Hi everyone in physio group 1,
I am at paediatric placement.
One of my patients is female and had supracondylar fracture of humerus. ORIF and k-wire was proceeded on the same day and POP was placed for six weeks. POP was removed now and she has been seen by physio 1/52 afterword.
It is almost a month since POP was removed, however her elbow flexion is still limited at around 90 degrees. Her elbow extension is lack of 10 degrees as well. Supination and pronation are WFL. She has been encouraged to move and use her arm as much as possible in her normal daily activities. She does dancing and will start swimming in shortly which she loves, so she is excited about it. She likes writing and to draw pictures, however she prefers using other UL than injured UL due to ROM limitation. Nil c/o pain at elbow with activities and at rest but she feels it is stuck at around 90 degrees of flexion.
Since the primary physio of this patient is none of my supervisors (one of my supervisors was covering for the day), my data collection was limited in outside of medical chart on the first day of Rx. The information from her chart: her PROM and AROM were almost unchanged since physio treatment has started. The therapists have tried a variety of treatments; such as passive ROM, AAROM, HR agonist, passive stretching, and soft tissue massage to increase her ROM, but none of them looks like working well on her. I have tried PROM, PAMs, and soft tissue massage, however her ROM was unchanged as well. The end feel was like bone to bone. Compensating movement from her shoulder and trunk rotation in some activities was noticed due to lack of elbow flexion during the sesssion.
I have been told that some calcification might be developed at the elbow during immobilized time, however the information was unclear yet. I was also told if the calcification has been occured, there was almost nothing that we as physios could do for the particular problem.
Do you agree with this? There was no chance to discuss with my supervisors regarding this patient since most of them were off on the day, so I will discuss this issue once they are on duty to increase my knowledge for future references. Searching on internet or finding journal articles and books regarding this issue will be helpful, since I have not done my musculo placement and my techniques and tools in musculo setting is limited. Some techniques we learned at uni have applied, but it would be great if someone has other ideas what can be done to increase ROM from physio point of view in this patient. Definitely I don't want this patient to learn the compensating movement, but at the same time she has to use the UL in her daily activities. I am also interested in how to use the UL without compensating movements within limited ROM.
1 comment:
hello, very interesting... I had to treat a patient for my outpatients placement who had her L ankle ORIF'ed and she found that her lack of ankle dorsiflexion was mainly due to the internal fixation itself, which was limiting the range. this could be the same or similar in your patients case as she is not experiencing pain. In that case it would then be a matter to consult with the surgeon on a review appointment regarding the removal of the ORIF. normally they do not routinely do this but considering the age of the patient and the potential for full recovery and the incidence of repeat injury is decreased, i.e compared with a 70 y.o who sustains an ankle fracture due to a fall, they would probably be more inclined in removing it to help her regain maximum function for the rest of her life. But another thing to consider, if she is a public patient the waiting list could potentially be at least months before the surgery would occur..
has their been any repeat X-rays done? so she is about 12 weeks on now, so there should be good union at this point in time, or like they are suggesting with the calcification, could there be a degree of malunion? also have you checked, or are you able to check if there may be a muscle length componenent due to the immobilisation??
Also i do recall from way back in second year that the elbow in particular can be one of the more difficult joints to fully rehab and in majority of cases, depending on the fracture site, FROM may never be obtained. This is just something to keep in mind.
I know I haven't exactly helped with any more treatment options, but with the elbow there probably isn't a whole lot more that you can do. I think the most important thing at the moment is actually finding out the exact cause of the range restriction and then identify treatment options to adress that impairment.
I hope that I have atleast helped in identifying some other factors that could be contributing to the patients loss of range.
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