.
Conventional radiographic assessment includ- B, Transverse CT image shows large osteophytes (arrowheads) in fossa coronoidea and fossa olecrani.
C and D, Sagittal CT reformation image (C) shows osteophytes in fossa coronoidea and fossa olecrani and
ed anteroposterior views (sitting patient, arm 90°
loose body in anterior aspect of joint. Diagram (D) shows angles formed with rays connecting maximal extent
elevated, elbow extended (if possible), wrist supi- of loose bodies (a1) or osteophytes (b1 [anterior], b2 [posterior]) to center of capitulum humeri. By adding these
nated, beam orientation anteroposterior) and lateral measured angles, degree of compromise was estimated separately for flexion and extension.

W516 AJR:194, June 2010

 Osseous Causes of Elbow Stiffness

For CT arthrography, 1 mL of local anesthetic

(mepivacain hydrochloride 2%, Scandicain, As-
traZeneca) and a mean of 6 mL of iodinated con-
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trast agent (iopamidol, 200 mg/mL, Iopamiro 200,

Bracco), were injected under fluoroscopic control.
The delay between the injection and CT was less
than 15 minutes.

Evaluation of Images
Both conventional radiography and CT or CT
arthrography were evaluated independently by
two experienced musculoskeletal radiologists
with 15 and 4 years of professional experience in
musculoskeletal radiology. After separate read-
ing, a consensus was reached. The readers were
blinded to the clinical findings.
The readers evaluated the presence of osseous
abnormalities potentially restricting flexion or ex-
tension using the anteroposterior and lateral views
A B
from conventional radiography and the transversal,
coronal, and sagittal reformations from the CT.
These abnormalities were categorized as calcified
loose bodies (located anteriorly and/or posteriorly)
and osteophytes (anterior, posterior, humeral, ulnar,
and/or radial). On images, the expected restriction
of motion caused by osseous structures (loose
bodies and/or osteophytes) was assessed. A circle
was drawn with the center in the capitulum humeri
on the conventional lateral radiograph or sagittal
CT reformation. Loose bodies and osteophytes
within this circle hampering the normal flexion
and extension were noted. Angles (a, b, and c) were
formed with rays connecting the maximal extent
of the loose bodies (a) or osteophytes (b and c) to
the center of the capitulum humeri. By adding
these measured angles, the degree of compromise
was estimated separately for flexion and extension
(Figs. 1–3). We used following formulas:

a1 + b1 + c1 = restriction of flexion,
a2 + b2 + c2 = restriction of extension
with angles measured in degrees. In the formulas, a1 =
angle restricted by loose bodies in the anterior aspect
of the joint; b1 = angle restricted by humeral osteo-
phytes in the anterior aspect of the joint; c1 = angle
restricted by ulnar and/or radial osteophytes in the
anterior aspect of the joint; a2 = loose bodies in the
posterior aspect of the joint; b2 = humeral osteophytes
in the posterior aspect of the joint; and c2 = ulnar ra-
dial osteophytes in the posterior aspect of the joint.
Standard of Reference
The standard of reference of the diagnostic ac-
curacy for loose bodies and osteophytes was ar-
throscopy (27/58, 47%) and open surgery (31/58,
53%). The standard of reference for expected re-
striction of motion determined on images was the
clinical restriction of motion in all 94 patients. The
C D
Fig. 2—60-year-old man with restriction of extension (15°) and restriction of flexion (5°).
A and B, Similar to Fig. 1, on lateral conventional radiograph, osteophyte in anterior aspect of humerus (arrow,
A) is suspected. It was not seen in anteroposterior view.
C and D, CT images correspond better with minimal restriction of motion of 5° produced by small osteophyte in
radial aspect of humerus (arrow, D). Fossa coronoidea, however, is completely free (arrowheads, C and D).
clinical restriction of motion was measured by or- 0.60 indicate moderate, 0.61–0.80 substantial, and
thopedic residents with a handheld goniometer. 0.81–1.00 almost perfect agreement. All analyses
were performed with statistical software (SPSS for
Statistical Analysis Windows, release 16.0.1, SPSS). A p value < 0.05
Sensitivity, specificity, and accuracy were cal- was considered statistically significant.
culated for the diagnosis of loose bodies and os-
teophytes at the various sites. Pearson’s correla- Results
tion was calculated between restriction of motion Diagnostic Accuracy for Detecting Loose
as expected on images and restriction of motion Bodies and Osteophytes
measured clinically. For assessing interobserver Accuracy for detecting loose bodies was
agreement, kappa values were calculated. Accord- 67% with conventional radiography and 79%
ing to Landis and Koch [11] kappa values of 0.41– with CT (Table 1). Sensitivity and specificity

AJR:194, June 2010 W517

 Zubler et al.

ly evaluated. The outlier could be explained

by a pseudarthrosis in the proximal humeral
shaft that was not visible on conventional ra-
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diography and CT images and that produced

a restriction of motion due to extreme pain.
Expected restriction of motion in the lat-
eral view on conventional radiography cor-
related significantly with clinical restriction
by one reader for flexion (R = 0.21, p = 0.04)
but not for the other measurements (exten-
sion, reader 1; flexion and extension, reader
2). Expected restriction of extension on CT
in the sagittal reformations correlated signif-
icantly with clinical restriction of motion by
both readers (R = 0.34 and 0.33, p = 0.001
and 0.001). Expected restriction of flexion
on CT in the sagittal reformations correlat-
ed significantly for one reader (R = 0.24, p =
0.02) (Tables 2 and 3).
A B
Interobserver Agreement
Conventional radiography—Interobserv-
er agreement for detection of loose bodies
on conventional radiography was substan-
tial overall (0.64) and in the anterior aspect
(0.67) but moderate in the posterior aspect
(0.53). Interobserver agreement for detection
of osteophytes was moderate or substantial at
the various sites: anterior, 0.6; posterior, 0.69;
humeral, 0.56; ulnar, 0.73; and radial, 0.58.
CT—Interobserver agreement for detec-
tion of loose bodies on CT was almost per-
fect: 0.83 (anterior, 0.86; posterior, 0.83).
Interobserver agreement for detection of os-
teophytes was substantial or almost perfect
at the various sites (anterior, 0.72; posterior,
0.73; humeral, 0.76; ulnar, 0.67; and radial,
0.8) (Table 4).

Discussion
C D
Our study shows that CT is more effec-
Fig. 3—66-year-old man with osteoarthritis of elbow; 25° restriction of flexion and 35° restriction of extension tive than conventional radiography for evalu-
were measured clinically.
A and B, Conventional radiographs show large anteriorly located loose body (arrow, A), explaining restriction of ating the osseous causes of elbow stiffness.
motion. The 35° restriction of extension was not completely explained by radiographs. The higher effectiveness of CT is based on
C and D, CT images show osteophytes in fossa olecrani (white arrowheads), main cause of restriction of better detection of loose bodies and osteo-
extension, and osteophytes in fossa coronoidea (black arrowheads). Restriction of motion is also explained by
phytes. Loose bodies and osteophytes in the
osteophytes in ulna (arrows, C). Large loose body on CT is shown in transverse CT image (arrow, D).
anterior and posterior joint space, especial-
ly in the fossa coronoidea and in the fossa
were 86% and 48% for conventional radiog- CT (sensitivity 81%, specificity 63%). Differ- olecrani, are often invisible on conventional
raphy and 93% and 66% for CT. Differenc- ences in accuracy were most pronounced for radiography. Such osteophytes in the fossae
es in accuracy were most pronounced for de- humeral osteophytes (accuracy 65% conven- may play an important biomechanical role.
tecting loose bodies in the dorsal joint space tional radiography vs 76% for CT, sensitivity The humeroulnar joint is a classical hinged
(accuracy, 64% for conventional radiography 41% vs 84%, and specificity 96% vs 65%). joint with one plane of motion in the flexion
vs 79% for CT; sensitivity, 60% vs 90%; and and extension direction. Therefore, any os-
specificity, 66% vs 74%). Restriction of Motion Measurements seous obstacle restricts motion.
Accuracy for detecting osteophytes was One single outlier was detected on corre- For therapy, loose bodies and osteophytes
69% with conventional radiography (sensi- lation plots and then removed for analysis. in the fossa olecrani and coronoidea are pref-
tivity 62%, specificity 87%) and 76% with Thus, 93 patients instead of 94 were final- erably removed by débridement, either by

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 Osseous Causes of Elbow Stiffness

TABLE 1:  Diagnostic Accuracy in Percentages of Conventional Radiography and CT for Loose Bodies and Osteophytes
No. of Findings
True-Positive True-Negative False-Positive False-Negative Sensitivity (%) Specificity (%) Accuracy (%)
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Parameter Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT Radiography CT

Loose bodies 25 27 14 19 15 10 4 2 86 93 48 66 67 79
Anterior 16 17 26 29 12 9 4 3 80 85 68 76 72 79
Posterior 12 18 25 28 13 10 8 2 60 90 66 74 64 79
Osteophytes 26 34 14 10 2 6 16 8 62 81 87 63 69 76
Anterior 18 28 21 15 1 7 18 8 50 78 95 68 67 74
Posterior 18 29 19 12 3 10 18 7 50 81 86 55 64 71
Humeral 13 27 25 17 1 9 19 5 41 84 96 65 65 76
Ulnar 22 30 16 11 1 6 19 11 54 73 94 65 65 70
Radial 7 14 40 38 2 4 9 2 44 88 95 91 81 90

TABLE 2: Correlation Between Restrictions of Motion Measurements With coronoid process through a posterior incision
Clinical Restriction and a hole is trephined through the olecranon
Conventional Radiography CT fossa in the distal humerus to allow access to
the anterior part of the elbow joint [14].
Reader Extension Flexion Extension Flexion
The use of CT in musculoskeletal radiol-
1 p = 0.13, R = 0.16 p = 0.28, R = 0.11 p = 0.001, R = 0.34 p = 0.02, R = 0.24 ogy has increased in recent years because of
2 p = 0.43, R = 0.08 p = 0.04, R = 0.21 p = 0.001, R = 0.33 p = 0.06, R = 0.19 the availability of high-resolution reforma-
Note—R = Pearsons`s correlation factor, Conv. radiographs = conventional radiographs. Bold indicates tions associated with MDCT. MDCT refor-
statistical significance. (p < 0.05). mations are widely used in musculoskeletal
radiology after acute bone trauma and post-
TABLE 3:  Restriction of Motion Measurements operatively after arthrodesis and spondylod-
esis [15, 16]. Our study emphasizes that CT is
Conventional Radiography CT
Handheld also useful for assessing loose bodies and os-
Goniometer Reader 1 Reader 2 Reader 1 Reader 2 teophytes in the elbow. The sagittal reforma-
Type of Motion Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) tions seem to be most important, given that
Flexion (°) 18 (20) 16 (17) 21 (18) 19 (17) 19 (18) quantitative assessment of restriction of flex-
ion and extension can be performed only in
Extension (°) 21 (15) 17 (17) 16 (19) 20 (18) 23 (21)
the sagittal imaging plane. Moreover, sagit-
tal reformations resemble conventional later-
TABLE 4:  Interobserver Agreement Results al tomograms. Before CT was available with
Conventional Radiography CT high-resolution reformations, conventional
lateral tomography was a preferred imaging
Parameter κ κ
technique by many elbow surgeons for as-
Loose bodies 0.64 0.83 sessing mechanical elbow stiffness [17].
Anterior 0.67 0.86 On sagittal reformations, the quantitative
Posterior 0.53 0.83 restriction of motion caused by the loose
bodies or osteophytes can be estimated by
Osteophytes 0.60 0.76
the method shown in this article. Our ortho-
Anterior 0.59 0.72 pedic surgeons are comfortable when they
Posterior 0.69 0.73 can correlate the restriction of motion on
Humeral 0.56 0.76 images with the restriction of motion mea-
sured in their patients before surgical in-
Ulnar 0.73 0.67
tervention. Admittedly, CT allows only a
Radial 0.58 0.80 gross radiologic estimation of the restric-
tion of motion. Soft-tissue abnormalities
open surgery or by arthroscopy. Open dé- combined medial and lateral approaches. rather than osseous abnormalities may be
bridement of the anterior and posterior com- A classical surgical technique is the Outer- responsible for restriction of motion as well.
partments of the elbow can be performed ei- bridge-Kashiwagi procedure. When this pro- Thus, theoretically a patient can suffer from
ther directly through a single posterior [12] cedure is performed, loose bodies and osteo- a considerable restriction of motion caused
or a single lateral approach [13] or through phytes are removed from the olecranon and by scars or a hypertrophic synovial plica

AJR:194, June 2010 W519


[18]. On the other hand, although such soft-
tissue abnormalities can be seen with MRI
[19, 20], we have not found any data report-
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ing the correlation of such findings (plicae,
scars) with elbow stiffness.
Our results contradict somewhat the re-
sults from a previous study [10] in which CT
arthrography and MRI were found not to be
more effective than conventional radiography
[10]. Dubberley et al. [10] found relatively
high sensitivities (88–100%) for the detection
of loose bodies with MRI and CT arthrogra-
phy but relatively low specificities of between
20% and 70%. Radiography had a similar
sensitivity and specificity of 84% and 71%.
One reason our study showed higher effec-
tiveness of CT over conventional radiogra-
phy may be related to the different CT tech-
nique. Dubberley et al. used double-contrast
CT arthrography and we used single-contrast
CT arthrography. Moreover, Dubberley et al.
used a section thickness of 1 mm, whereas
we used a section thickness of 0.67 mm, and
finally, they did not have our measurement
method to assess the expected restriction of
motion caused by osseous structures.
Our study had a number of limitations.
The retrospective study design is associ-
ated with an inhomogeneous study popula-
tion. However, the consecutive study inclu-
sion criteria guaranteed an unselected wide
range of abnormalities. The retrospective
study design may partially explain why the
accuracies were relatively low. We retrospec-
tively used the available arthroscopic reports
or surgical reports, but the surgeons them-
selves were not specifically asked to report
findings (e.g., osteophytes) as would have
been done in a prospective study. The rela-
tively low specificity and high false-positive
results for osteophytes on CT images may be
explained by the use of arthroscopy as stan-
dard of reference. Tiny osteophytes can be
probably missed during arthroscopy.
The absence of surgical correlation in
38% patients represents a limitation of the
study, but the overall number of patients
(58) with surgical correlation is still substan-
tial. A further limitation of our study is that
60% of the patients underwent CT arthrog-
W520 AJR:194, June 2010
Zubler et al.
raphy, whereas 40% underwent CT without
intraarticular contrast medium. The question
as to whether or not CT arthrography is su-
perior to conventional CT for loose bodies
is still controversial [7, 10, 21]. This contro-
versy is reflected by the referrals of patients
to our department for imaging for whom CT
and CT arthrography were requested for the
same clinical problem.
In summary, our study shows that CT is
more effective than conventional radiogra-
phy for evaluation of osseous elbow stiffness
on the basis of higher accuracy and higher
interobserver agreement for detecting loose
bodies and osteophytes, especially when
they are located in the fossa coronoidea or
fossa olecrani. Differences in accuracy be-
tween CT and conventional radiography are
most pronounced for detecting loose bodies
in the posterior joint space. Therefore, the
highest gain of diagnostic information with
CT can be expected in patients with restrict-
ed extension. Finally, our study presents a
CT measurement method that allows the pre-
diction of the clinical restriction of motion to
a certain degree.
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