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

Section 2 •  Elbow

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

182 Postoperative Orthopaedic Rehabilitation

© 2018 American Academy of Orthopaedic Surgeons