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Rehabilitation After ORIF of Elbow Dislocations

Cynthia Watkins, PT, DPT, CHT, and Charles L. Getz, MD

axially loaded. In addition, the valgus-carrying angle and slight degree of flexion convert the axial load into a valgus thrust. This mechanism results in injury of the stabilizing structures around the elbow. O’Driscoll described the stages of elbow instability as beginning with a failure of the LUCL, with pro- gressive disruption of the anterior and posterior capsule. In severe cases, the medial ulnar collateral ligament (MUCL) is also injured. This unlocks the forearm from the humerus, and allows the radial head to dislocate behind the capitellum. In cases of complex instability, the radial head is driven into the capitellum and the coronoid into the trochlea before the forearm is fully disengaged, resulting in various degrees of fracture of the radial head and coronoid in addition to the collateral ligament injuries. The terrible triad injury pattern consists of an elbow dislocation, radial head fracture, and coronoid fracture. PRLI is a relatively rare late sequelae of traumatic elbow dis- location or subluxation. It occurs when the LCL complex fails to heal sufficiently to prevent the forearm from rotating away from the humerus, resulting in either recurrent frank disloca- tions or subluxations of the elbow. Varus posteromedial rota- tory instability (VPRI) is caused by a varus load, which results in failure of the LCL under tension and fracture of the medial ulna joint line due to compression of the coronoid against the medial aspect of the trochlea. Simple Elbow Dislocations For the majority of patients with simple elbow dislocations, a brief period of immobilization followed by protected early range of motion (ROM) will result in a favorable outcome. In rare cases, the elbow will not be stable even with the elbow in 90 ° of flexion and the forearm pronated. These patients require operative stabilization of the elbow. Operative Treatment

Introduction Elbow joint stability is dependent on a highly congruent skel- etal articulation and collateral ligaments. Dislocations of the elbow are relatively common, being the second most com- monly dislocated major joint. Most simple elbow dislocations are managed with closed reduction, a brief period of immobi- lization, and early protected rehabilitation. Elbow dislocations associated with fractures of the radial head and the coronoid are complex injuries that are much more likely to require surgical intervention. Relevant Anatomy The elbow is stabilized by both the bony congruency of the joint and the periarticular soft-tissue structures. The soft- tissue structures on the medial side (Figure 19.1) are the medial collateral ligament (MCL) complex and the flexor pro- nator mass. The lateral (Figure 19.2) side soft tissues include the lateral collateral ligament complex (LCL) and the exten- sor and supinator muscular complex. The primary restraint to valgus instability is the radial capitellar joint, while the MCL is a secondary stabilizer that becomes the primary stabilizer if the radial head is removed. The bony congruency of the ulnar trochlear articulation is the primary restraint to varus stress, with the LCL being a secondary stabilizer. Supination and axial loading of the forearm causes the ulna and radial head to rotate away from the distal humerus, with the radial head translating posterior to the capitellum and the lateral ulna rotating away from the lateral trochlea. The lat- eral ulnar collateral ligament (LUCL) is the primary stabilizer to prevent this instability pattern, known as posterolateral rotatory instability (PRLI). Most elbow dislocations occur as a result of a fall onto an outstretched arm. The forearm is forcibly supinated and

Dr. Getz or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Mitek and Zimmer; serves as a paid consultant to Cayenne Medical; serves as an unpaid consultant to Zimmer; has stock or stock options held in OBERD; and has received research or institutional support from Integra, Rotation Medical, and Zimmer. Neither Dr. Watkins nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

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of the elbow are addressed, an external fixator is applied to maintain the reduction. Ideally, fixation of all of the injuries will be secure enough to start earlier rehabilitation. However, extensive repairs or swell- ing may require a delay in the initiation of therapy. Wound healing and infection prevention is the highest priority, then joint stability, and finally ROM after complex elbow repairs. Stabilization surgery can be done through a posterior inci- sion with full-thickness skin and subcutaneous flaps raised to allow access to the lateral and medial sides of the joint. Alternatively, separate direct lateral and medial incisions can be used. The laterally based incision requires less soft-tissue dissection and may lead to less wound healing problems than a posterior incision. The potential need for future additional surgery is also a consideration when planning the surgical approach. A lateral incision may be preferred if future surgical contracture release is planned, while a posterior incision would be preferred for later elbow replacement. Complex Instability: Fracture Dislocations Complex instability falls into two main catagories, terrible triad injuries and VPRI. Terrible triad injuries involve frac- tures in addition to the ligamentous injuries, as described for simple elbow dislocations. Surgery is recommended when the fractures of the coronoid or radial head would require intervention on their own. Surgery is also recommended if the joint is not congruently reduced or the elbow demonstrates clinical instability at greater than 45 ° of flexion. Surgery to address terrible triad injuries requires repair of types II and III coronoid fractures, radial head repair or replace- ment, and repair or reconstruction of the LCL. MCL repair often may be required to stabilize the elbow as well as applica- tion of an external fixator. Management of coronoid fractures can be difficult especially if there is comminution. Although the coronoid is most easily accessed from the medial side it can also be reached from the lateral side if a radial head replacement is required. Coronoid fractures can be fixed with a variety of techniques, including screws, small plates and screws, and tran- sosseous sutures. The decision for a single posterior incision or separate lateral and medial incisions is based on surgeon prefer- ence. These injuries often include extensive soft-tissue injuries, and swelling can be a problem. Wound healing problems can be a major complication of surgery for these injuries. VPRI may include subtle injuries and require operative intervention when the trochlea is not congruent and/or the radial capitellar joint is gapped on an anterioposterior elbow radiograph. Computed tomography (CT) is used to assess the joint alignment in suspected cases, as these injuries are often difficult to assess with plain radiographs. The coronoid frac- ture is addressed through a medial approach to the elbow by elevating the flexor carpi ulnaris muscle (FCU) anteriorly. The ulna nerve is identified and protected during this approach. The LCL requires a separate lateral approach to repair or reconstruct the ligament. If fixation is tenuous, an external fixation will be applied to offload the repaired joint and liga- ments, and protect the reduction.

Lateral (radial) collateral ligament

Annular ligament

Accessory lateral collateral ligament

Articular capsule

Lateral ulnar collateral ligament Figure 19.1 Illustration of the medial elbow ligamentous com- plex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehen- sive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.) A small number of patients will continue to have radio- graphic findings of instability at 7 to 14 days or clinical findings of instability at 14 days, thus will be considered for surgical stabilization. In the majority of these cases, the LCL and common extensor origin are found torn away from the lat- eral epicondyle, and can be anatomically repaired either with sutures through bone tunnels or with suture anchors. If the LCL is torn midsubstance, a ligament reconstruction with a tendon graft may be required (Figure 19.3). Uncommonly, the MCL will also require repair or reconstruction after the lateral repair. If the elbow continues to have instability after both sides

Anterior band

Posterior band

Transverse band

Figure 19.2 Illustration of the lateral elbow ligamentous com- plex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehen- sive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.)

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patient early about the expected ROM losses, especially elbow extension. A loss of 15 ° of elbow extension is not an uncom- mon sequela of even simple elbow dislocations. Patients are splinted in the operating room and placed in a sling. The splint rests the soft tissue to help reduce swelling and protect the repair. The splint is typically discontinued 7 to 10 days after surgery. The splint can be replaced with either a custom-molded orthoplast removable splint, or a prefabri- cated brace, which can be removed for hygiene and permit early ROM exercise while protecting the repair (Figure 19.4). Gentle active and active assisted exercises are typically initi- ated within the first 7 to 10 days after surgery. Active range of motion (AROM) rather than passive range of motion (PROM) is advocated to take advantage of the compressive stabilizing forces of the muscles surrounding the elbow. The patient is encouraged to remove the orthosis and perform these exercises at frequent intervals throughout the day. As the bone and soft tissues begin to heal, the ROM can be progressed and light functional activities can be initiated. Strengthening is begun once the joint is declared stable by the physician. In general, Figure 19.3 A–C , Illustrations of reconstruction of the lateral ulnar collateral ligament through an extended Kocher’s approach. (Reproduced with permission from Morrey BF. Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4(3):117–128, and with permission from the Mayo Foundation for Medical Educa- tion and Research, Rochester, MN.)

Postoperative Rehabilitation Although there is no “one-size-fits-all” approach to rehabilita- tion after operative fixation of elbow instability injuries, there are general principles that can be applied and utilized in indi- vidual cases. The initial postoperative management focuses on preventing and decreasing swelling, managing pain, and pro- tecting the repair. The primary rehabilitation goals after surgi- cal treatment of elbow dislocation are restoring joint mobility while protecting the surgical repair, preserving elbow stability, and eventually restoring function. Increases in ROM should not be gained at the expense of joint stability. Restoring a func- tional arc of motion is essential to enabling the patient to return to normal activities. While normal elbow ROM has been mea- sured as 0 ° to 140 ° of flexion and extension, and supination/ pronation 80 ° to 85 ° , the functional ROM to complete most activities of daily living (ADLs) has been established as 30 ° to 130 ° (flexion/extension) and 50 ° /50 ° supination/pronation, although some common tasks may require higher degrees of flexion and forearm rotation. It is important to educate the

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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

●●

Figure 19.4 Photograph of posterior elbow custom splint.

●●

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.

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●● AROM of the shoulder (protective orthosis may be worn for comfort) Edema Management

●● Elevate arm above heart level ●● Retrograde massage ●● Elastic compression sleeve Scar Management

●● Scarmassage 2 to 3 times daily with cocoa butter or vitamin E after sutures are removed Phase 1 (0–2 Weeks Postoperatively) Protection/Immobilization Customarily, the patient is placed into a custom-fabricated long-arm orthosis with varying degrees of elbow flexion and forearm rotation, depending on the repaired structures. The elbow is most stable at 90 ° of flexion. Pronating the forearmwill protect lateral ligamentous structures, while supination protects medial structures and stresses the lateral side. Care must be taken to pad the orthosis to protect bony prominences (medial/ lateral epicondyles, olecranon, and ulnar styloid), avoid undue pressure, and prevent skin irritation/breakdown. The patient is instructed to remove the orthosis three to four times daily for exercises, hygiene, and light functional activities. The orthosis is worn in this manner for approximately 6 weeks. Range of Motion AAROM exercises are begun at the first postoperative visit, gen- erally within 7 to 10 days after surgery. Exercises are started in a supine position. When the primary instability involves the LCL repair, extension is safest with the forearm pronated. If the insta- bility primarily involves MCL repair, extension is safest with the forearm in supination. If both the MCL and LCL are repaired or severely injured or repaired, then extension should be per- formed with the forearm in neutral rotation. Performing exer- cises in the supine position allows for scapular stabilization and helps the patient avoid substitution patterns. It also lowers shear forces to the coronoid process (if repaired), decreases the firing of the brachialis muscle, and allows gravity to assist with flexion. When performing supine elbow motion exercises, the patient lies supine, with the shoulder in 90 ° of forward flexion, and uses the unaffected arm to assist the affected arm through the stable arc of motion (Figure 19.5). If the patient cannot tolerate supine positioning or if the instability is minor, seated extension exer- cises are also an option. In the same supine position, the patient can use the unaffected hand to gently pronate and supinate the forearm with the elbow in flexion (Figure 19.6). This position also requires the patient to engage the triceps muscle when extending the elbow against gravity. Activation of the triceps helps to keep the joint stabilized. Usually, the patient will have some amount of an extension deficit, but if the patient has difficulty maintaining extension restrictions set by the physician, then a template orthosis can be fabricated to provide a block, preventing the patient from extending past the limits of stability that were determined at the time of surgery.

Figure 19.5 Photograph of supine active assisted elbow flexion/ extension.

Forearm rotation exercises are performed with the elbow in 90 ° of flexion and the forearm supported on the table. It is important to initiate rotation early, especially if the radial head has been repaired. These exercises can also be performed in the supine position when increased stability is required due to a LCL repair. Simple functional activities, such as flipping cards or turning pages of a magazine, can be used to reinforce active pronation and supination motion. Active and active assisted exercises of the shoulder, wrist, and hand are performed to avoid stiffness and muscle atrophy.

Figure 19.6 Photograph of supine active assisted supination/ pronation.

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Table 19.2

Summary of Rehabilitation during Fibroblastic Phase

Edema Management Ice, retrograde massage, compressive dressings

Scar Management

Pain Management HEP

Functional Goals

Protection

ROM

Use of affected arm for light functional activities, typing, donning clothing, tying necktie, eating. Encourage natural position of the arm when walking.

Moist heat applied at end range prior to exercises. AROM/ AAROM with emphasis

TENS, IFC, ice, medications as prescribed by physician

Scar massage, silicone sheets, desensitization, fluidotherapy

AROM/AAROM All joints of affected upper extremity, grade I and II joint mobilizations

Orthosis in

crowded areas.

Avoid activities that cause traction to the joint (carrying a heavy briefcase or bag). Avoid pushing heavy doors.

on end range.

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

assesses ligamentous stability and obtains plain radiographs to confirm that the joint is congruently reduced and that any fractures are healing. Joint stiffness, especially with extension deficit, is typical at this stage. The use of modalities, such as moist heat, prior to performing ROM increases tissue extensibility, increases blood flow, and relaxes the patient. Positioning the patient in the supine position with the affected elbow at the end range of available extension allows for a prolonged stretch prior to any ROM techniques. PROM for all joints of the affected upper extremity is now allowed. A low-load, prolonged force is applied to the point of discomfort, not pain, to avoid any inflammatory response. Joint mobilizations (grade I or II) are performed to increase mobility in areas that are lacking end range movement, typ- ically elbow extension and supination. It is important to vary the force and position of the mobilization as the patient exhib- its ROM gains. For example, with elbow extension, the force should always be applied perpendicular to the ulna at the ulno- humeral joint. As the patient gains extension, the therapist will need to adjust the patient’s hand and body positions during the mobilization to continue to deliver the force in a perpendicular fashion. Likewise, as pain subsides, grades III and IV mobi- lizations can be used, moving the joint further through the restricted ROM to achieve increases at the end-range points (Figures 19.7 and 19.8). It is also important to avoid overly aggressive PROM techniques. Ballistic, high-force movements can injure soft tissues that are beginning to heal and stimulate heterotopic ossification. Contract/relax techniques can be utilized during PROM to fatigue the bicep and brachialis muscles, and allow for increased elbow extension. This technique also engages the patient to participate and gives the patient a sense of control when having stretch applied to the arm. The patient can now start performing AROM and AAROM in sitting or standing positions. Exercises are generally begun

Phase 2 (Fibroblastic Phase, 2–8 Weeks Postoperatively) (Table 19.2) Goals ●● Increase ROM (add PROM as appropriate if stability of the elbow is no longer a concern) ●● Influence soft tissue and joint mobility through controlled stress ●● Avoid inflammatory response ●● Decrease edema ●● Decrease pain ●● Improve use for light functional activities Orthosis ●● Discontinued once fracture repair is stable, ligamentous stability is intact (usually 6–10 weeks) Exercises ●● Active and AA elbow flexion and extension ●● Initiate with forearm in pronation and progress to supi- nation. Examples: physioball roll, cane stretch ●● Active and AA forearm rotation. Examples: hammer stretch, AA manual stretch, neoprene strap Edema Management/Pain Management

●● Elastic compressive sleeve ●● Retrograde massage ●● TENS/interferential current Scar Management

●● Silicone sheet, as needed ●● Desensitization techniques ●● Scar mobilization Phase 2 (2–8 Weeks Postoperatively)

During this stage of recovery, the patient is weaned out of the orthosis for light activities and has typically discontinued use of the protective orthosis by around 6 weeks. The surgeon

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Figure 19.7 Photograph of ulnohumeral joint mobilization.

Figure 19.9 Photograph of active assisted elbow extension with a physioball.

in protected postures with the forearm in pronation and the elbow moving from flexion/extension, and are progressed to elbow flexion/extension with the forearm in supination. AROM exercises in proprioceptive neuromuscular facilitation (PNF) patterns are also useful at this stage to increase joint proprioception and encourage use of the arm in functional patterns. Manual force can be applied by the therapist and patient to provide graded resistance at varying points through- out the movement. In addition, the patient must perform inde- pendent exercises multiple times daily to maintain gains and increase mobility. Functionally, the patient should be encouraged to use the affected arm for light ADLs, such as self-care and meal prepa- ration. Styling hair, holding a cellphone, and tying neckties encourage elbow flexion. Folding laundry and typing promote forearm rotation. Patients are advised to allow the arm to swing naturally, avoiding the “sling” posture of elbow flexion, shoulder internal rotation, and adduction posture. Active and Active Assisted Elbow Flexion and Extension These exercises are begun with the forearm pronated and are progressed to supination as stability allows.

1. Physioball roll on plinth with forearm in pronation Patient uses bilateral upper extremities to roll the physioball on the plinth with forearms in pronation. This exercise can also be performed with the affected arm as an active exercise (Figure 19.9). 2. Active Assisted Elbow Extension with Cane Standing with the scapula against the wall, bend and straighten the elbow. A cane can be used to increase extension. Instruct the patient to keep the olecranon in contact with the wall to avoid external rotation from the shoulder. A towel may be placed behind the brachium for feedback to help the patient maintain the correct posture (Figure 19.10).

Figure 19.8 Photograph of radiohumeral joint mobilization.

Figure 19.10 Photograph of elbow extension cane stretch.

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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

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Table 19.3

Summary of Rehabilitation during Consolidation Phase

Strength and Endurance

Orthosis Management

Functional Goals

Protection ROM

HEP

Return to ADLs, recreational activities, return to work

AROM/PROM,

Static-progressive orthoses to achieve ROM goals

Isometrics progressing to PRES, functional

AROM/PROM Goal is full AROM and PROM.

Discontinue use of orthosis

strengthening exercises using weights, resistance bands

patterns (PNF), proximal muscle

strengthening (rotator cuff, scapular muscles), Work-simulated activities, including push/pull, lift/carry. Progress to weight- bearing activities and plyometrics.

AAROM = active assisted range of motion, ADLs = activities of daily living, AROM = active range of motion, IFC = interferential current therapy, PNF = proprioceptive neuromuscular facilitation, PRES = progressive resistive exercises, PROM = passive range of motion, ROM = range of motion, TENS = transcutaneous electrical nerve stimulation.

the patient has significant ROM loss, an orthosis may be used to obtain end-range motion. Custom-fabricated or commer- cially available splints, such as Dynasplint (Dynasplint System Inc, Severna Park, MD) or JAS (Joint Active Systems Inc, Eff- ingham, IL) may be worn to achieve this goal (Figure 19.12). We prefer custom orthotics that are remolded under the super- vision of a therapist. If the patient has limitation of both elbow flexion and extension, the patient may require two orthoses. In these cases, it is useful to wear the extension orthosis at night and the flex- ion orthosis at 30-minute intervals throughout the day. It is important to have the patient exercise in the newly available ROM upon orthosis removal to maintain ROM gains. Strengthening exercises are begun when bony union has occurred and soft tissues are not inflamed. Functional activ- ities and work conditioning are also performed. The work-simulated activities are tailored to the demands of the patient and the patient’s specific job.

Phase 3: Strengthening 1. Begin with isometrics in midrange 2. Progress to isotonic with light weight a. Bicep curls b. Tricep kickbacks/overhead tricep extension

c. Supination/pronation with resistance band/flexbar d. Wrist flexion/extension with weight or resistance band e. PNF patterns with weight or resistance band (Figure 19.13). 3. Closed-chain activities a. Push-ups i. Wall ii. Counter (Figure 19.14) iii. Floor iv. BOSU (Bosu Fitness LLC, San Diego, CA) (Figure 19.15) 4. Functional/work simulation Outcomes The approach to surgical treatment of elbow dislocations is determined by the extent of the anatomic injury, and has a bearing on the eventual outcome. For the terrible-triad patient, results were initially reported to be nearly uniformly poor. Improved understanding of the pathology and biomechanics of the elbow has led to about 70% good or excellent results with current treatment. Surgical indications for VPMI are still evolving, and reports of outcomes in these patients involve small case series. Simple elbow dislocations rarely require surgical stabilization, but when the elbow remains unstable a. Box lift (Figure 19.16) b. Push/pull (Figure 19.17) c. Plyometrics-Trampoline toss

Figure 19.12 Photograph of turnbuckle extension orthosis.

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Figure 19.15 Photograph of BOSU push-ups.

after closed reduction, the outcome of operative treatment is reported to be good or excellent results in 90% of cases.

Pearls

●● Healing of the surgical wounds and controlling edema are the first priority after surgical treatment of elbow instability. ●● Stability of the joint is more important than ROM; a stiff stable elbow can be surgically improved. The chronically unstable elbow is a difficult treatment dilemma, best treated by prevention.

Figure 19.13 Photograph of proprioceptive neuromuscular facilitation with a resistance band.

Figure 19.16 Photograph of the box lift exercise.

Figure 19.14 Photograph of counter push-ups.

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Chapter 19 • Rehabilitation After ORIF of Elbow Dislocations

Chan K, King GJ, Faber KJ: Treatment of complex elbow fracture- dislocations. Curr Rev Musculoskelet Med 2016;9(2): 185–189. Davila S: Therapist’s management of fractures and dislocations of the elbow, In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, eds. Rehabilitation of the Hand and Upper Extremity, ed 6. Philadelphia, PA, Elsevier, 2011. Doornberg JN, Ring DC: Fractures of the anteromedial facet of the coronoid process. J Bone Joint Surg Am 2006;88(10): 2216–2224. Heo YM, Yi JW, Lee JB, Lee DH, Park WK, Kim SJ: Unstable simple elbow dislocation treated with the repair of lateral collateral ligament complex. Clin Orthop Surg 2015;7(2): 241–247. Josefsson PO, Johnell O, Gentz CF: Long-term sequelae of sim- ple dislocation of the elbow. J Bone Joint Surg Am 1984;66: 927–930. Kaltenborn FM: Mobilisation of the Extremity Joints. Oslo, Norway, Olaf Norlis Bokhandel Universitetgaten, 1980. Lockard M: Clinical Biomechanics of the Elbow. Journal of Hand Therapy 2006;19(2):72–81. Maitland GD: Maitland’s Peripheral Manipulation, London, England, Butterworths, 1977. McKee MD, Schemitsch EH, Sala MJ, O’Driscoll SW: The pathoanatomy of lateral ligamentous disruption in complex elbow instability. J Shoulder Elbow Surg 2003;12:391–396. McKee MD, Pugh DM, Wild LM, Schemitsch EH, King GJ: Standard surgical protocol to treat elbow dislocations with radial head and coronoid fractures. Surgical technique. J Bone Joint Surg Am 2005;87(1):22–32. Morrey BF, An KN: Functional anatomy of the ligaments of the elbow. Clin Orthop Relat Res 1985;201:84–90. Morrey BF, Askew LJ, Chao EY: A biomechanical study of nor- mal functional elbow motion. J Bone Joint Surg Am 1981;63: 872–877. O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory insta- bility of the elbow. J Bone Joint Surg Am 1991;73:440–446. Richard MJ, Aldridhe JM 3rd, Wiesler ER, Ruch DS: Traumatic valgus instability of the elbow: pathoanatomy and results of direct repair. J Bone Joint Surg Am 2008;90(11):2416–2422. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84(4):547–551. Sardelli M, Tashjian RZ, MacWilliams BA: Functional elbow range of motion for contemporary tasks. J Bone Joint Surg Am 2011;93(5):471–477. Wolff AL, Hotchkiss RN: Lateral elbow instability: nonopera- tive, operative, and postoperative management. J Hand Ther 2006;19(2):238–243.

Figure 19.17 Photograph of the push/pull exercise.

●● Determining the stable ROM, including the position of the forearm, is essential to determining the early rehabilitation protocol. ●● The distracting weight of the forearm on the elbow can be negated by performing AA extension with the patient in the supine position. Summary Successful surgical treatment of traumatic elbow instability requires an understanding of the normal anatomy and the underlying instability pattern by both the surgeon and the ther- apist. The structures repaired must be protected as the elbow is being mobilized. Therefore, it is important to have open communication between the patient, therapist, and surgeon to achieve the desired goals. Bibliography An KN, Zobitz ME, Morrey BF: Biomechanics of the elbow, In Morrey BF, Sanchez-Sotelo J, eds. The Elbow and its Disor- ders, ed 4. Philadelphia, PA, Saunders, 2009, pp 39–63.

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