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Rehabilitation of elbow trauma
Hand Clin 20 (2004) 363–374
Rehabilitation of elbow trauma Shrikant J. Chinchalkar, BScOT, OTR, CHT*, Mike Szekeres, BScOT Department of Hand Therapy, Hand and Upper Limb Centre, St. Joseph’s Health Care, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6
Rehabilitation following elbow trauma is a challenging proposition. The elbow is a notoriously unforgiving joint, with significant bony congruity and a capsule that thickens and tightens with trauma. Despite the inherent challenges that are faced when treating an individual with a traumatic elbow injury, success can be achieved if rehabilitation focuses on a few important concepts. These concepts include initial control of inflammation, initiation of early range of motion (ROM), and promotion of functional use of the upper extremity as bone and ligament stability permit. These goals can be accomplished through the use of modalities, exercise programs to increase ROM and strength, splinting, continuous passive motion devices (CPM), and muscle re-education. Successful rehabilitation following elbow trauma relies on communication between the treating physician and therapist. Therapists must be aware of the rigidity of bony fixation achieved, the ligamentous stability, and the status of the other soft tissues surrounding the joint. Reflection and reattachment of the triceps muscle, repair of the lateral ulnar collateral ligament, or anterior transposition of the ulnar nerve are just a few of the important details that must be known before implementing any treatment program. These surgical details guide treatment because they determine the type of motion allowed, the safe arc of motion, and the limitations for functional use of the upper extremity by the patient following surgery. Several patient factors must be * Corresponding author. E-mail address: [email protected]. on.ca (S.J. Chinchalkar).
considered. The age of the patient, activity level, occupation, and perceived compliance affect decisions regarding treatment. The importance of the elbow for functional use of the upper extremity cannot be overstated, because it allows the forearm, wrist, and hand to be positioned in space. The functional arc of motion at the elbow has been reported to be from 30( short of full extension to 130( of flexion, together with 50( of pronation and supination [1]. This arc allows positioning of the hand in various planes of motion for personal, vocational, and recreational activities. Anatomy and kinematics of the elbow Anatomy of the elbow The elbow is a complex joint, acting as a link in the lever arm system to provide mobility and stability [2,3]. The distal humerus, proximal ulna, and the radial head form the three major articulations of the elbow joint. The elbow joint consists of the ulno-trochlear, radiocapitellar, and proximal radioulnar joints. A single and continuous joint capsule covers these articulations [4]. The capsule is normally extremely thin, almost transparent, but following trauma it becomes markedly thick, resulting in contracture formation and stiffness [3]. The lateral and medial collateral ligaments act as important stabilizers of the elbow joint [5,6]. The radial collateral ligament merges with the annular ligament. These two ligaments are primarily responsible for providing stability to the radial head. The lateral ulnar collateral ligament is situated posterior to the radial collateral ligament connecting the lateral epicondyle to the
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supinator crest of the proximal ulna. The lateral collateral ligament is uniformly taut throughout elbow motion, because it attaches to the lateral epicondyle at the axis of rotation [6–8]. The lateral ulnar collateral ligament has been identified as a primary stabilizer on the lateral side and has been found to be deficient in individuals with posterolateral rotatory instability [8]. The anterior fibers of the medial collateral ligament are taut in flexion and extension and the posterior fibers are taut only in flexion. The anterior bundle is therefore the primary constraint to valgus instability throughout the arc of motion and the posterior bundle is a stabilizer of the ulnohumeral joint during flexion [9]. Motion of the elbow joint is controlled by a variety of muscles. These muscles are supplied by the musculocutaneous, median, ulnar, and radial nerves [10]. Some muscles have multiple functions based on the position of the forearm in relation to the elbow joint [11,12]. The primary flexor of the elbow is the brachialis muscle. Brachioradialis acts as secondary flexor of the elbow and has maximum ability to exert a flexion force when the forearm is in a midprone position [12]. Active contraction of the biceps muscle occurs during active flexion of the elbow when the forearm is in a supinated or a midprone position. The primary extensor of the elbow joint is triceps. The anconeus muscle also may contribute to active extension of elbow [11]. This muscle has been noted to be active with most elbow motions and therefore is believed to be a stabilizer of the elbow joint [6,12]. Forearm pronation is driven by the pronator teres and pronator quadratus. The biceps and supinator muscles are the supinators of the forearm. The muscles of the elbow have short lever arms, because their insertions are close to the anatomic axis of rotation [11,13]. These muscles therefore have to generate significant force to cause motion [11,13]. The joint reaction forces across the elbow are greatest when the elbow is flexed from a fully extended position [2,13]. The vascular supply of the elbow joint consists of the brachial, radial, and ulnar arteries. The venous system consists of cephalic and basilic veins [10]. A series of lymph nodes are found on the medial region of the cubital fossa [10]. Trauma to the elbow joint affects the functioning of the lymphatic system and often results in significant swelling of the upper extremity. Early implementation of edema control is therefore necessary to encourage lymphatic drainage and gain motion.
Kinematics of the elbow and forearm The elbow joint is described as a trochoginglymoid joint having 2( of motion allowing flexion/extension and pronation/supination. The normal arc of motion at the elbow is 0(–145( [14–16]. Up to 60% of the compressive forces on the elbow are transmitted through the radiocapitellar joint. Forces are transmitted through the radiohumeral and ulnohumeral joints and to the collateral ligaments when the extremity is used for daily activity [2,14–16]. The anterior joint capsule provides varus– valgus stability when the elbow is in full extension. The joint capsule becomes redundant when the elbow is flexed; thus, this structure offers no contribution to the stability of the elbow joint in this position [16]. The anterior bundle of the medial collateral ligament and lateral collateral ligaments are variably taut throughout the elbow motion and therefore are jointly responsible for providing varus–valgus stability during flexion and extension of the elbow joint [4,5,9,17–19]. The radial head acts as a secondary stabilizer for resisting valgus stresses, whereas the medial collateral ligament is the primary stabilizer. Radial head excision with medial collateral ligament deficiency has marked effect on the valgus stability [16,20]. Following medial collateral ligament transection the elbow remains more stable with the forearm in supination with muscle activation than in pronation [21,22]. During postoperative periods, extension should be performed in supination and limited anywhere from 30(–60( initially (depending on the severity of ligamentous damage and associated osseous injuries) and increased by 10( each week [21,22]. The lateral ulnar collateral ligament is the primary stabilizer against posterolateral rotatory instability and varus instability in addition to stabilizing the radiocapitellar joint [8,16]. Because the ligament attaches at the axis of rotation, it is uniformly taut during elbow motion [18,19]. Division of the radial collateral ligament and lateral ulnar collateral ligament causes a significant increase in varus and posterolateral rotational instability. Active flexion with the forearm in pronation following sectioning of the lateral collateral ligament is more stable than passive flexion or active motion in supination [23–25]. Maintaining forearm pronation also keeps the extensor/supinator group of muscles at optimal tension, which contributes to the stability on the lateral side [14]. On reconstruction or repair of the
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lateral collateral ligament, active elbow motion with forearm in pronation is therefore desirable [24,25] (Figs. 1 and 2). When both collateral ligaments are traumatized, as commonly seen with elbow dislocations, early active motion of the elbow with forearm in midprone or neutral rotation is advisable. Stages of healing Following injury or surgery the connective tissues undergo inflammatory, fibroblastic, and remodeling phases [26]. During the inflammatory phase treatment is focused on protecting healing structures, maintaining stability, controlling pain, minimizing edema, and moving the elbow through a stable arc of motion by performing active assisted ROM exercises. In the fibroblastic phase, the tensile strength of the healing tissue is minimal and progressively increases with time. Increased collagen density contributes to contracture formation [3]. Gentle passive ROM exercises together with active ROM exercises are added to this program to influence the collagen remodeling in a way that allows motion of the joints. As the patient advances through the fibroplastic phase, thermal modalities such as whirlpool or hot packs are initiated to increase the plasticity of the surrounding tissues to make them more amenable to stretching. Light activities of daily living are encouraged. Patients are cautioned with respect to the aggressiveness of exercise so that an inflammatory response is not provoked. Static progressive splinting to gain ROM is considered, depending on the injury or surgery. During the remodeling phase, heat modalities combined with
Fig. 1. Extension of the elbow in pronation to protect the lateral ulnar collateral ligament and lateral-sided structures.
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passive, active, and progressive strengthening exercises enhance collagen orientation and plastic elongation of musculotendinous and capsular tissues. Low-grade joint mobilization techniques initially [27,28], progressing to high grades are also effective in increasing joint mobility and ROM. Static progressive splinting together with progressive resistive muscle strengthening increases mobility and strength. Endurance training and work hardening then are added to the program.
Modalities for rehabilitation Edema and pain control Edema and pain are common occurrences following an elbow trauma or surgery. These two factors are likely to limit mobility and function of the elbow. This may have a significant effect on patients’ participation in a rehabilitation program. Fear of moving the elbow joint may lead to contracture formation and stiffness. Patient education regarding these issues and therapeutic management leads to better cooperation during mobilization of the elbow joint. Initially compression bandaging and elevation of the elbow above heart level with pillows is ideal in controlling edema. Application of cold packs during the inflammatory phase further assists in controlling pain and swelling. As active assisted motion and eventually active and resisted active exercises are introduced, the muscle action further assists in venous return and lymphatic drainage, reducing pain and edema.
Fig. 2. Forearm rotation can be performed with the elbow held in greater than 90( of flexion to prevent undue stress on the ligamentous repair.
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Range of motion and strengthening exercises Range of motion exercises are divided into four categories: gravity-assisted or active-assisted, active, passive, and resistive or strengthening exercises. These exercises are introduced as the patient progresses from the inflammatory to the remodeling phase of healing. During range of motion exercises, patients are positioned supine or sitting with the arm on the table supported on pillows to decrease compensatory motion at shoulder and wrist joints and to isolate muscles groups effectively during motion. Following injury or surgery to the elbow, early protected motion using active-assisted or gravityassisted exercises are effective in minimizing intra-articular adhesion formation, in promoting articular cartilage healing, and in improving hemodynamics. Diagnosis-specific safe arc motion begins on the first postoperative day if possible. Because the motion of the injured arm is guided by the unaffected extremity, load requirement on the muscle and the compressive loads on the joint during motion are decreased, minimizing pain [26]. Active ROM exercises often are introduced as soon as pain and swelling allow, typically before 1 week [26]. Slow, sequential motion of agonists and antagonists stimulate tendon and proprioceptive end-organs, which further inhibits pain. Active ROM recruits intra- and extrafusal fibers to minimize cocontraction of the antagonists. Active motion assists in cartilaginous regeneration, stimulates arterial flow, and increases venous and lymphatic return. This enhances the tensile strength of the healing tissues. Passive ROM exercises of a graded nature are introduced during the fibroblastic phase and are continued into the remodeling phase if motion is restricted by collagen density. Passive ROM exercises are most effective if low load stresses are applied within tissue tolerance that do not elicit inflammatory process and pain. The passive stresses are modified or adjusted as motion is gained. On completion of passive ROM exercises, active ROM exercises are commenced to increase the amplitude of muscle contraction/excursion. Active ROM attempts are encouraged, attaining and maintaining the end range achieved through passive ROM exercises. Resistive or strengthening exercises may be introduced in early stages of remodeling. Isotonic exercises progressing to isometric, with no resistance and low repetitions initially, progressing
to low and high resistances with increasing repetitions are beneficial in gaining strength [29]. All of the muscle groups of the elbow, forearm, wrist, and hand are exercised within physical tolerance of the muscles. Free weights and elastic bands of graded resistance are used for strengthening. Endurance training and simulated work hardening can be added to the program once patients have minimal or no discomfort. Optimum dosage in frequency or repetition of ROM exercises is unknown. The authors’ preference, however, is that patients perform 5–10 repetitions every 2–3 hours initially, progressing to 15–20 repetitions on an hourly basis as long as these repetitions do not cause pain, inflammatory response, or muscle fatigue. Patients are encouraged to perform active ROM exercises of the shoulder, wrist, and fingers throughout their rehabilitation program. Depending on the stability of the elbow injury, a protective splint may be used when the shoulder joint is exercised. Forearm pronation/supination exercises are performed actively with the elbow in 90( of flexion or as dictated by ligamentous stability. Joint mobilization and manual therapy Mobilization of the joint in rehabilitation of elbow trauma has a role in reducing pain, decreasing muscle spasm, and gaining motion if followed immediately by active or passive motion. Initially oscillatory motions of the elbow are effective in stimulating tendon and proprioceptive end-organs, which inhibits muscle spasm and muscle cocontraction [27,28]. In the later stages of the fibroblastic phase, mobilization of a joint from midrange with a lower velocity–grade II and a lower velocity from midrange into resistance– grade III joint mobilization techniques are introduced. These maneuvers are performed with caution, however, keeping in mind the healing status of the bone, ligaments, and the surrounding soft tissues. Grade III and grade IV mobilizations together with longitudinal joint distraction techniques at end point of the joint range of motion are used during the remodeling phase of tissue healing. These joint mobilizations do not cause a permanent change in the joint and are effective only if followed by passive physiologic stretching. Proper positioning of the shoulder and the forearm is critical, ensuring that the stresses placed on the ligamentous and skeletal structures are not disrupting the healing process. The techniques
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used for gaining flexion or extension or pronation or supination are well described by Maitland and Kaltenborn [27,28]. Splinting Splinting is an important part of most rehabilitation programs following elbow trauma. Splinting of the elbow provides stability and reduces force transmission at the site of fracture or soft tissue injury to allow the osseous and ligamentous structures around the joint to heal [30]. Excessive immobilization of the joint may lead to secondary stiffness and contracture. The following section describes some of the splints fabricated during rehabilitation and details some general guidelines for treatment of elbow trauma commonly seen in therapy. For the ease of discussion, splinting has been divided into the categories of splinting for protection and splinting to regain motion. Protective splinting is initiated within 1–2 days following trauma, whereas splinting for the purpose of regaining motion often is initiated once sufficient healing has occurred and the application of a low load, prolonged stretch can be used to increase ROM. Splinting for protection Treatment following elbow trauma often requires the use of splints for protection and optimal positioning. A posterior resting splint (Fig. 3) holding the elbow at 90( of flexion is an effective way to immobilize the elbow to protect fractures and soft tissue injuries. A collar and cuff (Fig. 4) also may be used for stable injuries. This allows for easy removal for performing exercise programs but limits light functional use of the
Fig. 3. A posterior elbow resting splint.
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upper extremity when worn, because the forearm is held against the body. A collar and cuff also places the shoulder in an internally rotated position and can lead to stiffness of the anterior capsule of the shoulder. It is therefore extremely important that patients exercise their shoulder when placed in a collar and cuff. Positioning the elbow in 90( of flexion is usually the most comfortable position, because it reduces pressure within the capsule of the joint, as the capsule of the elbow joint is at its greatest capacity at approximately 80( of flexion [31]. Any deviation from this position increases the pressure in the capsule and can cause pain. Keeping the capsule from being filled with fluid or hematoma can be achieved by splinting the elbow joint in extension. Because most elbow trauma leads to an inability to achieve terminal elbow extension, extension splinting is beneficial. The extension splint is molded to the anterior aspect of the arm and extends 3–5 cm from the axillary fold to 4–5 cm proximal to the radial styloid (Fig. 5). It is important that the splint does not extend beyond this, because it can cause problems with the dorsal sensory branch of the radial sensory nerve at this level. A crisscross type of strapping pattern over the posterior aspect of the elbow just proximal to the olecranon process helps secure the elbow into the splint. Functional use of the upper extremity is limited significantly during extension splinting; therefore, this splint commonly is worn only at night. Splinting to regain motion Several dynamic and static progressive splints have been devised to regain motion of the elbow
Fig. 4. A collar and cuff for positioning the elbow at 90( following elbow trauma.
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Fig. 5. A nighttime extension splint.
that has become stiff because of trauma and immobilization. These splints typically are avoided for 3–6 weeks postinjury for fear of inducing increased pain, inflammation, or heterotopic ossification. Four splints the authors have found to be most effective are the static progressive flexion cuff, the serial static extension splint, the static progressive turnbuckle for elbow flexion and extension, and a static progressive or dynamic pronation/supination splint for proximal radioulnar joint stiffness. The static progressive elbow flexion cuff is a device used by the patient to hold the elbow in flexion for the purpose of obtaining a low load, prolonged stretch (Fig. 6). A posterior slab is molded around the upper arm and a cuff is placed around the wrist. The patient then adjusts the tension on the straps after placing them through the D-rings on the arm cuff. This cuff can be used once stability of the bone is no longer in question. When flexion is less than 100(, a splint with
Fig. 6. A static progressive flexion cuff.
a fixed hinge can be used to absorb the compression force placed on the joint by not having an optimal direction of pull (Fig. 7). The use of a fixed hinge transfers only the rotational component of the force to the elbow joint. Entrapment of the ulnar nerve during healing phases may inhibit gliding of the ulnar nerve and produce weakness of the muscles together with sensory disturbances. This often is noted during elbow flexion increases or with dynamic or static progressive flexion splinting. Patients therefore must be encouraged to watch for signs of paresthesia in the ulnar nerve when undertaking a splinting program to regain elbow flexion. The static progressive extension turnbuckle splint is simply a static elbow extension splint with some added hardware. The extension splint is cut at the cubital fossa, two hinges are added, and a turnbuckle is fixed to the anterior portion of the splint (Fig. 8). The patient then adjusts the turnbuckle to increase the extension stretch applied by the splint. Gelinas et al [32] found that using the turnbuckle splint for extension was beneficial for increasing ROM when worn up to 20 hours per day for a mean of 4.5 months, even after patients had gone through an intensive therapy program unsuccessfully. Such long wearing times for splints often are not tolerated, because they limit functional use of the upper extremity. The authors prefer to start splinting earlier in the fibroblastic phase of healing with a wearing time of 1–2 hours, 3–4 times per day and at night with a gentle stretch applied. Using static progressive splinting in conjunction with
Fig. 7. A static progressive flexion hinge. The hinge absorbs compressive force on the elbow for individuals with less than 100( of flexion to minimize pain and increase comfort.
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Fig. 8. A static progressive extension splint for extension.
intensive therapy is the most effective means of increasing motion at the elbow. Proximal radioulnar joint stiffness can occur with a variety of pathologies around the elbow joint. Fractures of the proximal ulna and radial head and dislocations are often causes of proximal radioulnar joint stiffness. Splinting for this stiffness usually involves a dynamic splint or a static progressive splint holding the forearm in maximal pronation or supination 4–6 hours per day. A static progressive splint is commercially available from Joint Active Systems (Effingham, Illinois; Fig. 9). The wearing schedule for these splints is similar to the turnbuckle described earlier. Continuous passive motion Several physiologic advantages of continuous passive motion have been reported. These include sinusoidal oscillations in intra-articular pressure, absorption of intra-articular hematoma, control of edema, hyaline cartilage remodeling, reorganization of collagen fibers, and enhancement of metabolic activity [33–36]. This mode of treatment is especially effective in the later stages of fibroplasia or during remodeling if patients have limited or unidirectional gains or muscle spasm or if patients are having difficulty maintaining achieved mobility with traditional splinting, ROM, and mobilization techniques. A combination of traditional treatment during the day (ie, splinting, ROM, and mobilization) and application of continuous progressive passive motion at night can increase ROM of the joint. Muscle excursion is maintained at night, enhancing the ability to maintain the achieved mobility. Continuous passive motion for restoration of motion is indicated only when fractures have stable fixation.
Fig. 9. A static progressive pronation/supination splint from Joint Active Systems.
A safe arc of motion within the limits of soft tissue constraints is used and as the tissue compliance increases, the arc of motion is adjusted accordingly. This method of treatment is contraindicated in fractures with tenuous fixation and ligamentous insufficiency [37]. Ultrasound Although commonly used in the upper extremity, studies to support the use of ultrasound are based primarily on animal subjects, and further investigation is needed. The literature does suggest that a low intensity, pulsed ultrasound may be effective for promoting the healing of wounds and increasing fibroblastic activity within soft tissues and also for resolving subacute inflammation [38]. Higher intensity ultrasound provides a thermal increase to the tissues and may increase the extensibility of scar tissue. This temporary increase is tissue extensibility is beneficial when followed by passive stretching. To effectively heat soft tissues within a reasonable amount of time, the area of application should not be greater than three times the size of the ultrasound head [39]. The authors do not advocate the use of ultrasound on the elbow for heating purposes because
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of the size of the area to be heated. Application of superficial heating modalities such as hot packs or whirlpool are more effective therapeutic techniques when followed by appropriate active and passive stretching exercises. These forms of heat are superior because they also can be used before home exercise programs.
insertion site of triceps. The use of electrical stimulation is limited in these cases, because it produces a contraction that is painful and patients often develop cocontraction as a protective mechanism against the pain.
EMG biofeedback and neuromuscular electrical stimulation
Fractures of the distal humerus
The musculocutaneous, median, ulnar, and radial nerves innervate the muscles crossing the elbow and the joint. The receptors of these nerves detect changes in tension, position of the joints, joint compression or distraction, muscle length, muscle force, and speed. These changes are relayed to the spinal cord and brain. Integrated signals then modify the activation of motor units to generate appropriate muscle tension required for desired function [29]. Following elbow trauma, injury to this receptor system is likely. In addition, immobilization or limited mobility of the elbow joint causes abnormal programming of the receptor system function. Often muscle guarding caused by cocontraction of the antagonist muscles or muscle spasms during active or passive mobilization of the elbow occurs, limiting range of motion [40,41]. The elbow flexors display greater hyperactivity than the extensors when active or passive extension forces are applied [42]. This induced shortened stretch reflex, caused by a disturbance of these receptor systems, may be one of the causes of elbow flexion contractures. EMG biofeedback (as an adjunctive treatment) is often an effective way to re-educate the muscles and to reduce contractures by inhibiting cocontraction of the antagonists. A dual channel EMG biofeedback instrument is most effective in re-education of the muscles [43,44]. A baseline measurement is taken to establish cocontraction of the antagonists. Patients then are encouraged to inhibit cocontraction of the antagonist by using verbal cues and proprioceptive facilitation stimulation while elbow motion is performed [45]. Once desired motion is attained, an EMG biofeedback triggered electrical stimulation for triceps strengthening is an effective method of treatment to gain elbow extension. Electrical stimulation of muscles combined with active contraction produces the strongest contraction possible for the purpose of strengthening and regaining active ROM. Resisted extension of the elbow following trauma can be painful at the
Injury-specific treatment guidelines
Rehabilitation of distal humerus fractures depends greatly on the initial management. The type of fracture, amount of fixation, surgical approach, and associated soft tissue and ligamentous injury all play a role in determining the course of the rehabilitation process. Most distal humerus fractures, regardless of location or type, are treated operatively with stable internal fixation [46]. The operative procedure often involves reflecting the triceps or performing an olecranon osteotomy. Initial therapeutic management must involve protecting the triceps mechanism and minimizing the hemarthrosis by splinting the elbow in full extension in the operating room. Because of the intra-articular nature of these fractures, arthrofibrosis is a common complication, so immobilization for prolonged periods should be avoided. Early mobilization helps to reduce intraarticular fibrosis, hematoma, edema, and pain. Patients usually are seen in therapy 1 day postoperatively and are fitted with a collar and cuff in 90( of flexion and an extension splint for night use. A collar and cuff permits easy initiation of elbow motion exercise during the day. The initial home program consists of elevation and ice for edema control, active-assisted flexion, gravityassisted extension, active pronation/supination, and maintenance exercises for the shoulder, wrist, and hand. If a triceps sparing approach was used, immediate active extension exercises are permitted. Once callus formation is radiologically evident, passive ROM and static progressive splinting are initiated to regain motion. Olecranon fractures Olecranon fractures are treated most commonly with open reduction and internal fixation. Surgical intervention often involves the placement of tension band wiring or plating to stabilize the fracture [47]. The triceps is protected in the early healing phase as activation stresses the fracture fixation. Splint use is similar to what is used for the treatment of distal humerus fractures. Active
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flexion exercises are permitted without restriction for stable fractures but are limited to 100( and are increased by 10( per week if fixation is tenuous. Radial head fractures Radial head fractures are the most common of all elbow fractures. Elbow instability may occur with larger fragments that often have some degree of associated ligamentous injury [48,49]. The management of radial head fractures is similar whether surgery is performed or not. Associated ligamentous injuries of the elbow are the primary determinant altering the therapy protocol. Simple undisplaced or minimally displaced radial head fractures without a mechanical block of motion are treated with a collar and cuff for comfort, pain and edema control, and early mobilization [49]. Forearm rotation with elbow held in 90( of flexion in an assisted manner using the uninvolved hand reduces compressive load on the radiocapitellar joint, preventing further displacement of the fracture yet allowing pain-free motion. Elbow extension and flexion should be performed with the forearm in pronation. Forearm supination has been demonstrated to increase the load at the radiocapitellar joint [11,13,16,25]. This may induce pain and further displacement of the fracture fragments because of the eccentric and isotonic contraction of the biceps and brachialis muscles, respectively. Several sessions of ROM exercises on a daily basis are recommended (preferably 10–15 repetitions on an hourly basis). As the pain subsides and the healing of the fracture becomes evident radiologically, rotation in graduated elbow extension is permitted. Close monitoring and static progressive extension splinting for elbow flexion contracture development is critical in gaining extension of the elbow joint. Graded strengthening of the elbow and forearm is introduced on healing of the fracture. Displaced radial head fractures requiring open reduction and internal fixation without ligamentous injury are positioned in a collar and cuff or a sling for day use and elbow extension splint for night. Early mobilization of the elbow and forearm and other therapeutic management is performed in a manner similar to that described previously. For patients requiring ligamentous repair in association with open reduction and internal fixation, radial head excision, or radial head arthroplasty, the management must address the preservation of ligamentous integrity [24,25,48,
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50,51]. If the lateral collateral ligament is deficient, the elbow is positioned at 90( of flexion with the forearm pronated in a splint on postoperative day 1. Early active elbow flexion and extension with the forearm maintained in pronation and forearm rotation with the elbow at greater than 90( of flexion is initiated on postoperative day 1 [24,25]. This active ROM program is performed for a period of 4–6 weeks postoperatively. Edema and pain control are as described previously. Whirlpool or hot pack treatment are added once the sutures/staples are removed, together with scar massage, desensitization, and application of silicone gel strips for scar remodeling. Close monitoring of elbow and forearm contractures and management with appropriate splinting (serial static or static progressive) are instituted, depending on the presence of symptoms and the stage of healing. Strengthening of the elbow and forearm is withheld for 8 weeks postoperatively or until fracture healing or consolidation is evident radiologically. It is critical that patients perform elbow flexion/extension strengthening exercises with forearm in pronation, initially with lighter weight and progressing gradually in midprone or neutral. Strengthening then can be performed in supination as these patients advance in their postoperative periods. Pronation/supination strengthening is initiated with the elbow at 90( to avoid stresses on the repaired ligaments. Graduated work hardening and return to work conditioning then is the final component of the therapy program. Coronoid fractures Fractures of the coronoid process are seen commonly with dislocation of the elbow with or without associated radial head fractures. There usually are associated ligamentous injuries [52]. Isolated coronoid fractures are uncommon. Fractures that are stable after reduction are treated with early active stable arc of motion defined in the operating room by the surgeon. Extension of the elbow may be blocked at 40(–60( short of full extension initially using an elbow hinge brace or a cast brace to minimize eccentric load on the anterior aspect of the coronoid process for unstable fractures [53]. A 10( increment of extension on a weekly basis then is permitted. The extension block splint is used for 4–6 weeks. Passive extension exercises or progressive mobilization splinting are delayed until fracture and ligament healing occurs. Pronation and supination
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exercises are performed with the elbow at 90( of flexion out of the splint. Because of the postoperative positioning required in these situations, the occurrence of flexion contractures is common. Early contracture control with serial elbow extension splinting at 4 weeks postoperatively may be introduced for optimal results. Strengthening exercises, however, may be delayed to 8–10 weeks postoperatively, depending on the fracture and ligamentous healing and elbow stability. Elbow dislocations Elbow dislocations represent 11%–28% of all elbow injuries, and the elbow is the second most common joint dislocated in the adult population [8]. Recurrence of simple elbow dislocations is uncommon because of the intrinsic stability of the joint. The collateral ligaments that are disrupted, however, must be protected during rehabilitation to prevent chronic varus/valgus instabilities or posterolateral rotatory instability. The primary goal of therapy following reduction of a simple dislocation is to increase serially ROM while maintaining the reduction and preventing undue stress on the healing collateral ligaments. All patients initially are splinted in a posterior elbow splint holding the joint in 90( of flexion for 5–7 days. Patients then begin protected active motion. If the elbow is stable once reduced, unrestricted active motion is permitted [17]. If instability is an issue, full flexion is permitted, but extension of the elbow past 40(–60( is avoided. Extension is increased by approximately 15( per week. Whether the forearm is supinated, pronated, or in neutral while performing extension depends on which ligaments are damaged, as previously discussed. If patients fail to achieve weekly goals for extension in therapy, a nighttime extension splint is fabricated at week 4–6. Passive stretching of the elbow should not be performed until after week 6 to ensure that the ligamentous stability is no longer an issue and that no heterotopic bone has formed. Aggressive stretching before week 6 may lead to greater stiffness, pain, and loss of functional use.
Summary The rehabilitation of elbow trauma presents numerous challenges. Involvement of the osseous structures, compromise of the ligamentous
stability, and loss of the soft tissue excursion necessary for elbow motion and function require due consideration during the treatment of elbow joint injuries. Stiffness of the elbow joint following trauma is common. This stiffness is caused by extrinsic and intrinsic factors. Contractures of the elbow joint develop as a result of contractures of the joint capsule, ligamentous structures, musculotendinous structures, intra-articular adhesions, and ectopic ossification. Early mobilization and splinting of the elbow following injury, within a safe arc of elbow motion, makes the elbow joint more compliant to the rehabilitative techniques outlined. Understanding the details of elbow anatomy, biomechanics, trauma, and surgical procedures for repairing the osseous and the ligamentous structures thus are the key factors in rehabilitating the elbow joint successfully. References [1] Morrey BF, Askew LJ, An KN. A biomechanical study of normal functional elbow motion. J Bone Joint Surg [Am] 1981;63A:872. [2] An KN, Morrey BF. Biomechanics of the elbow. In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders; 2000. p. 43–60. [3] Hotchkiss RN. Elbow contractures. In: Green DP, editor. Green’s operative hand surgery. New York: Churchill Livingstone; 1999. [4] Cage DJ, Abrams RA, Callahan JJ, et al. Soft tissue attachments of the ulnar coronoid process. An anatomic study with radiographic correlation. Clin Orthop 1995;320:154–8. [5] King GJ, Morrey BF, An AK. Stabilizers of the elbow. J Shoulder Elbow Surg 1993;2:165. [6] Morrey BF. Anatomy of the elbow. In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders; 2000. p. xxiii. [7] Cohen MS, Hastings H II. Rotatory instability of the elbow. The anatomy and role of the lateral stabilizers. J Bone Joint Surg [Am] 1997;79(2):225–33. [8] O’Driscoll SW, et al. Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop 1992; 280:186–97. [9] O’Driscoll SW, et al. Origin of the medial ulnar collateral ligament. J Hand Surg [Am] 1992;17(1):164–8. [10] Williams PL. Peripheral nervous system. In: Gray H, Williams PL, Bannister LH, editors. Gray’s anatomy: the anatomical basis of medicine and surgery. New York: Churchill Livingstone; 1995. p. 1224–74. [11] Amis AA, Dowson D, Wright V. Muscle strengths and musculoskeletal geometry of the upper limb. Eng Med 1979;8:41–8. [12] Basmajian JV. Muscle alive: their function revealed by electromyography. 3rd edition. Baltimore: Williams & Wilkins; 1974.
S.J. Chinchalkar, M. Szekeres / Hand Clin 20 (2004) 363–374 [13] Amis AA. Biomechanics of the elbow. In: Wallace WA, editor. Joint replacement in the shoulder and elbow. Oxford: Butterworth-Heinemann; 1998. [14] Werner FW, An KN. Biomechanics of the elbow and forearm. Hand Clin 1994;10(3):357–73. [15] Hotchkiss RN, DaVila S. Rehabilitation of the elbow. In: Nickel E, Botte MJ, editors. Orthopaedic rehabilitation. New York: Churchill Livingstone; 1992. [16] An KN, Morrey BF. Biomechanics of the elbow. In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders; 2000. p. 45–60. [17] Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin N Am 1999;30(1):63–79. [18] Olsen BS, et al. Kinematics of the lateral ligamentous constraints of the elbow joint. J Shoulder Elbow Surg 1996;5(5):333–41. [19] Olsen BS, et al. Lateral collateral ligament of the elbow joint: anatomy and kinematics. J Shoulder Elbow Surg 1996;5(2 Pt 1):103–12. [20] King GJ, et al. An anthropometric study of the radial head: implications in the design of a prosthesis. J Arthroplasty 2001;16(1):112–6. [21] Armstrong AD, et al. Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Surg [Am] 2000;25(6): 1051–7. [22] Armstrong AD, et al. Single-strand ligament reconstruction of the medial collateral ligament restores valgus elbow stability. J Shoulder Elbow Surg 2002; 11(1):65–71. [23] King GJ, et al. Single-strand reconstruction of the lateral ulnar collateral ligament restores varus and posterolateral rotatory stability of the elbow. J Shoulder Elbow Surg 2002;11(1):60–4. [24] Dunning CE, et al. Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg [Am] 2001;83A(12): 1823–8. [25] Dunning CE, et al. Muscle forces and pronation stabilize the lateral ligament deficient elbow. Clin Orthop 2001;388:118–24. [26] Da’vila SA. Therapist’s management of fractures and dislocations of the elbow. In: Callahan AD, Mackin EJ, Skirven TM, Schneider LH, Ostermen AL, editors. Rehabilitation of the hand and upper extremity. St. Louis: CV Mosby; 2002. p. 1230–62. [27] Maitland GD. Treatment. In: Peripheral manipulation. London: Butterworth Heinemann; 1993. p. 64–106. [28] Kaltenborn FM. Manual mobilisation of the extremity joints. Basic examination and treatment techniques. 4th edition. Oslo: Olf Norlis Bokhandel Holtegaten; 1989. [29] Smith LK, Weiss EL, Lehmkuhl LD. Aspects of muscle physiology and neurophysiology. In: Brunn-
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[46] Korner J, et al. A biomechanical evaluation of methods of distal humerus fracture fixation using locking compression plates versus conventional reconstruction plates. J Orthop Trauma 2004;18(5): 286–93. [47] Hak DJ, Golladay GJ. Olecranon fractures treatment options. J Am Acad Orthop Surg 2000;8: 266–75. [48] Smith GR, Hotchkiss RN. Radial head and neck fractures: anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5(2 Pt 1):113–7. [49] Morrey BF. Radial head fractures. In: Morrey BF, editor. The elbow and its disorders. Philadelphia: WB Saunders; 2000. p. 341–64.
[50] Herbertsson P, Josefsson PO, Hasserius R, Karlsson C, Besjakov J, Karlsson M. Uncomplicated Mason type-II and III fractures of the radial head and neck in adults. A long-term follow-up study. J Bone Joint Surg [Am] 2004;86A(3):569–74. [51] Ashwood N, Bain GI, Unni R. Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. J Bone Joint Surg [Am] 2004;86A(2):274–80. [52] 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; 84A(4):547–51. [53] Ring D, Jupiter JB. Fracture-dislocation of the elbow. J Bone Joint Surg [Am] 1998;80:566–80.
Rehabilitation of elbow trauma Shrikant J. Chinchalkar, BScOT, OTR, CHT*, Mike Szekeres, BScOT Department of Hand Therapy, Hand and Upper Limb Centre, St. Joseph’s Health Care, 268 Grosvenor Street, London, Ontario, Canada N6A 4L6
Rehabilitation following elbow trauma is a challenging proposition. The elbow is a notoriously unforgiving joint, with significant bony congruity and a capsule that thickens and tightens with trauma. Despite the inherent challenges that are faced when treating an individual with a traumatic elbow injury, success can be achieved if rehabilitation focuses on a few important concepts. These concepts include initial control of inflammation, initiation of early range of motion (ROM), and promotion of functional use of the upper extremity as bone and ligament stability permit. These goals can be accomplished through the use of modalities, exercise programs to increase ROM and strength, splinting, continuous passive motion devices (CPM), and muscle re-education. Successful rehabilitation following elbow trauma relies on communication between the treating physician and therapist. Therapists must be aware of the rigidity of bony fixation achieved, the ligamentous stability, and the status of the other soft tissues surrounding the joint. Reflection and reattachment of the triceps muscle, repair of the lateral ulnar collateral ligament, or anterior transposition of the ulnar nerve are just a few of the important details that must be known before implementing any treatment program. These surgical details guide treatment because they determine the type of motion allowed, the safe arc of motion, and the limitations for functional use of the upper extremity by the patient following surgery. Several patient factors must be * Corresponding author. E-mail address: [email protected]. on.ca (S.J. Chinchalkar).
considered. The age of the patient, activity level, occupation, and perceived compliance affect decisions regarding treatment. The importance of the elbow for functional use of the upper extremity cannot be overstated, because it allows the forearm, wrist, and hand to be positioned in space. The functional arc of motion at the elbow has been reported to be from 30( short of full extension to 130( of flexion, together with 50( of pronation and supination [1]. This arc allows positioning of the hand in various planes of motion for personal, vocational, and recreational activities. Anatomy and kinematics of the elbow Anatomy of the elbow The elbow is a complex joint, acting as a link in the lever arm system to provide mobility and stability [2,3]. The distal humerus, proximal ulna, and the radial head form the three major articulations of the elbow joint. The elbow joint consists of the ulno-trochlear, radiocapitellar, and proximal radioulnar joints. A single and continuous joint capsule covers these articulations [4]. The capsule is normally extremely thin, almost transparent, but following trauma it becomes markedly thick, resulting in contracture formation and stiffness [3]. The lateral and medial collateral ligaments act as important stabilizers of the elbow joint [5,6]. The radial collateral ligament merges with the annular ligament. These two ligaments are primarily responsible for providing stability to the radial head. The lateral ulnar collateral ligament is situated posterior to the radial collateral ligament connecting the lateral epicondyle to the
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supinator crest of the proximal ulna. The lateral collateral ligament is uniformly taut throughout elbow motion, because it attaches to the lateral epicondyle at the axis of rotation [6–8]. The lateral ulnar collateral ligament has been identified as a primary stabilizer on the lateral side and has been found to be deficient in individuals with posterolateral rotatory instability [8]. The anterior fibers of the medial collateral ligament are taut in flexion and extension and the posterior fibers are taut only in flexion. The anterior bundle is therefore the primary constraint to valgus instability throughout the arc of motion and the posterior bundle is a stabilizer of the ulnohumeral joint during flexion [9]. Motion of the elbow joint is controlled by a variety of muscles. These muscles are supplied by the musculocutaneous, median, ulnar, and radial nerves [10]. Some muscles have multiple functions based on the position of the forearm in relation to the elbow joint [11,12]. The primary flexor of the elbow is the brachialis muscle. Brachioradialis acts as secondary flexor of the elbow and has maximum ability to exert a flexion force when the forearm is in a midprone position [12]. Active contraction of the biceps muscle occurs during active flexion of the elbow when the forearm is in a supinated or a midprone position. The primary extensor of the elbow joint is triceps. The anconeus muscle also may contribute to active extension of elbow [11]. This muscle has been noted to be active with most elbow motions and therefore is believed to be a stabilizer of the elbow joint [6,12]. Forearm pronation is driven by the pronator teres and pronator quadratus. The biceps and supinator muscles are the supinators of the forearm. The muscles of the elbow have short lever arms, because their insertions are close to the anatomic axis of rotation [11,13]. These muscles therefore have to generate significant force to cause motion [11,13]. The joint reaction forces across the elbow are greatest when the elbow is flexed from a fully extended position [2,13]. The vascular supply of the elbow joint consists of the brachial, radial, and ulnar arteries. The venous system consists of cephalic and basilic veins [10]. A series of lymph nodes are found on the medial region of the cubital fossa [10]. Trauma to the elbow joint affects the functioning of the lymphatic system and often results in significant swelling of the upper extremity. Early implementation of edema control is therefore necessary to encourage lymphatic drainage and gain motion.
Kinematics of the elbow and forearm The elbow joint is described as a trochoginglymoid joint having 2( of motion allowing flexion/extension and pronation/supination. The normal arc of motion at the elbow is 0(–145( [14–16]. Up to 60% of the compressive forces on the elbow are transmitted through the radiocapitellar joint. Forces are transmitted through the radiohumeral and ulnohumeral joints and to the collateral ligaments when the extremity is used for daily activity [2,14–16]. The anterior joint capsule provides varus– valgus stability when the elbow is in full extension. The joint capsule becomes redundant when the elbow is flexed; thus, this structure offers no contribution to the stability of the elbow joint in this position [16]. The anterior bundle of the medial collateral ligament and lateral collateral ligaments are variably taut throughout the elbow motion and therefore are jointly responsible for providing varus–valgus stability during flexion and extension of the elbow joint [4,5,9,17–19]. The radial head acts as a secondary stabilizer for resisting valgus stresses, whereas the medial collateral ligament is the primary stabilizer. Radial head excision with medial collateral ligament deficiency has marked effect on the valgus stability [16,20]. Following medial collateral ligament transection the elbow remains more stable with the forearm in supination with muscle activation than in pronation [21,22]. During postoperative periods, extension should be performed in supination and limited anywhere from 30(–60( initially (depending on the severity of ligamentous damage and associated osseous injuries) and increased by 10( each week [21,22]. The lateral ulnar collateral ligament is the primary stabilizer against posterolateral rotatory instability and varus instability in addition to stabilizing the radiocapitellar joint [8,16]. Because the ligament attaches at the axis of rotation, it is uniformly taut during elbow motion [18,19]. Division of the radial collateral ligament and lateral ulnar collateral ligament causes a significant increase in varus and posterolateral rotational instability. Active flexion with the forearm in pronation following sectioning of the lateral collateral ligament is more stable than passive flexion or active motion in supination [23–25]. Maintaining forearm pronation also keeps the extensor/supinator group of muscles at optimal tension, which contributes to the stability on the lateral side [14]. On reconstruction or repair of the
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lateral collateral ligament, active elbow motion with forearm in pronation is therefore desirable [24,25] (Figs. 1 and 2). When both collateral ligaments are traumatized, as commonly seen with elbow dislocations, early active motion of the elbow with forearm in midprone or neutral rotation is advisable. Stages of healing Following injury or surgery the connective tissues undergo inflammatory, fibroblastic, and remodeling phases [26]. During the inflammatory phase treatment is focused on protecting healing structures, maintaining stability, controlling pain, minimizing edema, and moving the elbow through a stable arc of motion by performing active assisted ROM exercises. In the fibroblastic phase, the tensile strength of the healing tissue is minimal and progressively increases with time. Increased collagen density contributes to contracture formation [3]. Gentle passive ROM exercises together with active ROM exercises are added to this program to influence the collagen remodeling in a way that allows motion of the joints. As the patient advances through the fibroplastic phase, thermal modalities such as whirlpool or hot packs are initiated to increase the plasticity of the surrounding tissues to make them more amenable to stretching. Light activities of daily living are encouraged. Patients are cautioned with respect to the aggressiveness of exercise so that an inflammatory response is not provoked. Static progressive splinting to gain ROM is considered, depending on the injury or surgery. During the remodeling phase, heat modalities combined with
Fig. 1. Extension of the elbow in pronation to protect the lateral ulnar collateral ligament and lateral-sided structures.
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passive, active, and progressive strengthening exercises enhance collagen orientation and plastic elongation of musculotendinous and capsular tissues. Low-grade joint mobilization techniques initially [27,28], progressing to high grades are also effective in increasing joint mobility and ROM. Static progressive splinting together with progressive resistive muscle strengthening increases mobility and strength. Endurance training and work hardening then are added to the program.
Modalities for rehabilitation Edema and pain control Edema and pain are common occurrences following an elbow trauma or surgery. These two factors are likely to limit mobility and function of the elbow. This may have a significant effect on patients’ participation in a rehabilitation program. Fear of moving the elbow joint may lead to contracture formation and stiffness. Patient education regarding these issues and therapeutic management leads to better cooperation during mobilization of the elbow joint. Initially compression bandaging and elevation of the elbow above heart level with pillows is ideal in controlling edema. Application of cold packs during the inflammatory phase further assists in controlling pain and swelling. As active assisted motion and eventually active and resisted active exercises are introduced, the muscle action further assists in venous return and lymphatic drainage, reducing pain and edema.
Fig. 2. Forearm rotation can be performed with the elbow held in greater than 90( of flexion to prevent undue stress on the ligamentous repair.
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Range of motion and strengthening exercises Range of motion exercises are divided into four categories: gravity-assisted or active-assisted, active, passive, and resistive or strengthening exercises. These exercises are introduced as the patient progresses from the inflammatory to the remodeling phase of healing. During range of motion exercises, patients are positioned supine or sitting with the arm on the table supported on pillows to decrease compensatory motion at shoulder and wrist joints and to isolate muscles groups effectively during motion. Following injury or surgery to the elbow, early protected motion using active-assisted or gravityassisted exercises are effective in minimizing intra-articular adhesion formation, in promoting articular cartilage healing, and in improving hemodynamics. Diagnosis-specific safe arc motion begins on the first postoperative day if possible. Because the motion of the injured arm is guided by the unaffected extremity, load requirement on the muscle and the compressive loads on the joint during motion are decreased, minimizing pain [26]. Active ROM exercises often are introduced as soon as pain and swelling allow, typically before 1 week [26]. Slow, sequential motion of agonists and antagonists stimulate tendon and proprioceptive end-organs, which further inhibits pain. Active ROM recruits intra- and extrafusal fibers to minimize cocontraction of the antagonists. Active motion assists in cartilaginous regeneration, stimulates arterial flow, and increases venous and lymphatic return. This enhances the tensile strength of the healing tissues. Passive ROM exercises of a graded nature are introduced during the fibroblastic phase and are continued into the remodeling phase if motion is restricted by collagen density. Passive ROM exercises are most effective if low load stresses are applied within tissue tolerance that do not elicit inflammatory process and pain. The passive stresses are modified or adjusted as motion is gained. On completion of passive ROM exercises, active ROM exercises are commenced to increase the amplitude of muscle contraction/excursion. Active ROM attempts are encouraged, attaining and maintaining the end range achieved through passive ROM exercises. Resistive or strengthening exercises may be introduced in early stages of remodeling. Isotonic exercises progressing to isometric, with no resistance and low repetitions initially, progressing
to low and high resistances with increasing repetitions are beneficial in gaining strength [29]. All of the muscle groups of the elbow, forearm, wrist, and hand are exercised within physical tolerance of the muscles. Free weights and elastic bands of graded resistance are used for strengthening. Endurance training and simulated work hardening can be added to the program once patients have minimal or no discomfort. Optimum dosage in frequency or repetition of ROM exercises is unknown. The authors’ preference, however, is that patients perform 5–10 repetitions every 2–3 hours initially, progressing to 15–20 repetitions on an hourly basis as long as these repetitions do not cause pain, inflammatory response, or muscle fatigue. Patients are encouraged to perform active ROM exercises of the shoulder, wrist, and fingers throughout their rehabilitation program. Depending on the stability of the elbow injury, a protective splint may be used when the shoulder joint is exercised. Forearm pronation/supination exercises are performed actively with the elbow in 90( of flexion or as dictated by ligamentous stability. Joint mobilization and manual therapy Mobilization of the joint in rehabilitation of elbow trauma has a role in reducing pain, decreasing muscle spasm, and gaining motion if followed immediately by active or passive motion. Initially oscillatory motions of the elbow are effective in stimulating tendon and proprioceptive end-organs, which inhibits muscle spasm and muscle cocontraction [27,28]. In the later stages of the fibroblastic phase, mobilization of a joint from midrange with a lower velocity–grade II and a lower velocity from midrange into resistance– grade III joint mobilization techniques are introduced. These maneuvers are performed with caution, however, keeping in mind the healing status of the bone, ligaments, and the surrounding soft tissues. Grade III and grade IV mobilizations together with longitudinal joint distraction techniques at end point of the joint range of motion are used during the remodeling phase of tissue healing. These joint mobilizations do not cause a permanent change in the joint and are effective only if followed by passive physiologic stretching. Proper positioning of the shoulder and the forearm is critical, ensuring that the stresses placed on the ligamentous and skeletal structures are not disrupting the healing process. The techniques
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used for gaining flexion or extension or pronation or supination are well described by Maitland and Kaltenborn [27,28]. Splinting Splinting is an important part of most rehabilitation programs following elbow trauma. Splinting of the elbow provides stability and reduces force transmission at the site of fracture or soft tissue injury to allow the osseous and ligamentous structures around the joint to heal [30]. Excessive immobilization of the joint may lead to secondary stiffness and contracture. The following section describes some of the splints fabricated during rehabilitation and details some general guidelines for treatment of elbow trauma commonly seen in therapy. For the ease of discussion, splinting has been divided into the categories of splinting for protection and splinting to regain motion. Protective splinting is initiated within 1–2 days following trauma, whereas splinting for the purpose of regaining motion often is initiated once sufficient healing has occurred and the application of a low load, prolonged stretch can be used to increase ROM. Splinting for protection Treatment following elbow trauma often requires the use of splints for protection and optimal positioning. A posterior resting splint (Fig. 3) holding the elbow at 90( of flexion is an effective way to immobilize the elbow to protect fractures and soft tissue injuries. A collar and cuff (Fig. 4) also may be used for stable injuries. This allows for easy removal for performing exercise programs but limits light functional use of the
Fig. 3. A posterior elbow resting splint.
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upper extremity when worn, because the forearm is held against the body. A collar and cuff also places the shoulder in an internally rotated position and can lead to stiffness of the anterior capsule of the shoulder. It is therefore extremely important that patients exercise their shoulder when placed in a collar and cuff. Positioning the elbow in 90( of flexion is usually the most comfortable position, because it reduces pressure within the capsule of the joint, as the capsule of the elbow joint is at its greatest capacity at approximately 80( of flexion [31]. Any deviation from this position increases the pressure in the capsule and can cause pain. Keeping the capsule from being filled with fluid or hematoma can be achieved by splinting the elbow joint in extension. Because most elbow trauma leads to an inability to achieve terminal elbow extension, extension splinting is beneficial. The extension splint is molded to the anterior aspect of the arm and extends 3–5 cm from the axillary fold to 4–5 cm proximal to the radial styloid (Fig. 5). It is important that the splint does not extend beyond this, because it can cause problems with the dorsal sensory branch of the radial sensory nerve at this level. A crisscross type of strapping pattern over the posterior aspect of the elbow just proximal to the olecranon process helps secure the elbow into the splint. Functional use of the upper extremity is limited significantly during extension splinting; therefore, this splint commonly is worn only at night. Splinting to regain motion Several dynamic and static progressive splints have been devised to regain motion of the elbow
Fig. 4. A collar and cuff for positioning the elbow at 90( following elbow trauma.
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Fig. 5. A nighttime extension splint.
that has become stiff because of trauma and immobilization. These splints typically are avoided for 3–6 weeks postinjury for fear of inducing increased pain, inflammation, or heterotopic ossification. Four splints the authors have found to be most effective are the static progressive flexion cuff, the serial static extension splint, the static progressive turnbuckle for elbow flexion and extension, and a static progressive or dynamic pronation/supination splint for proximal radioulnar joint stiffness. The static progressive elbow flexion cuff is a device used by the patient to hold the elbow in flexion for the purpose of obtaining a low load, prolonged stretch (Fig. 6). A posterior slab is molded around the upper arm and a cuff is placed around the wrist. The patient then adjusts the tension on the straps after placing them through the D-rings on the arm cuff. This cuff can be used once stability of the bone is no longer in question. When flexion is less than 100(, a splint with
Fig. 6. A static progressive flexion cuff.
a fixed hinge can be used to absorb the compression force placed on the joint by not having an optimal direction of pull (Fig. 7). The use of a fixed hinge transfers only the rotational component of the force to the elbow joint. Entrapment of the ulnar nerve during healing phases may inhibit gliding of the ulnar nerve and produce weakness of the muscles together with sensory disturbances. This often is noted during elbow flexion increases or with dynamic or static progressive flexion splinting. Patients therefore must be encouraged to watch for signs of paresthesia in the ulnar nerve when undertaking a splinting program to regain elbow flexion. The static progressive extension turnbuckle splint is simply a static elbow extension splint with some added hardware. The extension splint is cut at the cubital fossa, two hinges are added, and a turnbuckle is fixed to the anterior portion of the splint (Fig. 8). The patient then adjusts the turnbuckle to increase the extension stretch applied by the splint. Gelinas et al [32] found that using the turnbuckle splint for extension was beneficial for increasing ROM when worn up to 20 hours per day for a mean of 4.5 months, even after patients had gone through an intensive therapy program unsuccessfully. Such long wearing times for splints often are not tolerated, because they limit functional use of the upper extremity. The authors prefer to start splinting earlier in the fibroblastic phase of healing with a wearing time of 1–2 hours, 3–4 times per day and at night with a gentle stretch applied. Using static progressive splinting in conjunction with
Fig. 7. A static progressive flexion hinge. The hinge absorbs compressive force on the elbow for individuals with less than 100( of flexion to minimize pain and increase comfort.
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Fig. 8. A static progressive extension splint for extension.
intensive therapy is the most effective means of increasing motion at the elbow. Proximal radioulnar joint stiffness can occur with a variety of pathologies around the elbow joint. Fractures of the proximal ulna and radial head and dislocations are often causes of proximal radioulnar joint stiffness. Splinting for this stiffness usually involves a dynamic splint or a static progressive splint holding the forearm in maximal pronation or supination 4–6 hours per day. A static progressive splint is commercially available from Joint Active Systems (Effingham, Illinois; Fig. 9). The wearing schedule for these splints is similar to the turnbuckle described earlier. Continuous passive motion Several physiologic advantages of continuous passive motion have been reported. These include sinusoidal oscillations in intra-articular pressure, absorption of intra-articular hematoma, control of edema, hyaline cartilage remodeling, reorganization of collagen fibers, and enhancement of metabolic activity [33–36]. This mode of treatment is especially effective in the later stages of fibroplasia or during remodeling if patients have limited or unidirectional gains or muscle spasm or if patients are having difficulty maintaining achieved mobility with traditional splinting, ROM, and mobilization techniques. A combination of traditional treatment during the day (ie, splinting, ROM, and mobilization) and application of continuous progressive passive motion at night can increase ROM of the joint. Muscle excursion is maintained at night, enhancing the ability to maintain the achieved mobility. Continuous passive motion for restoration of motion is indicated only when fractures have stable fixation.
Fig. 9. A static progressive pronation/supination splint from Joint Active Systems.
A safe arc of motion within the limits of soft tissue constraints is used and as the tissue compliance increases, the arc of motion is adjusted accordingly. This method of treatment is contraindicated in fractures with tenuous fixation and ligamentous insufficiency [37]. Ultrasound Although commonly used in the upper extremity, studies to support the use of ultrasound are based primarily on animal subjects, and further investigation is needed. The literature does suggest that a low intensity, pulsed ultrasound may be effective for promoting the healing of wounds and increasing fibroblastic activity within soft tissues and also for resolving subacute inflammation [38]. Higher intensity ultrasound provides a thermal increase to the tissues and may increase the extensibility of scar tissue. This temporary increase is tissue extensibility is beneficial when followed by passive stretching. To effectively heat soft tissues within a reasonable amount of time, the area of application should not be greater than three times the size of the ultrasound head [39]. The authors do not advocate the use of ultrasound on the elbow for heating purposes because
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of the size of the area to be heated. Application of superficial heating modalities such as hot packs or whirlpool are more effective therapeutic techniques when followed by appropriate active and passive stretching exercises. These forms of heat are superior because they also can be used before home exercise programs.
insertion site of triceps. The use of electrical stimulation is limited in these cases, because it produces a contraction that is painful and patients often develop cocontraction as a protective mechanism against the pain.
EMG biofeedback and neuromuscular electrical stimulation
Fractures of the distal humerus
The musculocutaneous, median, ulnar, and radial nerves innervate the muscles crossing the elbow and the joint. The receptors of these nerves detect changes in tension, position of the joints, joint compression or distraction, muscle length, muscle force, and speed. These changes are relayed to the spinal cord and brain. Integrated signals then modify the activation of motor units to generate appropriate muscle tension required for desired function [29]. Following elbow trauma, injury to this receptor system is likely. In addition, immobilization or limited mobility of the elbow joint causes abnormal programming of the receptor system function. Often muscle guarding caused by cocontraction of the antagonist muscles or muscle spasms during active or passive mobilization of the elbow occurs, limiting range of motion [40,41]. The elbow flexors display greater hyperactivity than the extensors when active or passive extension forces are applied [42]. This induced shortened stretch reflex, caused by a disturbance of these receptor systems, may be one of the causes of elbow flexion contractures. EMG biofeedback (as an adjunctive treatment) is often an effective way to re-educate the muscles and to reduce contractures by inhibiting cocontraction of the antagonists. A dual channel EMG biofeedback instrument is most effective in re-education of the muscles [43,44]. A baseline measurement is taken to establish cocontraction of the antagonists. Patients then are encouraged to inhibit cocontraction of the antagonist by using verbal cues and proprioceptive facilitation stimulation while elbow motion is performed [45]. Once desired motion is attained, an EMG biofeedback triggered electrical stimulation for triceps strengthening is an effective method of treatment to gain elbow extension. Electrical stimulation of muscles combined with active contraction produces the strongest contraction possible for the purpose of strengthening and regaining active ROM. Resisted extension of the elbow following trauma can be painful at the
Injury-specific treatment guidelines
Rehabilitation of distal humerus fractures depends greatly on the initial management. The type of fracture, amount of fixation, surgical approach, and associated soft tissue and ligamentous injury all play a role in determining the course of the rehabilitation process. Most distal humerus fractures, regardless of location or type, are treated operatively with stable internal fixation [46]. The operative procedure often involves reflecting the triceps or performing an olecranon osteotomy. Initial therapeutic management must involve protecting the triceps mechanism and minimizing the hemarthrosis by splinting the elbow in full extension in the operating room. Because of the intra-articular nature of these fractures, arthrofibrosis is a common complication, so immobilization for prolonged periods should be avoided. Early mobilization helps to reduce intraarticular fibrosis, hematoma, edema, and pain. Patients usually are seen in therapy 1 day postoperatively and are fitted with a collar and cuff in 90( of flexion and an extension splint for night use. A collar and cuff permits easy initiation of elbow motion exercise during the day. The initial home program consists of elevation and ice for edema control, active-assisted flexion, gravityassisted extension, active pronation/supination, and maintenance exercises for the shoulder, wrist, and hand. If a triceps sparing approach was used, immediate active extension exercises are permitted. Once callus formation is radiologically evident, passive ROM and static progressive splinting are initiated to regain motion. Olecranon fractures Olecranon fractures are treated most commonly with open reduction and internal fixation. Surgical intervention often involves the placement of tension band wiring or plating to stabilize the fracture [47]. The triceps is protected in the early healing phase as activation stresses the fracture fixation. Splint use is similar to what is used for the treatment of distal humerus fractures. Active
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flexion exercises are permitted without restriction for stable fractures but are limited to 100( and are increased by 10( per week if fixation is tenuous. Radial head fractures Radial head fractures are the most common of all elbow fractures. Elbow instability may occur with larger fragments that often have some degree of associated ligamentous injury [48,49]. The management of radial head fractures is similar whether surgery is performed or not. Associated ligamentous injuries of the elbow are the primary determinant altering the therapy protocol. Simple undisplaced or minimally displaced radial head fractures without a mechanical block of motion are treated with a collar and cuff for comfort, pain and edema control, and early mobilization [49]. Forearm rotation with elbow held in 90( of flexion in an assisted manner using the uninvolved hand reduces compressive load on the radiocapitellar joint, preventing further displacement of the fracture yet allowing pain-free motion. Elbow extension and flexion should be performed with the forearm in pronation. Forearm supination has been demonstrated to increase the load at the radiocapitellar joint [11,13,16,25]. This may induce pain and further displacement of the fracture fragments because of the eccentric and isotonic contraction of the biceps and brachialis muscles, respectively. Several sessions of ROM exercises on a daily basis are recommended (preferably 10–15 repetitions on an hourly basis). As the pain subsides and the healing of the fracture becomes evident radiologically, rotation in graduated elbow extension is permitted. Close monitoring and static progressive extension splinting for elbow flexion contracture development is critical in gaining extension of the elbow joint. Graded strengthening of the elbow and forearm is introduced on healing of the fracture. Displaced radial head fractures requiring open reduction and internal fixation without ligamentous injury are positioned in a collar and cuff or a sling for day use and elbow extension splint for night. Early mobilization of the elbow and forearm and other therapeutic management is performed in a manner similar to that described previously. For patients requiring ligamentous repair in association with open reduction and internal fixation, radial head excision, or radial head arthroplasty, the management must address the preservation of ligamentous integrity [24,25,48,
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50,51]. If the lateral collateral ligament is deficient, the elbow is positioned at 90( of flexion with the forearm pronated in a splint on postoperative day 1. Early active elbow flexion and extension with the forearm maintained in pronation and forearm rotation with the elbow at greater than 90( of flexion is initiated on postoperative day 1 [24,25]. This active ROM program is performed for a period of 4–6 weeks postoperatively. Edema and pain control are as described previously. Whirlpool or hot pack treatment are added once the sutures/staples are removed, together with scar massage, desensitization, and application of silicone gel strips for scar remodeling. Close monitoring of elbow and forearm contractures and management with appropriate splinting (serial static or static progressive) are instituted, depending on the presence of symptoms and the stage of healing. Strengthening of the elbow and forearm is withheld for 8 weeks postoperatively or until fracture healing or consolidation is evident radiologically. It is critical that patients perform elbow flexion/extension strengthening exercises with forearm in pronation, initially with lighter weight and progressing gradually in midprone or neutral. Strengthening then can be performed in supination as these patients advance in their postoperative periods. Pronation/supination strengthening is initiated with the elbow at 90( to avoid stresses on the repaired ligaments. Graduated work hardening and return to work conditioning then is the final component of the therapy program. Coronoid fractures Fractures of the coronoid process are seen commonly with dislocation of the elbow with or without associated radial head fractures. There usually are associated ligamentous injuries [52]. Isolated coronoid fractures are uncommon. Fractures that are stable after reduction are treated with early active stable arc of motion defined in the operating room by the surgeon. Extension of the elbow may be blocked at 40(–60( short of full extension initially using an elbow hinge brace or a cast brace to minimize eccentric load on the anterior aspect of the coronoid process for unstable fractures [53]. A 10( increment of extension on a weekly basis then is permitted. The extension block splint is used for 4–6 weeks. Passive extension exercises or progressive mobilization splinting are delayed until fracture and ligament healing occurs. Pronation and supination
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exercises are performed with the elbow at 90( of flexion out of the splint. Because of the postoperative positioning required in these situations, the occurrence of flexion contractures is common. Early contracture control with serial elbow extension splinting at 4 weeks postoperatively may be introduced for optimal results. Strengthening exercises, however, may be delayed to 8–10 weeks postoperatively, depending on the fracture and ligamentous healing and elbow stability. Elbow dislocations Elbow dislocations represent 11%–28% of all elbow injuries, and the elbow is the second most common joint dislocated in the adult population [8]. Recurrence of simple elbow dislocations is uncommon because of the intrinsic stability of the joint. The collateral ligaments that are disrupted, however, must be protected during rehabilitation to prevent chronic varus/valgus instabilities or posterolateral rotatory instability. The primary goal of therapy following reduction of a simple dislocation is to increase serially ROM while maintaining the reduction and preventing undue stress on the healing collateral ligaments. All patients initially are splinted in a posterior elbow splint holding the joint in 90( of flexion for 5–7 days. Patients then begin protected active motion. If the elbow is stable once reduced, unrestricted active motion is permitted [17]. If instability is an issue, full flexion is permitted, but extension of the elbow past 40(–60( is avoided. Extension is increased by approximately 15( per week. Whether the forearm is supinated, pronated, or in neutral while performing extension depends on which ligaments are damaged, as previously discussed. If patients fail to achieve weekly goals for extension in therapy, a nighttime extension splint is fabricated at week 4–6. Passive stretching of the elbow should not be performed until after week 6 to ensure that the ligamentous stability is no longer an issue and that no heterotopic bone has formed. Aggressive stretching before week 6 may lead to greater stiffness, pain, and loss of functional use.
Summary The rehabilitation of elbow trauma presents numerous challenges. Involvement of the osseous structures, compromise of the ligamentous
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