PUSHED ELBOW  MOI: FOOSH – hyperextension injury

 Rotational displacement of the ulna on the distal

 AKA Posterior Elbow Dislocation humerus
 Occurs when the radius and ulna are forcefully  Axial compression, elbow flexion, valgus
driven posterior to the humerus stress, and forearm supination
 Simple (no fx) or complex (has related fx) and  Most commonly, the dislocation is associated c a
staged damaged or torn anterior capsule
 Complex:
 Radial head CHARACTERISTIC/CLINICAL PRESENTATION
 Coronoid process  A person may feel immediate instability
 Olecranon  Popping sensation or noise upon dislocation
 Humeral condyles  Palpation & Observation:
 Capitulum  Olecranon is prominent creating a divot over
These fx may lead to disruption of MCL, LCL, or the triceps
Interosseous Membrane  Swelling, joint line tenderness, & decreased ROM
should be expected
 Terrible Triad – a term to describe a severe
complex dislocation c intra-articular fx of the PT MANAGEMENT
radial head and coronoid process  Vascular examination:
STAGES  Palpation of the brachial, radial, and ulnar
arteries
Stages Involvement Presentation  Neuromuscular screening:
1 LCL partially/completely Posterolateral  Dermatomes, myotomes, and reflexes
disrupted subluxation should be evaluated c emphasis on the ulnar,
2 Additional disruption Posterior median, and radial nerves.
anteriorly and dislocation,
posteriorly coronoid process is  Observe elbow:
perched on the  Ecchymosis
trochlea  Rubor
3–A All soft tse is disrupted Post dislocation by  Deformities
including MCL posterior posterolateral  Triangle sign:
band, anterior MCL rotary mechanism  Tip of the olecranon
intact but can withstand  Medial epicondyle
valgus stress; c
radial head &  Lateral epicondyle
coronoid process fx While in elbow flexion, resulting in a triangle
3–B Entire MCL is disrupted Varus, valgus, and configuration.
rotary instability
3–C Humerus has been Elbow can dislocate  Elbow extension sign – to rule out fx
stripped off all soft tse even when  Mayo Elbow Performance Index
immobilized  Disabilities of the Arms, Shoulder and Hand
 ST:
EPIDEMIOLOGY/ETIOLOGY  Valgus & Varus Stress Test, Lateral Pivot
Shift Test, and Apprehension Test
 Children under 10 y/o – PEDs are the most  Complications associated c PED:
common type of joint dislocation

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  Neurological deficit including
HYPOAESTHESIAS OF THE HAND IN THE ULNAR
NERVE DISTRIBUTION
 Concomitant fx
 Myositis ossificans
 Degenerative changes in the joint
RED FLAGS
 Hx of CA
 Fever
 Palpable enlarged mass
 LOM in undiagnosed condition
 Excessive swelling
 S/Sx of systemic infection or CA
 Significant unexplained elbow pain c no previous
films
 Loss of normal shape (unreduced dislocation)
 Unexplained deformity
 Red skin
 Hx of non–investigated trauma
 Unexplained significant sensory or motor deficit
SURGERY
 Elbow stiffness & pain
PT MANAGEMENT
 Splinting: 45 to 90 degrees of elbow flexion for 3
days to 3 weeks
 AROMEs on Upper Limb x A/P x 10 reps x 2 sets
 Effleurage on Upper limb x 5 mins
 Ice pack on Upper Limb x 15 – 20 mins
When the patient no longer requires immobilization:
 Gentle AROMEs and PROMEs in a pain-free range
targeting the entire UE
 Multi-angle isometric activities &
Proprioceptive Nuclear Facilitation patterns
for the elbow help decrease pain, increase
ROM, and begin to target strengthening
components in the preliminary stages of
recovery
When pain is no longer a barrier to treatment:
 PREs on UE x 10 reps x 3 sets (di ko sure to)
REFERENCE
 Physiopedia
VOLKMANN ISCHEMIC CONTRACTURE
 Deformity of the hand, fingers, and wrist which
occurs as a result of a trauma such as:
1. Fx
2. Crush injuries
3. Burns
4. Arterial Injuries
Following this trauma, there is a deficit in the
arterio–venous circulation in the forearm which
causes a decreased blood flow & the hypoxia can
lead to the damage of muscles, nerves, and
vascular endothelium. This results in a shortening
(contracture) of the muscles in the forearm
ANATOMY
 The bones are an important factor in a
Volkmann’s contracture. The humerus of the
upper arm is often involved in VIC.
 Fx of the supracondylar ridge causes a deficit in
the circulation of the brachial artery – it is caused
by the blocking of the circulation & deficit in
supply of blood that the muscles and nerve
malfunction. There is a contraction of the muscles.
 The muscles which are usually involved are the
flexors of the wrist. Yet there is also a
contracture occur in the extensors of the wrist,
but this is less common.
1. Superficial Muscles:
 Pronator Teres (median nn)
 FCR (median nn)
 FCU (ulnar nn)
 FDS (median nn)
 Palmaris longus (median nn)
2. Deep Flexors:
 FPL (median nn)
 Pronator Quadratus (median nn)
 FDP (median nn)
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 EXAMINATION
EPIDEMIOLOGY/ETIOLOGY
 The incidence of VIC is low. It counts 0.5%, which
means it is a rare disease
 The intracompartimental pressure occurs when
there is a bulging caused by a trauma. Thus, there
is not enough space for muscles, nerves, and
blood vessels that lie within this fascia. This
results in vascular defects and defects on nerves.
 Possible causes can be animal bites, fx of the
forearm, bleeding disorders, burns, excessive
exercise and injections of medications at the
forearm
CHARACTERISTIC/CLINICAL PRESENTATION
 5 P’s:
 Pain
 Pallor
 Pulselessness
 Paresthesias
 Paralysis
 Special Findings:
 Bleach view at the level of the skin
DIAGNOSTIC PROCEDURES
(Pallor)
 The wrist is in palmar flexion
 Clawed fingers
 Pain occurs with passive stretching of
the flexor
 Palpation of the affected region creates
persistent pain (Pain)
 It is possible that the pulsations cannot
be felt in the swollen arm, mainly in the
distal part (Pulselessness).
 There are also neurological limitations
noticeable from the muscles that pinch
the neutral pathways, there is a
decreased sensation (Paresthesia) and
there is an observable motor deficit
(Paresis)
MANAGEMENT
DIFFERENTIAL Dx
 Pseudo–Volkmann’s Contracture
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 The findings are specific as described in clinical
presentation subheading above
 The deformity in this condition can be divided into
different levels of severity
1. MILD
 Flexion contracture of 2 or 3 fingers c
no or limited loss of sensation
2. MODERATE
 All fingers are flexed and the thumb is
oriented in the palmar orientation. The
fist in this case can remain permanently
in flexion & there is usually a loss of
sensation in the hand
3. SEVERE
 All muscles in the forearm (flexors and
extensors) are involved. This is a
serious limiting condition
 An objection test to evaluate the ischemia and the
pressure in a muscle compartment is an invasive
test. It measures the absolute pressure in the
compartment of the muscle. This is also called the
Intracompartimental Pressure Monitoring (ICP)
 ICP can be measured by several means including:
 Wick Catheter
 Simple Needle Manometry
 Infusion Techniques
 Pressure Transducers
 Side–ported Needles
 Critical pressure diagnosing compartment
syndrome is unclear
 Different authors consider surgical intervention if:
 Absolute ICP >30 mmHg
 Difference between diastolic pressure
and ICP >30 mmHg
 Difference between MAP and ICP >40
mmHg
 Prevention is the best Mx in this condition. Often
times, the Mx require the surgical and physical
therapy intervention for a better outcome.
3
  VIC – supracondylar fx, and it must be ensured
that this fx heals
 When there is an intra–compartment pressure of
>30 mmHg, an urgent fasciotomy is
recommended to avoid further complications
 Raised ICP threatens the viability of the limb &
compartment syndrome represents a true medical
emergency. Thus, the need for decompression by
removal of all dressing down to skin, followed by
fasciotomy – surgical opening of the fascia
around the muscles to make more place for the
structures inside. This is done to prevent the
onset of VIC.
PT MANAGEMENT
 MILD
 Progressive splinting
 Tendon gliding
 GPS on Upper Limb x A/P x 10 reps x 3
sets
 Myofascial release on Upper Limb x 5
mins
 MODERATE (Post Op)
 Tendon slide
 GPS on Upper Limb x A/P x 10 reps x 2
sets
 PROMEs on Upper Limb x A/P x 10 reps
x 2 sets
 AROMEs on Upper Limb x A/P x 10 reps
x 3 sets (progress)
 FES on Upper Limb x 50 Hz x 300 us
 SEVERE (Post Op)
 PROMEs on Upper Limb x A/P x 10 reps
x 2 sets
 AROMEs on Upper Limb x A/P x 10 reps
x 3 sets (progress)
 FES on Upper Limb x 50 Hz x 300 us
REFERENCE
 Physiopedia & Brashear

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