Treatment Framework

Question 1

In the early phase of healing (acute), maximum protection is required. What is the time frame for this phase and what types of symptoms to patients present with?

Answer 1

Timeframe: 0-7 days post injury

Symptoms:

• Acute pain & inflammation
• ROM limited by pain
• Painful arc
• Positive impingement signs
• Muscle guarding
• Posture impairment (forward head, T kyphosis forward tipped scapula, IR of GH joint)

Question 2

Early: Maximum Protection Phase: What are the goals during this phase and what interventions can we use to achieve them?

Answer 2

Control pain, edema and spasm

• Modalities (RICE)
• Immobilization (avoid painful movement)
• Gr I or II mobs in pain free position
• PROM within pain-free range
• AAROM (e.g. cane, table top or pendulum type ROM exer)
• Limited resisted isometrics, manual resistance
• Posture training (C-T and scapular regions)
• Gentle stretching (Nirschl)
• Proximal Stabilizers, > distal mobility (Nirschl)

Question 3

In the intermediate phase of healing (subacute), moderate protection / controlled motion is required. What is the time frame for this phase and what types of symptoms to patients present with?

Answer 3

Timeframe: 7-21 days post injury

Symptoms:

• Pain at the end of range
• Soft tissue / muscle contractures with decreased length
• Decreased muscle strength with imbalance, typically to pec minor, levator scap
• Decreased muscle endurance: scap and GH stabilizers
• Decreased mobility in GHJ capsule, usually posteriorly
• Impaired SH rhythm

Question 4

Intermediate: Moderate Protection Phase: What are the goals during this phase and what interventions can we use to achieve them?

Answer 4

Controlled motion

1. Promote healing of injured tissue
2. Restore soft tissue, muscle and joint mobility
3. Develop neuromuscular control, endurance and strength
   - AA to AROM within limits of pain
   - Gr III and IV joint mobs & MWM
   - Stretching shortened musculature
   - Insertional site: light, NWB isometrics (e.g. to scap retractors, depressors and GH rotator cuff) at beginning of stage
   - Joint stabilization (e.g. GH rotator cuff alternating isometrics) or WB with resistance (later in stage)
   - DFM cross-fiber
   - Reinforce posture
   - Progress HEP

Question 5

In the advanced/return to function phase of healing (chronic), the goal is to return to previous levels of functioning. What is the time frame for this phase and what types of symptoms to patients present with?

Answer 5

Timeframe: >3 weeks post injury

Symptoms/Impairments:

• Soft tissue contractures, limited ROM / joint play
• Decreased muscle performance and endurance
• Decreased functional use of muscle

Question 6

Advanced: Return to Function Phase: What are the goals during this phase and what interventions can we use to achieve them?

Answer 6

1. Increase soft tissue / joint mobility
2. Improve neuromuscular control, coordination and strength/endurance
3. Progress functional activities
   - Muscle stretching and flexibility
   - Joint mobs: gr III and IV if indicated (usually resolved in previous phase)
   - Strengthening: PRE & PNF
   - Plyometric training
   - Function exer

Question 7

85% of all olecranon fractures are displaced and usually require ORIF. T/F. Why ORIF?

Answer 7

True (tension band wiring). Triceps attachment, without it, ulnar neuropathy, instability and post-traumatic arthritis.

Question 8

95% of supracondylar fractures are extension fractures. Why and what causes this? What about a flexion fracture?

Answer 8

Distal fragment is displaced and goes posterior and proximal. FOOSH with elbow hyperextension.

Flexion fracture, distal fragment goes anterior and lateral. Fall with flexed elbow.