Clinical Reasoning in Mx and Tx of Elbow

Question 1

What are the steps of the healing process?

Answer 1

1. Minimise pan, swelling, inflammation, haemorrhage to offer the best possible condition for healing.
2. protection of DAMAGED tissue
3. with collagen maturation and remodelling initiated controlled mobilisation
4. loading of the tissue.

Question 2

What would be expected during glides of dislocated elbow?

Answer 2

stiffness, hypermobile or reactive - hard bony) or firm (myofascial) end feel an asymmetry between sides

Question 3

What are treatments for dislocations

Answer 3

Active mobilisations - MWM
Passive Mobilisation
Stretches - contract-relax, hold-relax
PNF techniques
Re-educate motor control strategies

Question 4

S&S Medial epicondyle #

Answer 4

Sudden pop during a throw followed by pain.

Point tenderness over medial epicondyle

Although # usually acute traumatic event, medial epicondyle avulsion # is frequently preceded by a Hx of medial ebow pin.
May have weakness with throw

Question 5

What would be treatment of medial epicondyle #

Answer 5

Stable - conservative (early active, active/assisted ROM exercises)

Unstable- ORIFfollowed by early movement if deemed stable post-op

Question 6

How to restore joi8nt ROM ?

Answer 6

Early/active assisted flex/ext
Supination/pro several times per day, initiated 2-7 days pot reduction for dislocations

Forearm neutral Active sup/pro for early post # - if stable, as early as day 2. Can come ou of splint for exercises - the progresses to PROM and stretching

PROM/mobs 2 wees ost reduction, not aggressive or stretching, particularly in combined #/dislocation

NO stretching in early phases

Question 7

What are the types of exercises to restore strength and endurance?

Answer 7

Isometric, Isotonic, Open/Closed

Question 8

How can isometric exercises be used to restore strength and endurance?

Answer 8

Through multiple angles

Beginning with symptom-limited sub-mximal contractions. Slow onset and offset of contraction

Question 9

What will occur with a sudden contraction with fastbuild up in tension in presence of effusion cause?

Answer 9

pain

Question 10

How can isotonic exercises help to restore strength and endurance

Answer 10

submaximal, avoid symptom reproduction.

approx. 2-3 sets, 10-15 reps daily - promote endurance yet avoid overloading injured tissue.

Start no weight- slowly progress 0.5-1 khg increments

Question 11

When are open and closed chain exercises?

Answer 11

Closed - more control

Open -need to be done for functional rehab

Question 12

When does restoration of flexibility begin?

Answer 12

Only after strengthening is well under way -minimise stretch overload of healing tissue

Question 13

What are different ways to restore flexibility?

Answer 13

Static stretch
Active stretching/PNF
mwm

Question 14

How is general conditioning used in rehab?

Answer 14

Initiate ASAP
Avoid stress/protect injured area
Return to sport activities

e.g incorporate balls/racquet/any pieces of equipment early

Question 15

What are some long term problems of acute traumatic elbow injuries?

Answer 15

Loss of ROM (especially ext - linked to duration of immobilisation

Loss of strength
Recurrent instability 
Heterotopic ossifation
Neurovascular compromise
Chronic pain syndrome

Question 16

What is the treatment for medial elbow instability?

Answer 16

Very little high quality literature reporting optimal conservative management.

• rest/splinting to protect from valgus stress
• Limit ext ROM
• avoid PROM
• Exercise
• Restoration of elbow/wrist flexor/ extensor synergies

AVOID activities that promote valgus stress

Question 17

Exercises for medial instablity

Answer 17

pain free ROM (avoidingvalgus stress)
Proprioception
Strength
Endurance
Sport specific activities
Isometric-isotonic-proprioceptive-plyometric
If conservative management fails - surgery.

Question 18

Among whom is ulnar nerve injury common in?

Answer 18

30-60 yrs

Question 19

What is treatment for ulnar nerve injury?

Answer 19

Avoid sustained elbow flexion (don’t lean on elbow)
-splinting may help

Avoid repetitive elbow flexion and pronation
Avoid vibratory tols
Vitamin B6
Improve flexibility of forearm/wrist flexors and pronators
Surgical intervention if conservative management fails

Question 20

Signs of flexor tendinopathy

Answer 20

• pain over medal epicondyle.

Aggravating factors:

• resisted wrist flex and ulnar deviation
• resisted pronation
• • passive elbow and wrist extension in supination

Question 21

Treatment for flexor tendinopathy?

Answer 21

Conservative management of acute symptoms effective in majority of patients.

• Counterforce brace
• Address technique/equipment/biomechanical faults
• If fails, surgical intervention

Question 22

Treatment for displaced and non-displaced osteochondritis dissecans?

Answer 22

Limit number of throws - max 80/week

Non-displaced:
No throwing until symptom gone and full ROM restored.

Displaced:

• rest
• arthroscopic debridement

Question 23

What makes for a poorer prognosis in osteochondritis dessicans?

Answer 23

displaced, older patient, large lesion, lesion on weight bearing area.

Question 24

Treatment for radial nerve injury?

Answer 24

No evidence any particular treatment better than natural history,particlarly surgery.

Rest, Treat S&S