Rehabilitation Techniques for CRPS and Fractures

Fractures & Dislocations of the Upper Limb

•  Upper limb injuries include fractures and dislocations.
• Elbow dislocations constitute 10% to 25% of all elbow injuries in adults.
• Shoulder dislocations are the most frequent injury in the upper limb.
• Elbow dislocations can be simple (ligamentous) or complex (involving associated fractures).

Elbow Dislocation

• Simple dislocations are ligamentous injuries without associated fractures.
• Posterior dislocation is the most common type.
• Posterior dislocations are further categorized based on the direction of the ulna's displacement (e.g., posterior, posteromedial, posterolateral, direct lateral).
• X-rays and clinical appearance help assess elbow dislocation.

Complex Elbow Dislocations

• These dislocations are accompanied by associated fractures like radial head, coronoid process of ulna, and olecranon.
• The 'terrible triad' is a common complex elbow dislocation involving injuries to the coronoid process, radial head, and posterior-lateral dislocation of the elbow joint.
• Nerve and blood vessel injuries (e.g., ulnar/median neuropraxia, brachial artery injury) can sometimes occur with complex dislocations.
• Ulnar collateral ligament tear is sometimes associated with elbow dislocation.

Mechanism of Injury

• In children under 10, posterior dislocations are frequent, often due to falls.
• Posterior dislocations often follow axial compression, valgus stress, arm abduction, and forearm supination.
• Anterior dislocations mostly stem from direct force on the posterior forearm with a flexed elbow.

Treatment

• Simple posterior dislocations often involve closed reduction under sedation, followed by plaster cast or posterior splint for 2-3 weeks with the elbow at 90 degrees.
• Active range of motion exercises should begin early.
• Complex or unstable elbow dislocations, severe soft tissue or bony injuries need open reduction with internal fixation and possibly ulnar collateral ligament repair.

Reduction of Posterior Elbow Dislocation

• The 'palm-palm technique' is a common method.
• Examiner's palm grasps the patient's hand with fingers interlocked.
• Examiner's elbow is placed at the patient's antecubital fossa.
• By pushing downward on the patient's distal humerus, a distal humeral distraction is done.
• Posteriorly dislocated elbow is pulled back into the appropriate anatomical position.

Rehabilitation Considerations

• Extended casting and immobilization should be avoided as they can lead to post-traumatic stiffness for elbow injuries.
• Active range of motion (ROM) exercises are key to regaining flexibility.
• Elbow splinting for 5-7 days is often followed by a hinged elbow brace (30-90 degrees) to improve soft tissue rest.
• Active ROM should start early and involves muscle activation and compression across the elbow joint.
• Exercises involve increasing the ROM in hinged elbow brace by 10-15 degrees per week.
• Up to 2 weeks after injury, avoid passive ROM (as it increases swelling and inflammation), valgus stress, external rotation, and abduction.
• No strengthening or resistive exercises should be performed to avoid placing undue tension on healing ligaments.
• Strengthening usually starts at 6-8 weeks, with elbow flexion usually regaining first, followed by extension which can take 3-5 months to fully heal.

Radial Head Fracture

• Radial head fractures usually result from falls, often onto an extended arm.
• A fall on an outstretched arm with minimal or moderate elbow flexion is often causative.
• A direct blow to the elbow is less often causative.
• The fracture commonly causes swelling at the lateral aspect of the elbow, limited ROM, and maximal tenderness over the radial head.
• The typical deformity range is 10° to 15° limitation of normal ROM.

Types of Radial Head Fractures

• The Mason classification categorizes this type of fracture according to whether the fracture involves bone displacement, and its severity.

Treatment of Radial Head Fracture

• Treatment depends on the severity and the displacement.
• Simple, minimally displaced fractures (Type I) can be managed by immobilization in a cast for about 3 weeks.
• Moderately displaced fractures (Type II) are often treated with open reduction and internal fixation (ORIF) or immobilization with a cast for about 2 weeks.
• More severely comminuted fractures (Type III) are treated with ORIF, or resection of the radial head; followed by immobilization for two weeks.
• Dislocations associated with fractures (Type IV) need ORIF or replacement of the radial head.

Forearm Bone Shaft Fracture

• Monteggia and Galeazzi fractures are common types.
• Monteggia fracture is a proximal ulnar fracture with superior radio-ulnar dislocation.
• Galeazzi fracture is distal radius fracture with dislocation of the inferior radioulnar joint.
• Both require ORIF (Open Reduction and Internal Fixation) to treat fractures.

Both Bone Forearm Fracture Rehabilitation

• Phase I(0-2 weeks): Patients are immobilized with surgical incisions protected in a splint.
• Phase II(2-6 weeks): Active and active-assisted ROM of elbow, forearm, and wrist, avoiding repetitive twisting.
• Phase III(6 weeks onwards): Lifting and twisting restrictions are released according to surgeon preference.
• Proper communication with the treating surgeon is crucial.

Distal Radial Fractures

• These include Colles', Smith, Barton’s, and chauffeur's (radial styloid) fractures.
• Colles' fracture is a transverse fracture of distal radius, and it affects primarily the elderly and is often due to a fall on an extended wrist.
• Typical deformity when a Colles’ fracture happens is called a dinner fork deformity.
• Smith fracture is frequently from a fall on a flexed wrist, with the opposite (palmar) deformity of a Colles' fracture, called a garden spade deformity.
• Barton’s Fracture is an intra-articular type of distal radius fracture, often requiring open reduction and internal fixation (ORIF).

Carpal Bone Fractures

• Scapholunate fractures constitute up to 50-80% of carpal bone fractures.
• Due to a fall on an outstretched hand with a radially deviated wrist, that results in dorsiflexion.
• The symptoms involve a deep dull ache in the radial portion of the wrist, and the pain might be worse when pinching and gripping.
• The radial side of the wrist may also be slightly swollen or bruised.
• Treatment for scaphoid injuries depends on the severity and displacement of the injury.

Lunate Fracture

• Occurs via a fall on outstretched hand.
• The proximal fracture fragment is at risk of avascular necrosis.
• Clinically, this is suspected when axial compression on the 3rd metacarpal elicits tenderness.
• Pain in the anatomical snuff box is common when a lunate fracture is present.
• Treatment usually follows a short arm thumb splint and cast, followed by up to 7-10 days of observation.

Metacarpal Fractures

•  Bennett's fracture: Intra-articular fracture at the base of the first metacarpal, commonly associated with dislocation of the carpometacarpal joint.
• Management typically involves ORIF (open reduction and internal fixation) for unstable cases, and a thumb spica splint for stable ones.
• Boxer's fracture: Fracture of the 4th or 5th metacarpal neck, typically caused by forceful striking.
• Treatment includes immobilization, often with buddy taping, with closed reduction if possible. ORIF if highly displaced.

Treatment summary

• Treatment often involves immobilization of the affected joint to promote healing.
• Splints, casts, or taping techniques (buddy taping) are commonly used.
• Surgery (open reduction and internal fixation) may be necessary for severely displaced, unstable, or misaligned fractures.