Rehabilitation after Total Elbow Arthroplasty

Rehabilitation after Total Elbow Arthroplasty

Total Elbow Atrthroplasty Total elbow arthroplasty (TEA) Replacement of the ulnohumeral articulation with a prosthetic device. Goal of TEA is to provide pain relief from a variety of conditions that result in destruction of ulnohumeral joint: Osteoarthritis, Inflammatory arthritis, Septic arthritis, Post-traumatic arthritis, and acute fractures.

Main complaints: Pain Mechanical blocks to motion such as contractures or osteophytes.

REHABILITATION PROTOCOL- After Total Elbow Replacement Week 1: Hand and shoulder function encouraged immediately At 3 days, postsurgical splint and dressings are removed and replaced with a removable posterior extension splint to allow for gentle active range of motion. Active range of motion exercises for the elbow and forearm are performed six times a day for 10 to 15 minutes. Posterior extension splint should be worn between exercise sessions and at night.

Week 2: Passive and active ROM exercises may be initiated to the elbow. Range of motion is progressed as a home program, emphasizing extension and flexion. Week 6: Discontinue elbow extension splint during the day if elbow stability is adequate. Week 8: Discontinue elbow extension splint at night. Initiate gradual, gentle strengthening exercises for the hand and forearm. Light resistance may be begun to the elbow. Perform therapy within the patient s comfort level.

The patient is advised not to lift more than 1 kg during the first 3 months after surgery and will observe a 5 kg permanent lifetime lifting restriction for the extremity.

Rehabilitation After Fractures of the Forearm and Elbow

FRACTURES OF THE RADIUS AND ULNAR SHAFT The radius and ulna make up the bones of the forearm and the movement occur through the wrist to the elbow joints. The ulna a straight bone The radius a curved bone. A strong interosseous membrane holds the two bones together.

Some fractures of the forearm are coupled with a dislocation of the joint proximal or distal to the fracture. A fracture of the ulna with a dislocation of the radial head is called a Monteggia fracture dislocation. A fracture of the Radius with a dislocation of the distal radioulnar joint is called a Galeazzi fracture dislocation.

Generally fractures of the radius and ulna are fixed via direct methods such as open reduction internal fixation (ORIF) with plates and screws or indirect methods such as intramedullary (IM) devices.

BOTH BONE FOREARM FRACTURE REHABILITATION Phase I: (Weeks 0 2) Patient is placed into a splint and surgical incisions are protected. Sutures or staples are removed at week two. Elevation of extremity encouraged. Edema control and ROM of fingers.

Phase II: (Weeks 2 6) Active and active-assisted ROM of elbow, forearm, and wrist No repetitive forearm twisting 2.5 kg weight restriction though some surgeons prefer strict nonweight bearing.

Phase III: (Weeks 6 and Beyond) Lifting and twisting restrictions lifted once union has been achieved Work on regaining preoperative motion if not already achieved. Communicate with the treating surgeon regarding when union has been achieved and when restrictions may be removed or surgeon preference regarding weight lifting limits despite lack of full union.

FRACTURES OF THE ELBOW The elbow is an articulation of the distal humerus and the proximal ulna and Radius.

The bony articulation of the elbow helps maintain the stability of the elbow. The ulnohumeral articulation is considered a hinge type joint. The radiocapitellar joint is considered a pivot joint. The third articulation is between the radial head and proximal ulna.

Different types of joints of the elbow allow for flexion and extension as well as pronation and supination. The surrounding ligaments and capsule of the elbow are critical in the inherent stability of the elbow: The medial collateral ligament (MCL) and lateral collateral ligament (LCL) are critical in the stability of the elbow with regards to valgus and varus stresses.

The annular ligament is an important stabilizer to keep the radial head reduced, and the radial head itself is an important secondary stabilizer to valgus stress of the elbow. The anterior capsule is also important in elbow stability.

RADIAL NECK AND HEAD FRACTURES The radial head articulates with the capitellum at the elbow and may be injured in isolated radial head or neck fractures or in association with fractures of the forearm or elbow dislocations. Some of these fractures may be treated nonoperatively Initially these patients are placed into a simple sling for comfort, and encouraged to start motion immediately to prevent stiffness. Motion may be inhibited early due to the hemarthrosis that develops from the fracture, and the treating physician may aspirate the joint to reduce the volume to help facilitate early motion.

Active and passive motion are encouraged early on and restricted weight bearing for the first six to eight weeks until bony union is achieved. Keys for successful rehabilitation include maintaining preinjury motion.

Fractures that require operative treatment, the type of treatment depends on the extent of the injury.

Postoperative therapy generally consists of active and active-assisted ROM exercises. Passive exercises are discouraged. Nonweight bearing occurs for six to eight weeks until bony union is achieved. The rehab. protocol is changed with associated ligamentous disruptions.

SIMPLE OR COMPLEX ELBOW DISLOCATIONS Elbow dislocations can be broken up into simple and complex patterns. Simple dislocations of the elbow are those in which the injury is only ligamentous without any associated fractures. Complex dislocations are elbow dislocations with associated fractures. For the majority of simple dislocations, the treatment is nonoperative with initiation of early ROM.

The elbow is reduced and, the treating physician will place the elbow through a ROM with varus and valgus stress. As long as the elbow is stable throughout the arc of motion the patient is generally placed in a splint with the elbow flexed to 90 degrees for a week. Early ROM with a therapist is encouraged in case of without ligamentous injury.

Complex elbow dislocations are elbow dislocations that include associated fractures. The majority of complex fracture dislocations are treated with surgery.

Simple Elbow Dislocation Rehab. Protocol Phase I (0 1 Week): Elbow splinted in 90 degrees flexion for 5 to 10 days Phase II (1 6 Weeks): Splint removed and ROM initiated A sling or splint may be used in early phase for comfort Extension gradually increased over 3 to 6 weeks Avoid passive ROM.

Complex Elbow Dislocation Rehab. Protocol Phase I (0 1 Week): Elbow is splinted for one week Phase II (1 6 Weeks): Sutures or staples removed at two weeks Postoperative splint removed Flexion, extension, pronation, and supination ROM exercises started after splint removal Hinged elbow brace may be used by treating surgeon to help with stability Full, unprotected ROM delayed up to 4 weeks in elderly or severely comminuted fractures per surgeon preference. Phase III (6 8 Weeks and Beyond): Resistive exercises are initiated

GENERAL REHABILITATION CONSIDERATIONS AFTER ELBOW DISLOCATONS

Extended casting and prolonged immobilization lead to elbow posttraumatic stiffness. For simple elbow dislocations, early active ROM is the key to preventing post-traumatic stiffness and obtaining a favorable result. The elbow is splinted for 5 to 7 days to allow soft tissue rest. Soft tissue swelling can be controlled with compressive dressings and application of ice.

Beginning at day 5 to 7, a hinged elbow brace from 30 to 90 degrees is applied and active ROM is initiated. Active ROM requires muscle activation and assists to elbow stability and compression across the joint. ROM is increased in the hinged elbow brace 10 to 15 degrees per week. Passive ROM should be avoided because it increases swelling and inflammation.

Valgus stress to the elbow should be avoided because it may disrupt healing of the MCL and lead to instability or recurrent dislocation. During this time, no strengthening or resistive exercises should be prescribed because this may place tension on the healing ligamentous structures.

Dynamic splints or progressive static splints may be initiated if ROM is not steadily improving by 6 weeks. Elbow flexion returns first, with full flexion obtained by 6 to 12 weeks. Extension returns more slowly and may continue to improve for 3 to 5 months. Forced terminal extension should be avoided. At 6 to 8 weeks, strengthening can begin.

Post-Traumatic Elbow Stiffness

The elbow contains three major articulating surfaces. The articulation of the humeral trochlea and the trochlear notch of the ulna is the major facilitator of flexion and extension about the elbow. The radiocapitellar articulation supports motion in both the flexion and extension of the elbow in addition to supination and pronation of the forearm. The proximal radioulnar joint allows supination and pronation movements of the forearm.

CLASSIFICATION Type I involves soft tissue contractures; type II involves soft tissue contractures with ossification; type III involves nondisplaced articular fracture with soft tissue contracture; type IV involves displaced intra-articular fractures with soft tissue contracture; and type V involves post-traumatic bony bars blocking elbow motion.

HETEROTOPIC OSSIFICATION Heterotopic ossification (HO) is an important cause of posttraumatic stiffness of the elbow. Direct trauma, surgical intervention, and forceful passive manipulation may cause HO, which is directly related to the severity of the initial injury. Noted radiographically approximately 4 to 6 weeks following the event, HO presents with swelling, hyperemia, and loss of motion of the affected joint.

EVALUATION OF THE STIFF ELBOW History: The history of a patient presenting with a stiff elbow should include onset, duration, character, and progression of symptoms. Pain is an infrequent finding in post-traumatic elbow stiffness and implies arthrosis of the joint.

Physical Examination: The physical examination should consist of a thorough neurovascular examination with particular attention to the ulnar and median nerves, which may be involved in trauma to the elbow or encompassed by HO around the elbow joint. The presence of burns, scars, or areas of fibrosis on the skin surrounding the joint should be noted. The active and passive range of motion in flexion and extension and supination and pronation should be recorded.

It is important to understand that deficits in the flexion extension plane are a result of ulnohumeral pathology, whereas deficits in forearm supination and pronation imply a radiocapitellar or proximal radioulnar etiology. Crepitus through range of motion may indicate loose body, fracture, or degenerative changes.

Radiographic Evaluation Radiographic evaluation should consist of anteroposterior, lateral, and oblique views of the elbow. Fractures, bony blocks to motion, articular loose bodies, degenerative changes, and HO may be noted on the initial radiographs. Computed tomography with three-dimensional reconstructions is helpful in defining the articular anatomy and surgical planning in the presence of HO. Magnetic resonance imaging is not routinely used in the evaluation of elbow stiffness.

NONSURGICAL TREATMENT The goal of nonsurgical therapy is a functional, painless, and stable range of motion. Initial treatment of post-traumatic elbow stiffness consists of gradual passive manipulation progressing to active-assisted stretching of the elbow controlled by the patient or a physical therapist. Adjuncts to this therapy may include nonsteroidal anti-inflammatory drugs (NSAIDs), heat or ice application, and therapy modalities such as massage, iontophoresis, ultrasound, and electrical stimulation.

The next line of treatment for the stiff elbow is the use of splinting. Dynamic splinting in which a constant prolonged force is supplied through spring or rubber band tension has been used in patients with deficits in flexion and extension. Static progressive adjustable splints used for flexion extension deficits, supination pronation splints, and even serial casting are options. These splints sequentially increase as more motion is allowed by the soft tissues.

Closed manipulation under anesthesia has been used to treat elbow stiffness. This procedure is not without complications, including iatrogenic fracture, articular cartilage damage, and soft tissue damage leading to hemarthrosis and fibrosis.

SURGICAL TREATMENT Patients who continue to experience pain and limitation to a functional range of motion despite nonsurgical therapy are candidates for surgical treatment. The choice of procedure depends on the extent of damage to the articular cartilage, whether the loss of motion occurs in flexion or extension, and if bony blocks or HO contributes to the elbow stiffness.

POSTSURGICAL PROTOCOL restoring a functional range of motion, strengthening the surrounding musculature, and re-establishing motions needed for functional activity in the affected elbow.

Mobilization of the elbow is aided by sufficient pain control and should begin 2 days following surgery. This can be accomplished through gentle manipulation by physical therapists or through a continuous passive motion machine. Early forceful manipulation is contraindicated because of the possibility of causing heterotopic ossification. Extended rehabilitation similar to the preoperative rehabilitation, using dynamic or static splinting along with progressive manual stretching.

The use of perioperative radiation: to decrease the risk of postoperative heterotopic ossification. Current radiation regimens include 1000 centigray (cgy) over five treatments or a single 700- to 800-cGy dosage within 2 days of the surgery.