Rehabilitation of elbow trauma

Quadruple bilateral fracture-dislocation of the elbow and the wrist: A rare and complex case report

We report an exceptionally rare and complex case of quadruple bilateral fracture dislocation of the elbow and the wrist in a 39-year-old construction worker, who sustained the injury after falling from a scaffold of 9 m secondary to a 6.9 magnitude earthquake. The patient was treated with a combination of closed and open reduction, internal fixation, and radial head arthroplasty, and had a good functional outcome at 12 months follow-up, with no complications or instability. This case illustrates the challenges and the possibilities of managing such complex injuries, and adds to the scarce literature on this topic.

SpasticSim: a synthetic data generation method for upper limb spasticity modelling in neurorehabilitation

In neurorehabilitation, assessment of functional problems is essential to define optimal rehabilitation treatments. Usually, this assessment process requires distinguishing between impaired and non-impaired behavior of limbs. One of the common muscle motor disorders affecting limbs is spasticity, which is complicated to quantify objectively due to the complex nature of motor control. Thus, the lack of heterogeneous samples of patients constituting an acceptable amount of data is an obstacle which is relevant to understanding the behavior of spasticity and, consequently, quantifying it. In this article, we use the 3D creation suite Blender combined with the MBLab add-on to generate synthetic samples of human body models, aiming to be as sufficiently representative as possible to real human samples. Exporting these samples to OpenSim and performing four specific upper limb movements, we analyze the muscle behavior by simulating the six degrees of spasticity contemplated by the Modified Ashworth Scale (MAS). The complete dataset of patients and movements is open-source and available for future research. This approach advocates the potential to generate synthetic data for testing and validating musculoskeletal models.

Effectiveness of instrument assisted soft tissue mobilization (IASTM) and muscle energy technique (MET) on post-operative elbow stiffness: a randomized clinical trial

BACKGROUND

Stiffness is a common complication following trauma and surgeries around the elbow, which can result in upper limb functional disabilities. Soft tissue mobilization techniques such as Instrument-assisted Soft Tissue Mobilization (IASTM) and Muscle Energy Technique (MET) have limited evidence in elbow rehabilitation. This study aimed to compare their effects on postoperative elbow stiffness.

METHODOLOGY

26 subjects were recruited (13 each group) with postoperative elbow stiffness (minimum 6 weeks post surgery) and randomly allocated in two groups: IASTM and MET. Pain [Numeric Pain Rating Scale NPRS)], ROM (Goniometer), and Function [Disability of Arm, Shoulder and Hand (DASH) and Patient-Specific Functional Scale (PSFS)] were assessed at baseline and post-intervention.

RESULTS

The data of 26 subjects were analyzed and both groups significantly improved in outcome scores post-intervention. The improvements in ROM and function between groups were comparable, but NPRS and PSFS showed greater improvement in the IASTM group (p < 0.05).

CONCLUSION

IASTM and MET were both effective in improving outcomes in postoperative elbow stiffness. IASTM was more effective in improving pain and patient-specific function.

The use of static progressive and serial static orthoses in the management of elbow contractures after complex fracture dislocation injuries: A pediatric case study

INTRODUCTION

Contractures are the most common complication after traumatic injury to the elbow. Although evidence supporting the use of static progressive and serial static orthoses to help recover range of motion after these complex injuries is growing, there is currently a paucity of literature exploring its efficacy in pediatric populations.

CASE DESCRIPTION

The following case study presents the results of the use of static progressive and serial static orthoses with a young patient who presented with both elbow extension and flexion contractures after a complex fracture dislocation injury.

RESULTS

A noted and consistent improvement in both elbow extension and flexion can be observed after commencement of the static progressive and serial static orthoses. These results are consistent with the literature exploring the efficacy of these orthoses with adult populations with traumatic elbow injuries.

DISCUSSION

Further studies evaluating the use of static progressive and serial static orthoses in the management of elbow contractures after traumatic injuries in pediatric populations is needed to establish best practices with this particular patient population.

The Efficacy of Tele-Rehabilitation Program for Improving Upper Limb Function among Adults Following Elbow Fractures: A Pilot Study

Background: Active mobilization post-elbow fractures reduces the incidence of complications. Occupational therapists use tele-rehabilitation, incorporating technology into their practices. There is a lack of evidence-based trials regarding the integration of tele-rehabilitation during treatment. We therefore aimed to compare tele-rehabilitation treatment outcomes with conventional rehabilitation in improving the upper limb function post-elbow fractures. Methods: Eighteen participants post-elbow surgery due to fracture were divided into two groups according to age and fracture type. The groups received one month of treatment: the tele-rehabilitation group (N = 9, median age 33.0 ± 27.9 years, range 18.5–61.0) received 1–2 tele-rehabilitation treatments per week via a biofeedback system of elbow motion (the ArmTutor and 3D Tutor systems, MediTouch Ltd., Netanya, Israel) and 1–2 treatments in an outpatient clinic, and the control group (N = 9, median age 60.0 ± 37.0 years, range 20.5–73.0) received 3–4 treatments per week in the clinic. Both groups were instructed to self-practice at home. Four evaluations were performed: before and after the intervention, and 3 months and 1 year from surgery. The outcome measures included the Jebsen–Taylor hand function test; the disabilities of the arm, shoulder, and hand questionnaire; the patient-rated elbow evaluation; satisfaction; passive and active range of motion (ROM); and strength measurements. Results: Findings demonstrated a significant improvement in the ROM and in functional assessments in both groups. No statistically significant differences were found between the groups. The subjects in the tele-rehabilitation group reported a higher level of satisfaction and needed less help from a family member during practice. Conclusions: Tele-rehabilitation programs could be incorporated in the framework of treatment following elbow fractures. Tele-rehabilitation is a cost-effective treatment, suitable for patients with accessibility difficulties or who have difficulty arriving at the clinic.

Reproducibility and reliability of performance indicators to evaluate the therapeutic effectiveness of biofeedback therapy after elbow surgery: An observational case series

Electromyographic biofeedback (EMG-BF) therapy provides information on the state of contraction of the targeted muscles and relaxation of their antagonists, which can facilitate early active range of motion (RoM) after elbow surgery. Our aim in this study was to calculate the minimum detectable change (MDC) during EMG-BF therapy, initiated in the early postoperative period after elbow surgery.This study is an observational case series. EMG-BF of muscle contraction and relaxation was provided during active elbow flexion and extension exercises. Patients completed 3 sets of 10 trials each of flexion and extension over 4 weeks. The total range of flexion-extension motion and scores on the Japanese Society for Surgery of the Hand version of the disability of the arm, shoulder, and hand questionnaire and the Japanese version of the Patient-Rated Elbow Evaluation were obtained at baseline and weekly during the 4-week intervention period. A prediction formula was developed from the time-series data obtained during the intervention period, using the least-squares method. The estimated value was calculated by removing the slope from the prediction formula and adding the initial scores to residuals between the measured scores and predicted scores individually. Systematic error, MDC at the 95th percentile cutoff (MDC95), repeatability of the measures, and the change from the baseline to each time-point of intervention were assessed.The MDC95 was obtained for all 3 outcome measures and the range of values was as follows: RoM, 8.3° to 22.5°; Japanese version of the Patient-Rated Elbow Evaluation score, 17.6 to 30.6 points; and disability of the arm, shoulder, and hand questionnaire subscale: disability and symptoms score, 14.2 to 22.9 points.The efficacy of EMG-BF after elbow surgery was reflected in earlier initiation of elbow RoM after surgery and improvement in patient-reported upper limb function scores. The calculated MDC95 cut-offs could be used as reference values to assess the therapeutic effects of EMG-BF in individuals.

Biomechanical comparison of tension band wiring and plate fixation with locking screws in transverse olecranon fractures

BACKGROUND

Tension band wiring (TBW) is the standard method for treating transverse olecranon fractures, but high rates of complications and reoperations have been reported. Plate fixation (PF) with locking screws has been introduced as an alternative method that may retain the fracture reduction better with a higher load to failure.

METHODS

Twenty paired cadaveric elbows were used. All soft tissues except for the triceps tendon were removed. A standardized transverse fracture was created, and each pair was allocated randomly to TBW or PF with locking screws. The triceps tendon was mounted to the materials testing machine with the elbow in 90° of flexion. Construct stiffness was compared 3 times. Then, the elbows underwent a chair lift-off test by loading the triceps tendon to 300 N for 500 cycles. Finally, a load-to-failure test was performed, and failure mechanism was recorded.

RESULTS

The construct stiffness of PF was higher in the first of 3 measurements. No difference was observed in the cyclic test or in load to failure. Hardware failure was the failure mechanism in 8 of 10 TBW constructs, and all failures occurred directly under the twists of the metal wire. Hardware failure was the cause of failure in only 1 elbow in the PF group (P < .01).

CONCLUSION

There was no difference in fracture displacement following fixation with TBW and PF with locking screws in transverse olecranon fractures. However, assessment of the mode of hardware failure identified the metal cerclage twist as the weakest link in the TBW construct.

Development of an EMG-Based Muscle Health Model for Elbow Trauma Patients

Wearable robotic braces have the potential to improve rehabilitative therapies for patients suffering from musculoskeletal (MSK) conditions. Ideally, a quantitative assessment of health would be incorporated into rehabilitative devices to monitor patient recovery. The purpose of this work is to develop a model to distinguish between the healthy and injured arms of elbow trauma patients based on electromyography (EMG) data. Surface EMG recordings were collected from the healthy and injured limbs of 30 elbow trauma patients while performing 10 upper-limb motions. Forty-two features and five feature sets were extracted from the data. Feature selection was performed to improve the class separation and to reduce the computational complexity of the feature sets. The following classifiers were tested: linear discriminant analysis (LDA), support vector machine (SVM), and random forest (RF). The classifiers were used to distinguish between two levels of health: healthy and injured (50% baseline accuracy rate). Maximum fractal length (MFL), myopulse percentage rate (MYOP), power spectrum ratio (PSR) and spike shape analysis features were identified as the best features for classifying elbow muscle health. A majority vote of the LDA classification models provided a cross-validation accuracy of 82.1%. The work described in this paper indicates that it is possible to discern between healthy and injured limbs of patients with MSK elbow injuries. Further assessment and optimization could improve the consistency and accuracy of the classification models. This work is the first of its kind to identify EMG metrics for muscle health assessment by wearable rehabilitative devices.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Dynamic Splint for the Treatment of Stiff Elbow

Background

The purpose of this paper is to retrospectively evaluate the results of the treatment of elbow stiffness with the use of dynamic splints.

Methods

We included 17 patients with stable and congruent joints, with a range of motion of 100 degrees or less who had not responded to the rehabilitation program. Average previous mobility was 108–42 degrees, with a total arc of 66 degrees. The splints consist of an articulated brace with springs. On average their use began 94 days after surgery or trauma and continued for 86 days. Statistical analysis was performed. Average follow-up was 18 months.

Results

Postoperative mobility was 126–19 degrees, with a total arc of 107 degrees. Motion increased an average of 41 degrees. Six patients failed to recover a functional arc of motion.

Conclusion

Our results suggest that dynamic splints are useful in the treatment of elbow stiffness. We achieved an average improvement of 41° in the arc of motion, which in many cases has rendered arthrolysis unnecessary. Tailoring the splint to the individual patient is very important since its usage must be prolonged in order to achieve plastic deformity through the principle of progressive stretching.

Conservative management of the post-traumatic stiff elbow: a physiotherapist's perspective

Elbow stiffness is a common consequence following trauma with the management of this condition posing a challenge to therapists and surgeons alike. This paper discusses the role of conservative treatment, such as exercise and splinting, in the prevention and management of the stiff elbow, along with a review of available evidence, to justify their usage.

The use of braces in the rehabilitation treatment of the post-traumatic elbow

The elbow, the middle joint of the upper limb, enables the hand to be placed at various distances from the body. The articular, muscular and neuromotor complexity of the elbow is such that it is often prone to stiffness, especially if immobilized for long periods of time. Therefore, mobilization of the posttraumatic elbow must be started early. In the presence of lesions to the ligamentous structures, the joint must be protected to prevent these structures from being placed under tension during movement. Rehabilitation of the elbow includes the use of braces. Different types of brace are used depending on clinical situation and the objectives to be achieved. They can have fixed protection or locked articulation, allow an adjustable range of movement to restrict flexion-extension and pronation-supination, or allow dynamic and static progressive movement. The latter plays a special role in conservative treatment and following surgical release. However, the effectiveness of braces in the rehabilitation treatment of elbow stiffness depends on the patient's compliance. Their use requires a considerable amount of physician time to achieve the objectives envisaged by the rehabilitation program.

Clinical outcomes after posterior open elbow arthrolysis for posttraumatic elbow stiffness

Background:

Loss of motion is a well-known complication after elbow trauma and in severe cases, arthrolysis of elbow is the procedure of choice. The posterior approach might have some advantages especially in post-traumatic patients who have undergone the same surgical approach in the past.

Objectives:

The aim of this study was to evaluate the short-term outcomes of elbow arthrolysis through posterior approach. Moreover, we assessed the effect of operation on the patients’ quality of life.

Patients and Methods:

During a retrospective-cohort study, the medical records of 14 patients (12 men, two women) whose range of movement had been limited post-traumatically and had undergone elbow arthrolysis with posterior approach were reviewed. Before intervention, the patients had a flexion less than 100 degrees or an extension lag of 30 degrees or more. For evaluation of the final outcomes, they were invited to participate in our study and the final range of motion, visual analogue score (VAS), disability of arm, shoulder and hand (DASH), Mayo elbow score (MES) and short form health survey (SF-36) scores were measured in the patients.

Results:

Mean age of the participants was 28.7 years. The interval from initial injury and arthrolysis was 16 months and the patients were followed for 14 months. The mean range of motion in patients before surgery was 35.8 degrees, which was increased to a mean of 108.9 after the surgery, indicating a 73.1 degrees improvement. The means of VAS, DASH, Mayo elbow and SF-36 scores in the patients were 1.6, 34, 68 and 43, respectively. A significant inverse correlation was found between the preoperative range of motion and final range of motion.

Conclusions:

According to our results, elbow arthrolysis through posterior approach could be an effective technique with low complications. Since the final range of motion improved significantly, it might be a valuable method in promoting the patients’ quality of life.

Elbow rehabilitation in traumatic pathology

The elbow, intermediate joint of the upper limb, frequently undergoes to pathological events and is especially prone to stiffness. Rehabilitation plays an important role in recovering functional activities. For the rehabilitation team, this goal always represents a challenge, as the treatment has to be continuously modeled and calibrated on the needs of the individual patient, even many times during the same rehabilitation cycle. Containing the effects of immobilization, avoiding to excessively stress the healing tissues, satisfying specific clinical criteria before moving to the next rehabilitation stage, basing the rehabilitation plan on up-to-date clinical and scientific data that can be adapted to each patient and to his/her needs are the basic principles of the rehabilitation plan, which can be chronologically grouped into four rehabilitation stages. After summarizing the general principles of elbow treatment, the specific principles of rehabilitation after elbow fractures and elbow instability are presented, and then the rehabilitative approach to the most frequent and feared pathological conditions of the elbow, namely stiffness, is described.

Mobilization brace in post-traumatic elbow stiffness

Invalidating elbow contractures, a frequent problem after injury, are commonly treated by physical therapy or surgical release. In both cases, results can be frustrating: physical therapy is often not sufficient to gain functional range of motion, and after surgical release it is common to lose part of the motion gained in operating room. Thanks to the viscous-elastic properties of the soft tissue, the mobilization elbow braces can stretch the retracting or retracted tissues inducing a biological lengthening of collagen fibres. In post-traumatic contracture, mobilization braces are effectively employable in two main critical situations: to treat recent onset contractures which do not respond to simple physical therapy and to help in preserving range of motion gained after surgical release. We report our experience with mobilization brace used in 42 patients, 5 for post-traumatic contracture, 4 for contracture following articular fracture fixation and 33 after surgical release. Classification, indications and treatment protocols of the mobilization braces utilized are reported.

Static progressive versus three-point elbow extension splinting: a mathematical analysis

Elbow joint contractures are often treated by using static progressive, dynamic, turnbuckle, or serial static splinting. These splint designs are effective in regaining functional elbow range of motion due to the high forces applied to the contracted tissues; however, regaining terminal elbow extension remains a challenge. Static progressive splints are commonly used to initiate treatment, however, are considered less effective in regaining terminal extension. Recently, the concept of converting a static progressive splint into a three-point static progressive splint (TPSPS) to regain terminal extension has been introduced. This paper mathematically analyzes the compressive and rotational forces in static progressive and TPSPSs. Our hypothesis was that three-point static progressive splinting was superior to the standard static progressive elbow extension splint in applying rotational forces to the elbow at terminal extension.

The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children

OBJECTIVES

To investigate the time required for elbow range of motion (ROM) recovery after supracondylar and lateral condylar fractures in children and to analyze the relationship between the ROM recovery and the related factors.

DESIGN

Retrospective study.

SETTING

Tertiary pediatric orthopaedic care unit at a general hospital.

PATIENTS/PARTICIPANTS

Forty-five children with distal humerus supracondylar fractures and 16 children with lateral condylar fractures were followed. Twenty-seven children with distal forearm fractures, which were immobilized with long arm casts, were used as a control group to study elbow flexion-extension recovery after immobilization without elbow fracture.

MAIN OUTCOME MEASUREMENTS

Elbow ROM was measured with a goniometer in a series of follow-up visits after cast removal until 90% ROM of the uninjured side had been reached. Morrey's definition was used to define ROM required for functional activity of daily living.

RESULTS

The supracondylar fracture group took 29.5, 39.0, 6.1, and 11.0 days to achieve 90% ROM in extension, flexion, supination, and pronation directions. The lateral condylar fracture group needed 30.2, 35.6, 2.3, and 8.9 days, respectively, in 4 directions. In the distal forearm fracture group, the elbow total flexion-extension angle required less than 2 weeks to reach a total arc of 135 degrees. The supination range was easier to recover than the pronation motion. The flexion recovered last among 4 directions in supra- and lateral condylar fractures.

CONCLUSIONS

In the uncomplicated distal humerus supracondylar and lateral condylar fractures, it takes 5 weeks to restore original elbow ROM after removal of long arm cast without physical therapy. This information could be applied in the education material to caregivers of children with elbow injuries.

Optimizing elbow rehabilitation after instability

Elbow instability is a common clinical problem that requires careful assessment and treatment to achieve a successful outcome. Rehabilitation is a key element in achieving a stable mobile elbow. Careful communication between the treating therapist and surgeon is essential so that an optimal rehabilitation program can be developed and implemented. By understanding the patterns of injury and the biomechanics of the elbow, a good outcome can be achieved in most patients who have elbow instability.

Chronic posttraumatic elbow disorders treated with metallic radial head arthroplasty

BACKGROUND

Metallic radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. The purpose of this study was to evaluate the functional outcomes of a metallic radial head arthroplasty in patients with chronic posttraumatic elbow disorders.

METHODS

The results of thirty-two metallic radial head arthroplasties in thirty-two consecutive patients were retrospectively reviewed. The indications for the radial head arthroplasty included posttraumatic nonunion and malunion of the radial head, elbow instability following previous excision of the radial head, and failure of a silicone radial head implant used to treat an acute radial head fracture. The study included thirteen male and nineteen female patients followed for a minimum of two years. The radial head arthroplasties were performed at an average of 2.4 years after the injury. Analysis included chart review, personal interview, physical examination, radiographic examination, and strength testing as well as the administration of general and region-specific questionnaires.

RESULTS

The mean duration of follow-up was eight years. The average Mayo Elbow Performance Score was 83 of 100 points, with seventeen (53%) of the thirty-two results rated as excellent; four (13%), as good; seven (22%), as fair; and four (13%), as poor. The average score for subjective patient satisfaction was 8.5 points on a 10-point scale. Patients had significantly less motion and strength in the affected elbow than in the unaffected elbow. Seventy-four percent of the patients demonstrated some degree of posttraumatic arthritis. There were no significant differences in ulnar variance and the ulnohumeral joint space between the affected and unaffected arms. Over the course of the study, no metallic radial head arthroplasties required revision.

CONCLUSIONS

Metallic radial head arthroplasty for the treatment of posttraumatic elbow disorders appears to be a safe and durable procedure that can provide a functional range of motion and pain relief for at least five to ten years. However, longer follow-up is needed to evaluate progression of lucencies adjacent to stems and osteoarthritis.

Elbow arthroscopy: surgical techniques and rehabilitation

Elbow arthroscopy allows for direct visualization into the elbow joint, minimizes the potential for postoperative edema and discomfort, as well as protects the ligamentous structures. Arthroscopic procedures for the elbow and postoperative management are described for patients who have undergone loose body removal, synovectomy, and capsulectomy. The effect of early mobilization on the elbow complex and the role that splinting may play, as well as the controversies surrounding the use of continuous passive motion are discussed. Arthroscopy can significantly reduce the time frame, as well as improve the functional outcome, of a postoperative rehabilitative program. There is evidence to support the reduced need for postoperative therapy, as well as quicker return to premorbid activity. However, the evidence to suggest that there is significant difference between open vs. arthroscopic repairs with regard to functional outcome is inconsequential. Complications after an arthroscopic release can arise, such as prolonged edema, which may lead to protracted joint stiffness or delayed healing. Iatrogenic nerve injury is also a potential risk that may pose devastating consequences for the individual's functional outcome. In light of all these facts, it is imperative that arthroscopic procedures be performed by experienced surgeons, who can then refer the patient to a skilled hand therapist who will work in conjunction with and communicate to the physician if complications arise.

Total elbow arthroplasty

The surgical and therapeutic management for total elbow arthroplasty is reviewed. Surgical overview and techniques, stability issues, factors affecting therapy, and a proposed postoperative treatment plan are presented. Specific therapy management following total elbow replacement has not been published before in a peer-reviewed journal. Further study is needed to obtain patient outcome data following the proposed therapy plan.

Static progressive splinting for posttraumatic elbow stiffness

OBJECTIVES

To determine the value of static progressive splinting in helping patients with posttraumatic elbow stiffness regain functional motion and avoid operative treatment for stiffness.

DESIGN

Retrospective case series.

SETTING

Level I Trauma Center.

PATIENTS AND INTERVENTION

Over a 3-year period, 29 consecutive patients with elbow stiffness after trauma (flexion contracture greater than 30 degrees or flexion less than 130 degrees) were treated with static progressive elbow splinting when a standard exercise program was no longer achieving gains in motion. Three patients were treated after the injury alone; 14 were treated after operative treatment of the initial injury, and 12 after a secondary operative contracture release for posttraumatic stiffness. Splinting was initiated on an average of 55 days (range, 15 to 200 d) after injury or operative treatment.

MAIN OUTCOME MEASUREMENTS

Ulnohumeral range of motion before and after splint treatment.

RESULTS

The flexion arc improved from 71 degrees (range, 0 to 100 degrees) before splinting to 112 degrees (range, 20 to 150 degrees) after splinting. After splinting, 3 patients had a flexion contracture greater than 30 degrees and 10 patients (34%) had fewer than 130 degrees of flexion. Only 3 patients-2 with heterotopic bone and 1 with an associated ulnar neuropathy-requested an operation to address elbow stiffness. Patients who were splinted after the initial injury (n=17, average improvement (fl-ext)=51+/-37 degrees) regained greater motion during splint wear than patients treated after elbow capsulectomy (n=12, average improvement (fl-ext)=22+/-24 degrees).

CONCLUSIONS

Static progressive splinting can help gain additional motion when standard exercises seem stagnant or inadequate, particularly after the original injury. Operative treatment of stiffness was avoided in most patients.