Green CH-19

Section 2 •  Elbow

elbow and paresthesias in the ring and small fingers. Uncon- trolled neuritis and neuropathy with associated pain can lead to elbow contracture as well as reflex sympathetic dystrophy and chronic regional pain syndrome (CRPS). Prolonged ulnar compression can also lead to muscle atrophy or wasting of ulnar innervated muscles, including the hand interossei. Pain management techniques, including medication, trans- cutaneous electrical nerve stimulation (TENS), biofeedback, and relaxation techniques may be employed to decrease pain and increase the ability to participate with the therapeutic exercises. The patient is encouraged to use the affected arm for func- tional activities, within protected guidelines, throughout the rehabilitation process. For example, if in a splint, the patient may still be able to use the affected hand as a helper for ADLs. When a patient has a weight limit on lifting, it is still beneficial to use the elbow for unweighted ADLs. Since the function of the elbow is to position the hand for functional activities such as dressing, bathing, and eating, patients are usually highly motivated to progress toward these goals. Authors’ Preferred Protocol Phase 1 (Inflammatory Phase, 0–2 Weeks) (Table 19.1) Goals

Protect the repair Decrease edema Decrease pain

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Figure 19.4  Photograph of posterior elbow custom splint.

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the elbow has enough healing to tolerate strengthening around 8 weeks after surgery. Comminuted coronoid or radial head fractures may need to be protected for a longer duration. Dependent on the amount of soft-tissue trauma, there may be substantial swelling and edema in the first 14 days postop- eratively. Capsular thickening and co-contracture of the bra- chialis muscle develops within days of the injury, leading to restricted movement of the elbow, especially with extension. Edema management can include elevation, retrograde mas- sage, and the use of light compressive dressings and sleeves. Pain also contributes to stiffness and muscle guarding. The therapist needs to distinguish between the normal level of pain associated with the injury and surgery versus pain from nerve irritation. Care must be taken to monitor the ulnar nerve on the medial aspect of the elbow for irritation/instability. Symptoms will include tenderness to palpation of the medial aspect of the

●● Influence scar formation/remodeling ●● Prevent contracture Orthosis

●● Custom-fabricated long-arm orthosis with elbow in 90 ° of flexion and neutral forearm (radial head fracture) or pro- nated forearm (LCL repaired) ●● Hinged elbow brace Exercises ●● Supine AA elbow flexion/extension (forearm in pronation if LCL repaired) ●● AA supination/pronation (supine or seated) ●● AROM/active-assisted range of motion (AAROM) of the wrist ●● Tendon gliding exercises

Table 19.1

Summary of Rehabilitation during Inflammatory Phase

Edema Management

Scar Management

Pain Management

Functional Goal

Protection ROM

HEP

Light use of

Elbow AAROM in protected arc, AROM to unaffected joints

TENS, IFC, ice,

Scar massage,

Elevation,

AAROM in protected arc

Long-arm orthosis; hinged brace

affected hand while wearing protective orthosis

medications as prescribed by physician

silicone sheets, desensitization

retrograde massage, compressive dressings

AAROM = active assisted range of motion, AROM = active range of motion, ROM = range of motion, IFC = interferential current therapy, TENS = transcutaneous electrical nerve stimulation.

180 Postoperative Orthopaedic Rehabilitation

© 2018 American Academy of Orthopaedic Surgeons