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OCS prep > Elbow APTA (2) > Flashcards

Elbow APTA (2) Flashcards

1
Q

If a pt has varus instability, which structure is primarily compromised?

A
  • RCL
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2
Q

What are the 3 primary scenarios that could generate varus instability?

A
  • simple or complex dislocation
  • varus elbow stress
  • iatrogenic causes
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3
Q

What are 2 potential causes of varus instability that could result from relative repetitive stress?

A
  • chronic overuse due to significant weightbearing through the UE; e.g., crutch use
  • postural deformity; cubitus varus deformity. Could occur following childhood fx or be congenital
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4
Q

Is corticosteroid injection concerning for generating varus instability?

A
  • yes
  • there are cases of posterolateral rotational instability that followed lateral epicondylitis treatment managed with injection
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5
Q

What is the typical cause of a varus posteromedial rotary instability?

A
  • elbow subluxation that avulses portions of the RCL, or the RCL in its entirety from the lateral epicondyle and fractures the anteromedial tip of the coronoid.
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6
Q

A pt presents with lateral elbow pain following a traumatic subluxation. What may be of concern?

A
  • varus posteromedial rotary instability, or RCL avulsion
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7
Q

What is a standard presentation for pts with long-standing varus posteromedial rotary instability?

A
  • clicking/popping with flexion/extension

- aggravation of symptoms with attempts to abduct the arm

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8
Q

What is preferred management for varus posteromedial rotary instability?

A
  • surgery; usually ORIF

- typically poor outcomes with nonoperative management

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9
Q

What are the general rehab considerations post-op stabilization for varus posteromedial rotary instability?

A
  • stability and alignment are key to successful outcomes
  • shoulder abduction should be avoided for at least the first 4 weeks
  • should be careful with force transmission through the elbow at >60* flexion to support the healing of the coronoid px
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10
Q

What is the expected mechanism of injury for a posterolateral rotary instability?

What is happening anatomically?

A
  • combination of axial compression, valgus stress, and supination
  • the ulna supinates or ER away from the trochlea, subluxing the humeroulnar and humeroradial joints, rather than a radial head dislocation
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11
Q

What is the typical pt presentation with a posterolateral rotary instability?

A
  • vague elbow discomfort, lateral elbow pain
  • clicking/snapping/clunking with supination
  • “something not right” with elbow extension with supination
  • giving way with loaded elbow flexion with supination
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12
Q

What is the common differential dx with a posterolateral rotary instability?

A
  • RCL insufficiency
  • lateral epicondalgia/tendinopathy
  • radial tunnel syndrome
  • cervical spine referral
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13
Q

What are common dx that may be secondary to a posterolateral rotary instability?

A
  • lateral tendinopathy

- neural inflammation

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14
Q

What are primary considerations to nonoperative management of posterolateral rotary instability?

A
  • hinged elbow brace with forearm in supination to protect healing structures (more likely w/ acute injury) for 4-6 weeks
  • avoidance of shoulder abduction and IR when performing elbow flexion/extension exercise
  • little literature support for strengthening exercise, although conceptually it makes sense to strengthening secondary supports
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15
Q

What are typical causes of ulnar (medial) collateral ligament insufficiency?

A
  • traumatic valgus stress (FOOSH)

- insidious onset/overuse (overhead throwing athletes)

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16
Q

What portion of the UCL is most vulnerable to valgus loading?

A
  • anterior portion
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17
Q

Valgus force is greatest at the elbow during which phases of the throwing motion?

A
  • cocking/late cocking to the acceleration phase
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18
Q

What test is appropriate to screen for varus posteromedial rotary instability? How is it performed?

A
  • Gravity assisted varus stress test
  • seated/standing w/ shoulder in 90* active abduction. Pt actively flexes/extends elbow. Positive with reproduction of symptoms such as clicking/grinding/popping, or pain
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19
Q

What is a major drawback for the lateral pivot shift test?

A
  • pts usually need to be under anesthesia. This is a dumb test.
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20
Q

What does the lateral pivot shift test for? What is the general sequence of motions?

A
  • tests for posterolateral rotary instability
  • pt in supine, shoulder flexed past 90, elbow in extension. Therapist axially compresses towards humerus, provides valgus/supination force while flexing elbow. Elbow subluxes at ~40-70, then reduces with further flexion
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21
Q

What are 3 tests other than the lateral pivot shift that are appropriate to screen for posterolateral rotary instability?

A
  • push-up sign
  • chair sign
  • press up maneuver
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22
Q

What test is appropriate to screen for RCL insufficiency? How is it performed?

A
  • varus stress test
  • Elbow in full extension, then flexed between 5-30*. Therapist applies varus force at varying angles. Positive if increased laxity compared to contralateral side.
  • not sensitive enough for posterolateral rotary instability. Really only sensitive enough to pick up stage II disruption or > of the RCL
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23
Q

When would it be expected to begin rehab for post-op posterolateral rotary insufficiency repair?

A
  • probalby not earlier than 2 weeks. First two weeks the elbow is immobilized.
  • however, can still do shoulder isometrics, manual work, or modalities
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24
Q

What angle would the elbow be immobilized in for the first two weeks following post-op posterolateral rotary insufficiency?

A
  • 45-90* flx in neutral or slight pronation
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25
Q

When can a pt expect to get rid of their brace following posterolateral rotary instability repair?

A
  • ~8 weeks. Will be progressively increasing extension from week 2-8. Brace typically has a block for extension.
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26
Q

When can a pt expect to begin strengthening exercise at the elbow following posterolateral rotary instability repair?

A
  • ~10 weeks, depending on pt’s symptoms

- may wait until week 16.

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27
Q

When can a pt expect to return to sports following posterolateral rotary instability repair?

A
  • 16 weeks at the earliest. May be up to 9 months.
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28
Q

When is normal ROM expected following posterolateral rotary instability repair?

A
  • ~8 weeks
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29
Q

What are the primary movements to avoid/be careful with during posterolateral instability repair recovery?

A
  • extension and supination
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30
Q

What is standard differential dx for UCL insufficiency?

A
  • medial tendinopathy
  • posteromedial impingement by ulnohumeral compression
  • radiocapitellar overload syndrome
  • elbow OA
  • ulnar neuritis
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31
Q

Would a pt w/ UCL insufficiency describe more instability in pronation or supination?

A
  • pronation; flexors relatively become lax, so lose a bit of secondary stability
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32
Q

How long is the elbow immobilized following RCL repair?

A
  • typically up to 2 weeks
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33
Q

When can a pt expect to start AROM following RCL repair?

A
  • ~4 weeks
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34
Q

Can joint mobs be done 4 weeks out following RCL repair?

A
  • yes, per this protocol; but only grade I or II for pain. I wouldn’t.
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35
Q

When is a pt expected to have normal ROM following RCL repair?

A
  • by 12 weeks
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36
Q

When can strengthening at the elbow begin following RCL repair?

A
  • 12 weeks; initially the elbow flexors with the forearm in pronation for the first 2 weeks
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37
Q

When can a pt expect to return to sport following RCL repair?

A
  • 16 weeks to 9 months
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38
Q

What is the mechanism that creates valgus extension overload syndrome?

A
  • compression of the olecranon against the humerus with valgus stress, generating a posteromedial impingement
  • associated with “tremendous” forces acting on the elbow especially into hyperextension
  • often associated with throwing athletes
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39
Q

What can a clincian expect for presentation with valgus extension overload syndrome for:

  • PROM
  • AROM
A
  • PROM: limited extension, flexion contraction and painful combined pronation, valgus force, and extension
  • AROM: painful extension
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40
Q

What complications may be associated with a valgus extension overload syndrome?

A
  • locking/catching

- suggestive of chondromalacia, osteophytes, or loose bodies

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41
Q

What is appropriate management for valgus extension overload syndrome?

A
  • rest, NSAIDs, initially
  • then correction of throwing mechanics; shoulder, core, etc
  • local strengthening may target eccentrics for elbow flexors, and progressive power for triceps
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42
Q

What syndrome may occur as a result of UCL insufficiency?

A
  • radio-capitellar overload syndrome (lateral compression injury)
  • chronic abutment of radial head against the capitellum
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43
Q

What is typical presentation for a pt w/ a lateral compression injury?

A
  • TTP at radial head or tip of distal lateral humerus
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44
Q

What is a potential complication from a chronic lateral compression injury?

A
  • in adults, chondromalacia, cartilage/bony degeneration

- in kids, osteochondritis dessicans

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45
Q

What is the biggest risk factor for child/adolescent development of “little leaguer’s elbow”?

A
  • number of pitches thrown
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46
Q

When is operative management of a UCL injury usually required?

A
  • in conjunction with a displaced fx.

- if non-displaced fx, usually managed non-operatively

47
Q

What is the test with the best statistics when screening for UCL insufficiency?

A
  • moving valgus stress test (spec: 1.0, sens: .75); others don’t have validity research behind them
  • pt upright with shoulder in 90* abduction and elbow maximally flexed. Add modest valgus torque to elbow until end range ER, then quickly extend to ~30* of elbow flexion
  • positive if medial elbow pain is reproduced AND maximal pain is between 120-70* elbow flexion
48
Q

What ROM should produce maximal provocation of symptoms during the moving valgus stress test?

A
  • 120-70*
49
Q

What is execution of the valgus stress test? What is it best for screening?

A
  • elbow in full extension, then 5-30* flexion with modest valgus force. Assessing gapping/pain on the medial elbow. Compare laxity to CL side.
  • best for assessing insufficiency of the anterior band of the UCL.
50
Q

Why is the position of slight flexion used for varus/valgus stress tests?

A
  • slight elbow flexion reduces the influence of bony stabilizers and the capsule for stability
51
Q

What are the outcomes for pts with non-operative management of UCL rupture?

A
  • fairly successful for non-athletes
  • throwing athletes may not return to prior levels of competition depending on the severity of injury with non-operative management
52
Q

In general, what is agreed upon as an important factor for elbow instability rehab?

A
  • shoulder strengthening…sweet

- another significant component mentioned throughout the chapter is core stability/integrated mechanics

53
Q

What ROM limitation in baseball pitchers was associated with elbow symptoms?

A
  • limited IR >25*. When addressed, improved elbow symptoms
54
Q

A “Tommy Johns” surgery is a reconstruction of what ligament?

A
  • UCL
55
Q

What’s the difference between a primary repair of the UCL and a reconstruction?

A
  • primary repair uses the existing UCL

- reconstruction is Tommy Johns, or updated variant using the flexor-pronator mass

56
Q

What is the expectation for ROM immobilization following UCL reconstruction?

A
  • likely first 2 weeks, with hinged brace to faciltiate gradual ROM increases afterward
57
Q

How soon can a pt begin strengthening after a UCL reconstruction? When can they expect to begin throwing again? Return to sport?

A
  • 4-6 weeks post-op
  • interval throwing won’t begin until at least 4 months post-op
  • return to sport is 9-12 months post-op
58
Q

The elbow is the _____ most commonly dislocated joint in adults.

A
  • 2nd
59
Q

What is the most common direction for elbow dislocation?

A
  • posterolateral or posterior
60
Q

What is the most common mechanism of elbow dislocation?

A
  • FOOSH
61
Q

What are some concerns to screen for with an elbow dislocation?

A
  • fracture

- nerve injury

62
Q

What nerve(s) are most injured with a simple dislocation vs a complex dislocation?

A
  • simple: ulnar and median

- complex: radial

63
Q

A pt comes in following what was dx’d as a simple elbow dislocation, which was reduced in the ED, but they’re still having some discomfort. A recent radiograph shows a ulnohumeral distance of 5mm. Is this a concern?

A
  • simple elbow dislocation is managed non-operatively, and typically reduced in the ED.
  • an ulnohumeral distance of >4mm is indicative of continued elbow instability
64
Q

What are the considerations for bracing vs mobilization following simple elbow dislocation?

A
  • for a stable elbow joint, bracing would be inappropriate, and immediate functional mobility is recommended
  • if unstable, a brace or cast could be appropraite, but immobilization for >14 days increases the risk of stiffness
65
Q

For simple dislocations that are stable after reduction, what is the expected timeline for progression of activities?

A
  • immediate mobilization is typically appropriate, with sling use as necessary
  • aerobic exercise involving the UE can begin ~4 days later
  • strengthening can begin 7 days later
  • recommendations based on military population
66
Q

With a disloaction where there is continued instability, what are the expectations for ROM?

A
  • will limit elbow extension to ~60, increasing by 10 each week
67
Q

What would you want to see prior to beginning strengthening following a simple dislocation with instability?

A
  • full ROM
68
Q

With an RCL deficient elbow, ________ of the forearm should increase stability, while with a UCL deficient elbow, _______ of the forearm should increase stability.

A
  • pronation for RCL deficient

- supination for UCL deficient

69
Q

How soon should you be worried about deficient ROM following a simple dislocation? What is recommended?

A
  • would want to see normal ROM within 6 weeks

- can use a hyperextension elbow brace for 9 months to a year at night

70
Q

What is the focus of rehab following operative management of a simple dislocation?

A
  • focus is to protect healing structures

- ROM can begin w/in 7-10 days in protected postures

71
Q

What are outcomes like following simple dislocation?

A
  • typically very good. 95% return to previous occupations
72
Q

What defines a complex elbow dislocation?

A
  • extensive soft tissue injury in addition to a fracture
73
Q

What is the “terrible triad” of a complex elbow dislocation?

A
  • elbow dislocation
  • radial head fx
  • coronoid fx
74
Q

What is standard treatment for a complex elbow dislocation?

A
  • reduction
  • fx fixation
  • establishing a stable arc of motion (60*-full flx)
  • if unable to establish the stable arc of motion, other procedures such as ligament repair/reconstruction need to happen
75
Q

What 3 things would raise suspicion of elbow fx?

A
  • hx of trauma
  • fat pad sign (effusion over the posterior aspect of the elbow)
  • inability to fully extend the elbow
76
Q

With a complex fx, how quickly should the pt have surgery for fixation

A
  • recommended w/in 24 hours
77
Q

What is the general healing time for bones in an adult?

A
  • 12-16 weeks
78
Q

What are two considerations for post-op fx management for PT in terms of interventions?

A
  • swelling management; manual lymphatic drainage or K taping

- early ROM to prevent elbow stiffness

79
Q

What are common complications of elbow fractures? (5)

A
  • elbow stiffness
  • instability
  • non-union
  • post traumatic arthrosis
  • heterotopic ossifications
80
Q

Olecranon fractures are common in which demographic?

A
  • the elderly
81
Q

What are characteristics of the most common type of olecranon fracture?

A
  • displaced fracture where the UCL remains intact
  • disrupts triceps function
  • the displaced fracture is intraarticular
82
Q

What are the two common surgical interventions for olecranon fx?

A
  • bony fragment excision with triceps repair
  • ORIF
  • similar outcomes with both, but > potential for complications with the ORIF
83
Q

Radial head fxs are more common in what demographic?

A
  • female

- 20-60 yo

84
Q

What are the 3 common mechanisms for radial head fx?

A
  • axial load on pronated forearm
  • direct blow to elbow
  • hyperflexion injury
85
Q

A pt comes in after falling in a way where she felt like her elbow was bent too far. She’s got significant TTP at the lateral elbow. What may be of concern?

A
  • radial head fx
86
Q

What are the 4 types of radial head fracture per the Mason Johnson classification?

A
  • Type I: undisplaced fx
  • Type II: large, displaced fx
  • Type III: comminuted fx
  • Type IV: fx associated with dislocation
87
Q

What is the typical duration/position of immobilization if needed following a radial head fx?

A
  • usually 3 weeks or less to avoid complications

- full extension rather than flexion to improve ROM

88
Q

Are outcomes for simple vs complex radial head fx managed with ORIF the same?

A
  • not clear
  • some research shows that complex will result in poorer outcomes, but another 11 year retrospective study didn’t find a difference
89
Q

When is radial head excision appropriate or not?

A
  • if the UCL is intact, radial head excision will have little effect on stability
  • if the UCL is not intact, it’s not a good idea
  • if going to excise, should occur within the first 24 hours to 10 days
90
Q

When is radial head replacement indicated?

A
  • Mason Johnson Type IV radial head fractures
  • concurrent UCL or RCL dysfunction with instability
  • coronoid fx with fragmentation involving >50% of the coronoid (Type III)
91
Q

What’s the common demographic/MOI for a capitellum fx?

A
  • usually young male with high impact trauma or elderly with low/moderate impact
92
Q

Are isolated coronoid fxs common? What is the proposed mechanism for an isolated coronoid fx?

A
  • they are not common; part of the “terrible triad”, or part of varus posteromedial instability
  • theorized MOI is an axial load with 0-20* elbow flx; increased flx engages the radial head, which would likely be injured as well. These are high energy injuries
93
Q

What should be avoided during early ROM for a complex coronoid fx following surgical stabilization?

What amount of elbow flexion can the pt expect to get back?

A
  • avoid varus forces during early ROM

- ~110* flx can be expected

94
Q

What are the more common complications following elbow trauma? (6)

A
  • elbow stiffness
  • heterotopic ossificans
  • complex regional pain syndrome
  • neural injury
  • arterial injury
  • compartment syndrome
95
Q

What is the differentiation between intrinsic and extrinsic elbow stiffness?

A
  • extrinsic is due to any tissue that is outside of the joint (skin, muscle, capsule, ligaments, heterotopic ossificans)
  • intrinsic would be any intraarticular structures, joint congruency, and articular surface degeneration
  • most elbow stiffness would be a combination of both
96
Q

What is the typical presentation for elbow stiffness?

A
  • loss of extension w/ mild/moderate pain
  • likely supination/pronation are affected, but can remain intact in some cases
  • ulnar neuritis is a commonly associated diagnosis
97
Q

With treatment for elbow stiffness, when trying to improve PROM, what is a primary concern?

A
  • stretching/mobs should be gentle
  • potential to develop heterotopic ossificans with more aggressive stretching
  • aggressive manipulation may cause capsular tearing and increased loss of motion
98
Q

What are useful adjuncts to manual therapy when treating elbow stiffness?

A
  • splints, braces, etc to improve ROM (e.g., turn-buckle, or dynamic hinge brace)
99
Q

When is surgical release appropriate for elbow stiffness/loss of ROM?

A
  • with chronic symptoms for up to 12 months with loss of functional ROM
100
Q

Following release for elbow contracture (elbow stiffness), how long can a pt expect to make gains to ROM?

A
  • can make gains for up to 6 months post-op
101
Q

For most elbow surgeries, what nerve is most likely impacted with complications?

A
  • ulnar n.
102
Q

Is heterotopic ossificans (HO) more likely at the hip or the elbow?

What is the rate of HO with fracture/dislocation at the elbow?

A
  • more frequently reported at the hip, however the elbow is at greater risk to develop HO
  • rates reported as high as 56% following elbow fx or dislocation
103
Q

What are the most common locations for HO to develop in the elbow?

A
  • between the brachialis and anterior capsule

- between the triceps and posterior capsule

104
Q

What is the standard presentation for heterotopic ossificans?

A
  • pain with progressive loss of ROM
105
Q

How early can HO be picked up in imaging?

A
  • 5th week with plain films

- 2nd week with bone scan

106
Q

What is often in the differential for HO at the elbow?

A
  • septic arthritis
  • infection
  • thrombophlebitis
  • CRPS
107
Q

What is the primary aim of PT management for HO at the elbow?

A
  • prevention of a permissive environment for HO development; i.e., decreasing risk of excessive inflammation
  • interventions like CPROM, AAROM, education re: avoiding pain during activities
108
Q

What is the predominant feature of CRPS?

A
  • pain that is disproportionate to the injury

- Also, autonomic, sensory, and motor impairments that develop through the course of CRPS

109
Q

What age/genders are more likely to be dx’d w/ CRPS? Is is more likely in the UE or the LE?

A
  • more likely in females, typically ~40yo

- ~2x more likely in the UE

110
Q

What is the difference between CRPS I and II?

A
  • CRPS I is associated with a minor injury such as sprain, strain, fx, or surgery
  • CRPS II is associated with a known nerve injury prior to onset of symptoms
111
Q

What is the theorized pathophysiology behind CPRS?

A
  • not well understood
  • thought to be multifactorial, with dysfunction in the sympathetic nervous system, somatic sensory nervous system, an exaggerated inflammatory response, hypoxia in the integumentary system, and potential psychosocial overlay
112
Q

What are the 3 stages of CRPS?

A
  • they all overlap, but:
  • acute inflammation
  • dystrophy
  • atrophy
113
Q

What is the presentation for CRPS? What can be expected?

A
  • intractable pain in a nonperipheral nerve distribution
  • edema with sensory and motor changes in the area
  • hyperalgesia, hyperpathia, and allodynia may be present
  • may have increased hair or nail growth
  • glossy, thin appearance to skin (dystrophic stage)
  • skin becoming thin, dry, and cyanotic (atrophic stage)
114
Q

What are some key interventions for CRPS?

A
  • desensitization
  • graded motor imagery
  • isometric exercises
  • postural correction
  • ROM
  • intervention must be individually tailored

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