Week 7 Elbow Fractures Flashcards
Traumatic Elbow Injuries
FOOSH
Simple Dislocations
Elbow Fractures
Forearm Fractures
Traumatic Elbow Injury: A fracture and/or dislocation that occurs at or near the elbow injuring the distal humerus, proximal ulna or radius, and/or the joints that comprise the elbow: humeroradial, humeroulnar, or proximal radioulnar joint.
The same MOI for instability is the same MOI for fractures.
Got it
Elbow fractures:
Represent 5-6% of all fractures
(Olecranon process/Radial head) most common fracture
(Pain/LOM) is a common sequelae following elbow trauma
Rates of stiffness after elbow trauma range from 5%-40%
Stiffness can occur any time during the healing process
Radial head; LOM
Elbow fractures
Distal Humerus Extra-articular – proximal to the capsule and articular surface Extra-capsular vs. Intracapsular Extra-capsular – outside of the capsule Intracapsular – inside the capsule Intra-articular – goes through the articulating surface Radial Head – Types I, II, III Ulna Olecranon – Types I, II, III Coronoid – Types I, II
The type of fracture (I-III) is related to the (velocity/strength) of the mechanism. Type (I/II) is described as a nondisplaced fracture, type (I/II) is described as a displaced, but simple fracture, type (I/III) is described as a convoluted and displaced fracture.
The problem is, you can’t just say a simple fracture has less chance of stiffness at the elbow vs a convoluted fracture. There is no correlation that is based on the different type of fracture that will determine level of elbow stiffness. A type I fracture can become a stiff elbow just like a type III fracture.
velocity; I; II; III
Forearm Fractures - Essex-Lopresti, Galeazzi & Monteggia
Represent less than 10% of forearm fractures
Named fractures common in adolescents and young adults via (low/high) velocity injuries
Distal (Radius/Ulna) Fracture is most common forearm fracture (300K+ annually)
MUGR
Monteggia fracture-dislocation: (Radius/Ulna)
Galeazzi fracture-dislocation: (Radius/Ulna)
Younger people are the ones that are more involved in high velocity activities.
These three fractures (Essex-Lopresti, Galeazzi, Monteggia)
are rare but they are significant in being challenging to rehab
high; Radius; Ulna; Radius;
Essex-Lopresti Injury
Tear of the (MCL/IOM) (central band)
Comminuted fracture of the ____ head
Dislocation of the (DRUJ/PRUJ) – radius migrates proximally
Cause typically is a FOOSH with the elbow (flexed/extended) and forearm (pronated/supinated)
Degree of radial head comminution is related to the energy of the fall
Do not memorize these fractures, just get an understanding
IOM – Interosseous membrane
DRUJ 0- distal radial ulnar joint
The comminuted fracture pistols upward
The faster they’re falling the greater the shatter of the radial head.
The problem with the injury is the radius becomes shorter.
If the radius becomes shorter on the DRUJ, you will have (radial/ulnar) variance. So if the radius cant be set at the proper length you’ll have a positive ulnar variance which leads to problems pronating and gripping.
IOM; radial; DRUJ; extended; pronated; ulnar;
Galeazzi Fracture
Consists of:
Fracture of the radius (typically mid-distal 1/3rd of the shaft
Most typically fx is just above the proximal border of the pronator ______
Dislocation of (DRUJ/PRUJ) - Ulna dislocation
You are hoping for a good fixation that does not change the overall alignment of the radius and ulna at the wrist
After reduction can’t do rotation on these patients for a long time. Soft tissue needs to heal so will end up with stiffness in the transverse plane.
quadratus; DRUJ;
Monteggia Fracture
Image - Divergent dislocation between ulna and radius and fracture of the proximal radius
“Monteggia” denotes a group of injury types including:
Dislocation of the PRUJ
Dislocation of the DRUJ
Proximal (radial/ulnar) fracture
Monteggia “like” - Olecranon fracture (disruption to the overall proximal radioulnar joint, has the same issues)
ulnar;
Rehabilitation Guidelines for Simple Dislocations and Elbow fx
Therapy initiated within _ week post closed reduction
Ligament reconstructions are rare
Sling, Long Arm Orthosis, Hinge brace for immobilization between exercise sessions
(A/AAROM/PROM) for flexion/extension in neutral rotation
Pronation/Supination performed in elbow (flexion/extension)
Residual laxity - Limit extension to _ degrees in hinge brace for - weeks
Greater the period of immobilization the (smaller/greater) the likelihood of stiff elbow
Progress strengthening and functional use over - months
Similar to reconstruction guidelines
Therapy – want to initiate quick and early
Simple fracture - ligament reconstructions are rare.
NO PROM!
If you are not sure, keep them in neutral. Pronation/supination performed in elbow flexion because it is the most neutral.
1; A/AAROM; flexion; 30; 3-8; greater; 3-9;
Medical Management of Fractures
Restore articular congruity - need to know if they did or didn’t because sometimes they can’t
Stable anatomic reduction
Stable rigid fixation - Necessary for early active mobility: if so, can do early active mobility, if not, may have to hold off
Got it
Rehabilitation depends on medical management of fracture and surgeon/therapist experience
Non-operative vs. operative management
Long arm cast or Orthosis 10 days – 8 weeks
Acute elbow flexion
Forearm and wrist neutral
Immobilization vs. Early Motion - Depends on fixation and stability
Got it
Types of Fixation
Determines when therapy is initiated
Rigid: Full, (early/late), pain-free (AROM/PROM)
Stable: Protected (early/late) (AROM/PROM) (limited range)
Tenuous: (Early/Delayed) protected (AROM/PROM)
Need to know what surgeon is thinking.
If the script says protected early AROM you will know it is stable.
early; AROM; early; AROM; Delayed; AROM
Joint Effusion: Fat pad elevation (Sail Sign)
Look for any swelling in fractures. Xray to the right – effusion (dark pockets the white arrows are pointing to). Fluid is more (radiolucent/radiopaque) so that is why it is dark pockets. Soft tissue is being pushed away from the bone because swelling is taking up the space. It is called the ___ sign.
radiolucent; sail
Drop Sign
If no support for olecranon at the elbow, the trochlear notch drops down and the ligaments can’ hold it in place. Need to stimulate (compression and proprioception/tension and somatosensation) to keep the joint together. Don’t do exercises in (standing/supine) because it can make the drop sign worse.
compression and proprioception; standing;
Complications
Malunion or non-union
“A malunion occurs when a fractured bone heals in an abnormal position, which can lead to impaired function of the bone or limb and make it look like it is ‘bent’. Similarly, a nonunion is the result of a fractured bone failing to heal after an extended period of time”
Ectopic Ossification (HO vs. MO): HO – heterotopic ossification. Myositis ossificans – where bone forms in muscle . Where bone sits in the muscle belly.
Nerve injury
Instability
Stiffness
Xray on bottom left – looks like dorsa fin of the shark on the radius. Ectopic ossification in bone where the bicep attaches - pulls so much on the bone during healing that it created the dorsal fin.
Image on the top is a nerve injury (ischemic loss of forearm muscles due to nerve injury from the fracture. ) called _____ ischemic fracture.
Bottom right – _____ deformity on the left arm - you can see it doesn’t have normal carrying angle and looks like a gun stock.
Volkmann’s; gunstock;
Elbow Fracture
Impairements >>>>>>>>>>> Dysfunction Pain: Tendon? Nerve? Instability?
Decreased Mobility:
Stiffness? Muscle Weakness? Muscle length?
Edema:
Acute? Chronic? Insidious?
Got it
Patient’s can be functional with some loss of extension; They are motivated to work on (flexion/extension); and its hard to substitute for loss of (pronation/supination)
Normal
Extension – Flexion = _ – _ degrees
Pronation – Supination = -/_ each
Functional
Extension – Flexion = -
Pronation – Supination = - each
Functional Revised
Full flexion and full pronation needed for contemporary tasks -
Cell phone, keyboarding
Patients are motivated to work on flexion because you can’t get food in your mouth if you can’t flex your elbow. Think of ADLs you have to do.
If you cant supinate, can you read your phone? It is awful trying to get supination back.
Higher expectations for more functional supination than pronation in today’s society. With the demands on working on your phone and things like that, we need a little bit more.
flexion; supination; 0-140; 0-80/85; 0-80/85; 30-130; 0-50;
Elbow Function, Participation, Occupation-based
The elbow is the link for everything that we do.
Mobile link for activities - Eating and reaching
Stability for WB activities- Pushing up from a chair
Combined elbow and forearm movements
Elbow flexion with supination- Eating and grooming
Elbow extension with pronation- Reaching, throwing, or pushing
Without the elbow can’t push from a chair.
Got it
Early Motion is key
The timing and degree of (immobilization/early motion) is dependent on the medical/surgical management of the fractures
early motion
Rehabilitation Guidelines Following Elbow Fracture/Dislocation
LCL precautions due to tear or repair -
forearm (pronated/supinated)
(varus/valgus) protection activities
Avoid shoulder (internal/external) rotation
MCL precautions due to tear or repair -
forearm (pronated/supinated)
(varus/valgus) protection activities
Avoid shoulder (internal/external) rotation
LCL & MCL precautions due to tear or repair -
forearm (neutral/supinated)
(varus/varus & valgus) protection activities
Avoid shoulder (internal/rotation)
If someone is showing signs of stiffness, need to be (less/more) aggressive.
(Strength gains/ROM) is the primary goal. Don’t think of s&c at 4 weeks, should be thinking of getting ROM back in a staged progression.
pronated; varus; internal; supinated; valgus; external; neutral; varus & valgus; rotation; more; ROM
Rehabilitation Guidelines Following Elbow Fracture/Dislocation
Phase I: Protective (- weeks)
Therapy initiated - days post fracture/joint stabilization
Elbow flexion-extension AROM using (overhead/underhead) protocol to decrease drop sign.
Protective phase – at the least put them in _ degrees of flexion with a brace to immobilize them. Safe to move within restrictions. If underwent surgery for LCL, don’t want varus forces on the elbow.
0-3; 1-5; overhead; 90
Early Controlled Protected Pronation/Supination to Neutral
(AROM/AAROM) in this picture – gentle overpressure to get more flexion, do the opposite to get more extension. You can also work on pronation and supination (get to _ degrees of flexion because it is the most stable position for that)
AAROM; 90
Varus Protected Position/Activities
If you lay down with arm at side and bring it up, there is no varus moment on the elbow. Don’t do it (supine/standing or prone) – creates a varus torque.
standing or prone
Rehabilitation Guidelines Following Elbow Fracture/Dislocation
Phase II: Mobilization/Post-Protection (- weeks)
Emphasis on (strength gains/restoration of motion) without risk to healing bone or soft tissue
Protect forearm rotation with elbow at _ degrees of flexion and limited arc
Post-protection phase – when in this area need to communicate with the surgeon.
3-8; 90
Rehabilitation Guidelines Following Elbow Fracture/Dislocation
Recovery phase (- weeks)
When we get to weeks 8-12 we start to do more with the pt.
Start doing total arm strengthening in this phase .
8-12;
UE weightbearing progression
(Partial/Full) – Wall, Table, knees
(Partial/Full) – Push-up position on the floor
Can have them go on their knees and get them used to WB on their arms and knees and then can move them to their feet progressively. Can control WB when on the knees.
Partial; Full;
Treatment: Forearm Fractures
Modifications to Elbow program
Immobilization - weeks -
IOM repair – longer
Allow limited elbow ext/flx
Derotation/Long Arm Orthosis
Edema management
(AROM/PROM) of uninvolved joints
After - weeks, begin gentle progressive ROM exercises, then progress to strengthening
4-8; AROM; 4-6
ROM Assessment
Just taking a look at A/PROM with a goniometer is not enough! End feel Tone/Stiffness throughout the range Alterations/Movement Deviations Muscle Length as ROM
You need to feel the end feel.
Deviations – when we flex the elbow goes medial. When we extend it goes lateral. Is that normal in the pt you are dealing with.
Muscle length- can determine if it is muscle or joint by measuring at different angles. Elbow flexion should be different when flexing by your side vs up overhead. Iron out why? Must be muscle length tension relationships?
Got it
Contractures
(Intrinsic/Extrinsic) Sources Incongruity of articular surfaces Bony block or hardware block Ectopic bone or Heterotopic bone Joint Effusion
Intrinsic
Contractures
(Intrinsic/Extrinsic) Sources
Joint Capsule Shortening/Fibrosis Adhered Brachialis Collateral Ligament shortening/fibrosis Muscle tightness
Adhered brachialis – brachialis may be causing an issue here
Collateral ligaments – have they tightened up?
Muscle tightness – measuring biceps and triceps tightness
Extrinsic
Examination of Extrinsic Sources
Assess muscle length of biceps and triceps
Biceps tightness limits (flexion/extension) of the elbow
Triceps tightness limits (flexion/extension) of the elbow with shoulder flexion
extension; flexion
Orthotic Intervention for ROM Deficits
Trying to increase extension range in the picture
Need _ minutes a day to make a difference. Keep increasing (intensity/time) until the patient reaches TERT the pt can deal with- how many hours a day can you be in that brace? If you can do 24 hours in that brace, go for it (obv with breaks to work on flexion). Have to build them up to be able to do that. Won’t start 24/7 with the elbow off of the bat.
60; time;
Which patients require an orthoses to improve ROM?
Modified Weeks Test (MWT) -
Compare PROM gains in extension (amount of degrees in extension because that is where the stiffness is the problem) after 15 mins of preconditioning (heat and exercise)
Comparing pretherapy and then what they gain after the heat and exercise
If person increases 20 degrees - (no orthosis needed/static orthosis)
If person increases 15 degrees - (static/dynamic) orthosis
If person increases 10 degrees - (dynamic/static progressive or serial static) orthosis
If person increases 0-5 degrees (dynamic/static progressive or serial static)
no orthosis needed; static; dynamic; static progressive or serial static
Nerve injuries – post fx
Most common nerve for PR fracture - (radial/median)
Most common nerve for forearm fracture - (radial/median)
Most common nerve injury post elbow fracture (median/ulnar)
radial; median; ulnar
Motor Screen/MMT/Key muscles/Proximal innervation (high)/Distal innervation (low)
High: flexor carpi ulnaris
Low: abductor digiti minimi
(median/ulnar) nerve
High: flexor digitorum superficialis
Low: opponens pollicis
(median/ulnar) nerve
High: extensor carpi radialis longus and brevis
Low: extensor pollicis longus
(median/radial) nerve
ulnar; median; radial
Presence of motor signs commonly seen with nerve injury
Froment's sign Jeanne's sign Wartenburg's sign hypothenar or first dorsal interosseous atrophy (median/ulnar) nerve
Inability to make the OK finger sign
Thenar muscle atrophy
(median/ulnar) nerve
Wrist drop
Loss of finger extension with wrist neutral or extended
Atrophy of the posterior compartment of the forearm
(radial/median) nerve
ulnar; median; radial
Sensory screen
Pad of small finger
(median/ulnar) nerve
Pad of index finger
(median/ulnar)
First dorsal webspace
(ulnar/radial) nerve
ulnar; median; radial
Neurodynamic assessment
Phalen’s test
(median/ulnar) nerve
Elbow flexion test
(median/ulnar) nerve
Maudsley’s test
(radial/median) nerve
median; ulnar; radial
Neural hyperalgesia
Spiral groove of the humerus
(median/radial) nerve
Medial to biceps tendon cubital fossa
(median/radial) nerve
Posterior to medial epicondyle
(median/ulnar) nerve
radial; median; ulnar
Direct or indirect pressure provocative palpation
Origin of the flexor carpi ulnaris
Dorsal ulnar cutaneous nerve
Hook of the hamate
(median/ulnar) nerve
Midline of the volar forearm
Carpal tunnel
(median/ulnar) nerve
Origin of the supinator
Dorsal sensory radial nerve
(median/radial) nerve
ulnar; median; radial
