8-A836A-2018-Books-00085-Green chapter 19-ROUND1

Chapter 19 • Rehabilitation After ORIF of Elbow Dislocations

●● 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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© 2018 American Academy of Orthopaedic Surgeons

Postoperative Orthopaedic Rehabilitation