Green CH-19

Section 2 •  Elbow

therapist’s opposite hand distracts the ulna and pro- vides a scooping motion. The patient performs self-mobilizations at home by placing a small rolled-up towel in the elbow crease and applying force to the distal ulna. c. Proximal radioulnar mobilizations to increase forearm rotation. The therapist will perform a volar medial glide to increase supination or a dorsolateral glide to increase pronation. Alternating isometrics are performed to increase joint proprioception, followed by AROM exer- cises, such as card flipping or rotation with a hand-held dowel or light hammer. 5. Grip and Wrist Strengthening: Putty squeezes or light wrist weights 6. Soft-Tissue Mobilization/Scar Management Retrograde massage can continue as long as there is edema present in the area. Patients often continue to wear the elas- tic compression sleeve for 3 to 4 weeks after the orthosis has been discontinued. The patient is instructed to per- form scar massage twice daily using vitamin E or cocoa butter. If there is hypertrophic scar, a silicone scar sheet can be used. Scar sensitivity may require desensitization techniques using various textures or immersing the arm in particles (Fluidotherapy  ). Complications Persistent pain, warmth and edema accompanied by a decrease in ROM may signal heterotopic ossificans. Pain, edema, stiff- ness in fingers, and skin discoloration may signal CRPS. Phase 3: Scar Maturation and Fracture Consolidation (Approximately Weeks 8–6 Months) (Table 19.3) Goals ●● Increase endurance ●● Return to functional activities, including recreation and work Orthosis ●● Static-progressive or dynamic splinting, as needed, to achieve end-range motion (especially elbow extension and supination) Exercises ●● AROM/AAROM/PROM, no restrictions ●● Strengthening: Graded progressive resistive exercises with weights or resistance band ●● Closed-chain activities ●● Plyometrics ●● Functional/work simulation Phase 3: Range of Motion At this phase, AROM and PROM, including composite move- ments, are allowed. Passive stretching and joint mobilizations may be employed to increase ROM in areas of limitations. If ●● Maximize ROM Increase strength ●●

Figure 19.11  Photograph of supination strap stretch, which can be used to improve forearm rotation.

3. AROM/AAROM forearm: keeping the elbow at 90 ° of flex- ion Patient performs active pronation/supination seated at a table with the forearm supported. A weighted dowel or hammer can be used to provide stretch at end range. AA manual stretch can be performed with the patient using the uninvolved hand to provide the rotatory force. Also, a neoprene strap can be utilized to maintain the forearm in end-range supination with a low-load prolonged stress to the tissues (Figure 19.11). This is a simple, convenient way for patients to perform this stretch. If tissues do not respond to the strap (hard end feel), static-progressive or dynamic supination orthoses may be used. 4. Joint Mobilizations a. Ulnahumeral distraction to increase elbow exten- sion. Patient lies supine with the elbow in a loose packed position, which is the position of maximal joint compression. The distal humerus is stabilized by one of the therapist’s hands (or with a Mulligan belt [Mulligan Mobilisation Belt  ]) while the opposite hand applies the distracting force 45 ° to the ulnar diaphysis. As the patient gains increased elbow extension, the therapist must vary the angle of the applied force (see Figure 19.7). Alternating isometrics are performed following the joint mobilizations to increase joint pro- prioception. The patient then actively uses the arm through the newly available ROM. b. Ulnahumeral distraction to increase elbow flexion. The distal humerus is stabilized by the therapist while the

184 Postoperative Orthopaedic Rehabilitation

© 2018 American Academy of Orthopaedic Surgeons