Elbow

Surgical intervention to Medial valgus stress overload

"Tommy John's Surgery" • Immobilized in brace • May perform wrist, hand, and shoulder ROM • By 3rd week, ROM to the elbow should be 20-110 • Resistance to the wrist and shoulder can begin and submax isometrics to the elbow • ER to the shoulder should be avoided, valgus force • 4-6 weeks ROM 0-130 with slow progression of concentric and eccentric flexion and extension to tolerance • 2-4 months, functional training may begin • Plyometrics and strengthening to all joints • 10-12 months before returning to overhead throwing sports

Six Symptoms Indicating Vascular Obstruction

1. Severe pain in the forearm muscles 2. Limited and extremely painful finger movement 3. Purple discoloration of the hand with prominent veins 4. Initial paresthesia followed by loss of sensation 5. Loss of radial pulse and later loss of capillary return 6. Pallor, anesthesia, and paralysis

Operative Management of Lateral Collateral Ligament Injury cont.

Advanced strengthening (week 8) • Advance strengthening phase, goal is to increase strength • 10 week plyometric and eccentric activities Interval sports program (week 16) • FROM needed

Management of Lateral Collateral Ligament Injury Nonoperative Management

Begins immediately following the traumatic event Goal: to restore ROM within the limits of elbow stability while slowly applying progressive stresses to the healing structures • Control pain and swelling • Hinged elbow brace with the forearm in a neutral or slightly pronated position, restricted early 30-90 and slowly increase to full pain free. • Strengthening activities may begin early • During the advanced phase (weeks 2 through 8 post- injury), functional progressions and sport specific activities are initiated.

Treatment: Nondisplaced Fracture of olecranon

Immobilization for 6 to 8 weeks • Positioning somewhat controversial • Some recommend placing the affected arm in extension or slight flexion • Some recommend placing the affected arm in 45 to 90° of flexion • Some concern that flexion should not exceed 45° because of the risk of displacing fracture fragments • Gentle active ROM exercises after 3 weeks of immobilization • Flexion not to exceed 90° for the first 6 to 8 weeks after injury so that fracture fragments can heal

Management of Lateral Epicondylitis #1

Initial acute management • Resolving pain and swelling with the judicious use of ice massage directly over the affected area • Phonophoresis or iontophoresis • Physician-prescribed analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) • Rest • Protection of the area from unwanted stress to allow for healing • Wrist cock-up splint in severe cases to minimize stress; remove splint as needed

Management of Lateral Epicondylitis #2

Initial healing stage • Avoid any and all motions that may adversely affect healing. • Short-term modifications in activities of daily living (ADLs), sports, and job-related activities must be addressed to provide a pain-free environment for healing. • When this initial program fails to bring significant relief of symptoms, some physicians elect to inject the area with a steroid to reduce the inflammation.

Treatment Fractures of the Distal Humerus

Initial phase of recovery • Focuses on motion and strengthening exercises • General body conditioning, and active motion of the hand, wrist, and shoulder of the injured limb • Then, gentle active motion exercises • Progressive active motion of the elbow and resistance exercises proceed • As radiographic evidence confirms solid union • A minimum of 6 weeks has elapsed since surgery (consistent with the healing constraints of bone tissue) • Patient demonstrates improved motion without pain

Operative Management of Lateral Collateral Ligament Injury - Intermediate phase

Intermediate phase (week 4-7) • Gradual increase in PROM to elbow • Hinge brace protected at 30-100 • Unlock the brace 10 degrees per week, may discontinue brace at 6 wk • Full PROM by 8-10 wks, not to over stress endrange flexion and extension • By end of this stage, strengthening activities should be focus on dynamic stability, light isotonic for the wrist, forearm, elbow, shoulder, and scapular stabs

Operative Management of Lateral Collateral Ligament Injury - post operative phase

Postoperative phase (week 0-3) • Placed in a posterior elbow splint at 90 and full forearm pronation • Allow adequate soft tissue healing • No ROM activities at this stage especially supination usually 4-6 weeks • AROM /PROM to the wrist and shoulder can occur as long as no pain in the lateral elbow • Gripping exercises and shoulder isometric except IR/ER

Soft Tissue Injuries of the Elbow Lateral Epicondylitis

Tennis elbow • Affects the common wrist extensor origin of the extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, and extensor digiti minimi • Repetitive overuse • Can affect anyone involved with repetitive activities of the wrist extensors • Symptoms: pain with palpation of the lateral epicondyle, with active or resisted wrist extension

Fractures of the Distal Humerus (Supracondylar Fractures)

Transverse fracture of the distal third of the humerus • Usually occurs in children • Two types: • Type I is the most common and refers to an injury that occurs as a result of a fall on an extended, outstretched arm in which the distal humerus fragment is displaced posteriorly. • Type II is considered a flexion injury. • Closed reduction and immobilization for 4 to 6 weeks • Kept in a flexed position

Treatment for Intercondylar "T" or "Y" Fractures

Type I nondisplaced fracture: • Treatment can be immobilization for approximately 3 weeks, followed by progressive, gentle active motion. • Resistance exercises are deferred until secure bone union has been confirmed radiographically. • With types II and III displaced fractures, the treatment is open reduction and internal fixation (ORIF) with the use of Kirschner wires, side plates, and lag screws to secure and stabilize the displaced fracture fragments.

Treatment Options for Radial Head Fractures

Type I nondisplaced radial head fractures • Immobilization ranging from 5 to 7 days up to 3 to 4 weeks Type II • Radial head can be excised or stabilized with an ORIF procedure.

Treatment of Intercondylar "T" or "Y" Fractures in Older Adults

Type IV treated differently for adults and elderly patients with poor bone quality (osteoporosis). • Usually treated with an ORIF procedure to stabilize the fragments • Elderly patients with generally poor bone • The "bag of bones" technique • Calls for the use of a "collar and cuff" sling, with the affected elbow flexed • With the elbow flexed and able to hang freely within the sling, gravity is used to help obtain possible reduction of the fracture fragments

Medial Valgus Stress Overload

Valgus extension overload (VEO) • Results are seen in athletes, from repetitive throwing and racquet sports such as javelin throwing, baseball, racquetball, and tennis. • A number of forces act on the elbow, including valgus stress with tension across the medial aspect of the elbow. • These forces are maximal during the acceleration phase of throwing. • 2300/s, producing shear forces 300N and lateral forces 900N

Olecranon Fractures

• After falling on the point of the elbow (olecranon process), or indirectly from forceful contraction of the triceps • Nondisplaced or displaced fractures • Displaced fractures of the olecranon have four subclassifications 1. Avulsion fracture, displaced 2. Oblique or transverse fracture 3. Comminuted fracture 4.Fracture-dislocation

Medial Epicondylitis

• An overuse condition that affects the origin of the pronator teres, flexor carpi radialis, flexor digitorum sublimis, and flexor carpi ulnaris at the medial epicondyle of the elbow • Occurs less often than lateral epicondylitis • Dominant feature: pain on palpation over the medial epicondyle, active motion, and particularly with resisted wrist flexion and full passive wrist extension • Golfer's Elbow

Rehab for Intercondylar "T" or "Y" Fractures

• Early postimmobilization period, no passive manipulation or passive stretching can be performed. • After wound closure • Whirlpool bath • Elbow flexion and extension, as well as forearm pronation and supination • Specific joint mobilization techniques when bone union is secure • May have residual loss of motion

Lateral Collateral Ligament Injury

• Elbow is the second most commonly dislocated large joint behind the shoulder • Hyperextension • Posterolateral rotation

Fracture-Dislocations

• Fall on an extended outreaching arm causes isolated elbow dislocations and combined fracture-dislocations • Occurs most often in men, with the nondominant arm representing about 60% of these injuries • Posterior elbow dislocations most common • Isolated posterior elbow dislocations • The elbow is placed in 90° of flexion in a splint for 3 to 6 weeks of closed reduction and immobilization • Myositis ossificans

Rehabilitation After Dislocation

• Focus on early protected active motion. • Passive stretching again is strictly avoided during the early recovery phases of healing. • With radial head excision, a loss of 25° to 30° of pronation and supination can be expected if postoperative immobilization lasts longer than 4 weeks. • As with isolated dislocation, loss of full elbow extension is not uncommon.

Fractures of the Elbow

• Fractures of the distal humerus (supracondylar fractures) • Intercondylar "T" or "Y" fractures • Radial head fractures • Olecranon fractures • Fracture-dislocations

Intercondylar "T" or "Y" Fractures

• Injuries that extend between the condyles of the distal humerus and involve the articular surfaces of the elbow joint • Type I: a non-displaced fracture that extends between the two condyles • Type II: a displaced fracture without rotation of the fracture fragments • Type III: a displaced fracture with a rotational deformity • Type IV: a severely comminuted fracture with significant separation between the two condyles

Acute Rupture (Grade III Ligament Rupture) of the Medial (Ulnar) Collateral Ligament

• Managed conservatively with ice, NSAIDs, analgesics, and, most important, rest and protection • Progression from the acute, maximum-protection phase to return-to-normal function parallels treatment outlined for valgus stress injuries. • A longer period of recovery is needed and rest and joint protection from valgus stress will last longer.

management of medial valgus stress overload

• NSAIDs, analgesics prescribed by physician • Ice massage, phonophoresis, or iontophoresis to reduce pain and swelling • Rest and protection • Omitting activities that produce medial valgus stress (no throwing) • Short-term rest from the activity, during which the patient should participate in running, cycling, and strength training • Performing flexibility exercises • Injury to the elbow may cause excessive scar tissue formation • Gentle low-load static stretching • Low-load, long duration (LLLD) stretch

Complications of Fractures of the Distal Humerus

• Nonunion, malunion, and joint contracture • Perhaps the most disastrous complication results from vascular compromise. • Fracture fragments are displaced; hemorrhage beneath the deep fascia produces an ischemic injury that creates an arterial and venous obstruction (usually affecting the brachial artery), leading to Volkmann ischemic contracture.

Management of Lateral Epicondylitis #4

• PTA must carefully instruct the patient to • Perform all exercises within a pain-free range of motion (ROM). • Avoid stressful, pain-producing activities. • Do concentric and eccentric muscle contractions. • Light resistance when having patients perform these exercises for the first time • Performance of slow, controlled eccentric contractions • Surgery is rarely necessary for this condition. • Excising bad tissue of the extensor carpi radialis brevis musle

Treatment: Displaced Fracture of olecranon

• Physical therapy begins during the initial stages of immobilization. • Active motion of the hand, wrist, forearm (pronation and supination), and shoulder • A general physical conditioning program • Active elbow flexion not to exceed 90° for the first 2 months after injury • Secure bone healing at 8 weeks • Progressive concentric and eccentric loading is added as motion increases and secure fixation of the fragments has occurred

Operative Management of Lateral Collateral Ligament Injury

• Reconstruction technique is intended to recreate the ulnar aspect of the lateral collateral ligament complex. • Allograft or autograft, or even a plantaris allograft • Initiation of rehabilitation program immediately following the surgical procedure • Postoperative phase (week 0-3) • Intermediate phase (week 4-7) • Advanced strengthening (week 8) • Interval sports program (week 16)

Management of Medial Epicondylitis

• Regaining lost motion caused by pain and muscular dysfunction is critical for function and a return to normal daily activities. • The normal elbow ROM is 0° to approximately 145° of flexion. • Most daily activities can be carried out within a functional ROM of 30° to 130° of flexion. • Normal pronation of 75° and supination of 85° exceeds the functional arc of motion of 50° needed to carry out most ADLs.

Radial Head Fracture

• Result of a fall on an outstretched arm • Approximately one third of all elbow fractures and nearly one fifth of all elbow trauma • Normal carrying angle Four types • Type I: a nondisplaced fracture • Type II: a marginal fracture with displacement • Type III: a comminuted fracture of the entire radial head • Type IV: any radial head fracture with elbow dislocation

Management of Lateral Epicondylitis #3

• The PTA can enhance the effectiveness of low-load, long- duration static stretching by • Applying moist heat packs (provided the acute inflammatory process has ended) • Applying ultrasound to the lateral epicondyle to stimulate local circulation and relieve congestion caused by metabolic waste products and relax soft tissues in preparation for stretching • As pain is reduced, resistance with active motion exercises, generally, submaximal isometrics

Treatment for fracture-dislocations

• The most common complication • Loss of extension • 10 weeks after dislocation, a 30° flexion contracture is common, with a 10° flexion contracture typically observed 2 years later • Centers on the appropriate management of the fracture (most commonly the radial head) and reduction of the elbow