Shoulder and Elbow Rehabilitation Quiz

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Questions and Answers

What is the primary focus of non-operative treatment options for shoulder instability?

Immediate surgical intervention for all dislocations

Application of weights for decompression

Increasing overall shoulder stability through exercises (correct)

Joint replacement surgery

Which method involves the patient hanging their arm off the edge of a bed?

Operative treatment

Hippocratic method

Stimson’s gravity method (correct)

Kocher’s method

What is the appropriate limitation for external rotation after surgery as specified during rehabilitation?

Limited to 90 degrees initially

No limitation on movement

Limited to 30 degrees initially, then up to 45 degrees at 6 weeks (correct)

Limited to 15 degrees during the first week only

What is the main target of rehabilitation programs following shoulder interventions?

Strengthening the rotator cuff and scapular muscles Signup and view all the answers

Which surgical indication suggests the need for intervention for a shoulder dislocation?

Glenoid rim fractures larger than 5 mm Signup and view all the answers

What physical position is required for the Hippocratic method of shoulder reduction?

Supine with arms crossed Signup and view all the answers

What are common precautionary measures following shoulder surgery?

Avoid provocative shoulder positions that risk dislocation Signup and view all the answers

What is a major drawback of performing an open surgical reduction?

It necessitates detailed knowledge of joint anatomy post-operation Signup and view all the answers

Which intervention is NOT typically used in managing mild to moderate Volkmann's contracture?

Debridement of injured muscle Signup and view all the answers

What is a common outcome of untreated post-traumatic ossification?

Painful calcification within muscle Signup and view all the answers

What is the correct management for a non-displaced supracondylar fracture of the elbow?

Immobilization with a long-arm cast Signup and view all the answers

Which statement about the management of moderate Volkmann's contracture is correct?

Extensor transfer procedures are performed. Signup and view all the answers

What factor does NOT contribute to the formation of post-traumatic ossification?

Quick surgical intervention Signup and view all the answers

In what position should the elbow be immobilized for an anterior displacement in a supracondylar fracture?

Extension Signup and view all the answers

Which of the following therapeutic methods is NOT part of the management for post-traumatic ossification?

Reactive immobilization Signup and view all the answers

What is the purpose of activating and strengthening weak agonist muscles in therapy for Volkmann's contracture?

To ensure equilibrium in agonist and antagonist pull Signup and view all the answers

What is the rationale behind placing the arm in external rotation after a Bankart lesion?

It approximates the lesion to its anatomic position. Signup and view all the answers

What is the typical duration of immobilization in a sling for individuals under the age of 40?

3-6 weeks Signup and view all the answers

Which exercises are recommended during the immobilization period?

Active range of motion exercises for the elbow, wrist, and hand. Signup and view all the answers

What is NOT a goal during Phase 2 (6-12 weeks) of rehabilitation?

Initiating strengthening exercises immediately. Signup and view all the answers

Which musculature should be focused on first when beginning strengthening exercises in Phase 3?

Rotator cuff musculature and scapular stabilizers. Signup and view all the answers

What type of exercises should be included when stretching is permitted in Phase 2?

Passive stretching through self-stretching or joint mobilizations. Signup and view all the answers

In the management of posterior dislocation, how does the protocol differ from anterior protocol?

It follows the same progression with specific guidelines. Signup and view all the answers

Which approach is recommended for mobility exercises during rehabilitation?

Incorporate AAROM to achieve full range of motion. Signup and view all the answers

What is the primary focus of strengthening during rehabilitation for a proximal humeral fracture?

Posterior musculature such as infraspinatus and teres minor Signup and view all the answers

What complication is most commonly associated with fractures of the humerus?

Adhesive capsulitis (frozen shoulder) Signup and view all the answers

During the initial stages of rehabilitation for a proximal humeral fracture, what activity should be avoided for at least 6 weeks?

Extension and internal rotation Signup and view all the answers

What is the recommended immobilization duration for patients under 40 years of age after a proximal humeral fracture?

3-6 weeks Signup and view all the answers

What type of fracture is referred to as a Holstein-Lewis fracture?

Spiral fracture of the lower third of the humerus Signup and view all the answers

What common dysfunction may occur following a humeral shaft fracture?

Altered scapulohumeral rhythm Signup and view all the answers

What is the primary goal during the rehabilitation of a proximal humeral fracture?

Preventing disuse atrophy and maintaining range of motion Signup and view all the answers

After a distal humeral fracture, the most common neurovascular injury associated is:

Radial nerve palsy Signup and view all the answers

What is the preferred management for a stable fracture shaft of the humerus?

Closed Reduction in upright position with POP or cylinder cast Signup and view all the answers

Which type of supracondylar fracture is most commonly seen in children?

Displaced extension type with an 'S-deformity' Signup and view all the answers

Which indication is appropriate for considering operative treatment of a humeral fracture?

Nonunion with persistent symptoms Signup and view all the answers

In the rehabilitation phase II for humeral fractures, what type of exercises should be initiated?

Early active, resistive, and stretching exercises Signup and view all the answers

What fixation method is most commonly used for plating a fracture shaft of the humerus?

Plates and screws Signup and view all the answers

During rehabilitation phase III, what is the maximum weight limit for isotonic exercises?

5 lbs Signup and view all the answers

Which mechanism of injury is most often associated with supracondylar fractures of the humerus in children?

Fall on an outstretched hand (FOOSH) Signup and view all the answers

What exercise is encouraged during phase I of rehabilitation for a humeral fracture?

Pendulum exercises for the shoulder Signup and view all the answers

What is a primary consequence of brachial artery injury following a supracondylar fracture?

Volkmann's contracture Signup and view all the answers

Which of the following muscles is NOT typically involved in a Volkmann's contracture?

Extensor carpi radialis longus Signup and view all the answers

What are the common clinical signs of Volkmann's contracture referred to as the '5 P's'?

Pain, pallor, pulselessness, paresthesias, paralysis Signup and view all the answers

What medical emergency is associated with a compartment syndrome exceeding 30 mmHg?

Tissue necrosis Signup and view all the answers

Which statement regarding the management of Volkmann's contracture is incorrect?

Immediate amputation of the limb is standard treatment. Signup and view all the answers

Which nerve primarily supplies the flexor muscles involved in Volkmann's contracture?

Median nerve Signup and view all the answers

What is the most common cause of Volkmann's contracture?

Supracondylar fracture Signup and view all the answers

Which treatment is specifically recommended when intra-compartment pressure is greater than 30 mmHg?

Urgent fasciotomy Signup and view all the answers

Study Notes

Fractures & Dislocations of the Upper Limb

Clavicle fractures, also known as broken collarbones, are common in adults (2-5%) and children (10-15%).
They account for 44-66% of all shoulder fractures and are the most common fracture in childhood.
Treatment choice is debated, with options including conservative and surgical management.
Treatment selection depends on factors including biologic age, functional demands, and the type of fracture.

Clavicle Fracture Classification

Allman classified clavicle fractures into three groups based on location:
- Group I: Middle third (midshaft) fractures (80%)
- Group II: Distal third fractures (12-15%), a common site for non-union. Neer further categorized Group II based on the coracoclavicular ligament position.
- Group III: Proximal third fractures (5-6%)

Clavicle Fracture Mechanism of Injury

Clavicle fractures are often caused by a direct blow to the shoulder (e.g., falling onto shoulder or car collision).
Can also occur due to a fall onto an outstretched arm, or during childbirth.

Clavicle Fracture Complications

Malunion: Although common, it rarely causes functional impairment.
Non-union: Rare.
Neurovascular involvement: Subclavian vessels and brachial plexus can be at risk, especially with high-velocity trauma.
Degenerative arthritis of acromioclavicular or sternoclavicular joints.

Clavicle Fracture Union Time

Early union occurs in 1-2 weeks in children.
In adults early union occurs in 3-6 weeks and consolidation in 12 weeks.
Callus formation is visible and palpable.
Immobilization duration is not consistent, with recommendations ranging from two to six weeks.

Clavicle Fracture Conservative Management

Undisplaced fractures are typically treated conservatively.
Immobilization with a sling is often used for 2-4 weeks.
A figure-of-eight brace is sometimes used to prevent secondary fracture shortening.
Treatment continues until clinical union is confirmed (no pain, tenderness or movement at fracture site) in appropriate timeframe (6–8 weeks).
Radiographic union can be checked with follow-up x-rays.

Clavicle Fracture Surgical Management

Surgical management is indicated for fractures with significant displacement (>2cm), severe skin tenting (open fractures requiring debridement), associated neurovascular injury, or non-union (failure of conservative treatment).
Surgical methods include open reduction and internal fixation using plates and screws, or intramedullary fixation.

Clavicle Fracture Rehabilitation

Physical therapy programs typically start with gentle motion exercises like pendular exercises.
Gentle range-of-motion (ROM) exercises begin 2-4 weeks post-injury and strengthening exercises are initiated 6-10 weeks post-injury.
Full activity, including sports, is typically permitted 3 months post-injury when pain-free motion and radiographic union are achieved.
Patients should be aware of their body mechanics to maintain proper posture and avoid problems associated with using a sling (e.g., slouching, shrugging, etc.)
Important to take note of situations like coughing and sneezing which can cause clavicle movement. Avoidance of these movements as much as possible or learning active-assisted coughing techniques is helpful.

Shoulder Dislocation

Anterior dislocations comprise the majority (>95%).
Posterior dislocations are less common (<5%).
True inferior dislocations are rare (<1%).
Multidirectional dislocations are due to ligament laxity and are typically painless.

Anterior Shoulder Dislocation Mechanism of Injury

Usually an indirect fall. It may be direct when there is a blow to the shoulder from behind.
Caused by an excessive amount of abduction and external rotation of the arm.
The glenohumeral joint is most susceptible to dislocation in the 90° abduction and 90° external rotation.

Anterior Shoulder Dislocation Complications

Bony: Bankart lesion, Hill-Sachs lesion, neck of humerus, greater or lesser tuberosity fractures
Soft tissue: Soft tissue Bankart lesion, subscapularis tear and rotator cuff tear
Vascular: Axillary artery injury, avascular necrosis of humeral head
Nerve: Axillary nerve neuropraxia
Recurrent dislocation
Shoulder stiffness with prolonged immobilization

Anterior Shoulder Dislocation Tests

Dugas test: Inability to touch the opposite shoulder with the affected hand

Anterior Shoulder Dislocation Clinical Picture

Arm held in an abducted and externally rotated position; internal rotation and adduction may be limited.
Loss of normal contour of the deltoid and acromion is noted, posterior fullness.
Humeral head is palpable anteriorly.
All movements are limited and painful.
Palpable fullness below the coracoid process and towards the axilla.

Posterior Shoulder Dislocation

Rare and often missed.
More common in epileptics and those with electrocution.
Caused by overpull of the subscapularis and latissimus dorsi muscles.
Involves an indirect force applying flexion, adduction, and internal rotation to the humerus.
Often a result of a fall on an outstretched hand.
Imaging is challenging, and a lateral view is essential; an axillary view is preferred.

Posterior Shoulder Dislocation Clinical Picture

Arm is adducted and internally rotated.
Clinically locked in internal rotation, unable to externally rotate the shoulder.
May or may not lose deltoid contour.
May note posterior prominence of the humeral head.
Tear of subscapularis muscle (weakness in internal rotation).

Luxatio Erecta (Inferior Shoulder Dislocation)

Also known as an inferior dislocation.
Cause: Severe hyper-abduction forces.
Arm is in an abducted position.
Reduction is done by in-line traction and gentle adduction.

Shoulder Dislocation Management

Emergency—usually needs to be reduced within 24 hours to avoid avascular necrosis of the humerus head.
Reduction techniques (e.g., closed reduction or open reduction).
- Hippocratic method
- Stimson’s gravity method
- Kocher’s method.
Post-reduction immobilization methods

Operative Indications for Shoulder Dislocation

Irreducible shoulder
Displaced greater tuberosity fractures.
Glenoid rim fractures bigger than 5 mm.
Multiple recurrent dislocations

Non-operative Shoulder Dislocation Treatment

Pain and edema reduction
Protecting static stabilizer and strengthening dynamics
Improve shoulder stability.
Exercises designed to enhance joint proprioception and address kinetic chain deficits.

Surgical Shoulder Dislocation Treatment Post-Procedure Precautions

If subscapularis is cut, no resisted internal rotation for 4-6 weeks.
External rotation is usually limited to 30 degrees initially then 45 degrees at 6 weeks.
Avoid provocative postures (external rotation, abduction, distraction, extension).

Humerus Fracture

Proximal humerus, including surgical and anatomical neck, greater and lesser tubercles.
Humeral shaft.
Distal humerus. Includes fractures of the condyle, epicondyles, and supracondylar fractures.

Proximal Humerus Fracture—Neer Classification

Anatomical neck
Surgical neck
Lesser tuberosity
Greater tuberosity

Proximal Humerus Fracture Complications

Adhesive capsulitis (Frozen shoulder)
Multi-part fractures lead to avascular necrosis
Neurovascular injuries.

Proximal Humerus Fracture Treatment

Stable and minimally displaced—sling immobilization and early motion.
Significant displacement—ORIF in younger adults, hemiarthroplasty for elderly or comminuted fractures.
Bony healing usually takes 6-8 weeks in adults.

Humeral Shaft Fracture Treatment

Closed reduction and immobilisation in upright position by POP or cylinder cast and/or functional brace.
Operative treatment indications include: inadequate reduction, nonunion, open fractures, segmental fractures, or associated vascular/nerve injuries.
Most common—plates and screws; sometimes intramedullary nails.

Humeral Shaft Fracture Rehabilitation

Phase 1 (0-6 weeks):
- Active ROM of neck, shoulder, elbow, wrist, and hand.
- Pendulum exercises.
- Passive self-assistive exercises.
Phase II (6-12 weeks):
- Early active, resistive, and stretching exercises.
- Therabands for internal rotators, external rotators, flexion, extension, & abduction.
Phase III (>12 weeks):
- Begin isotonic exercises (rubber tubing to weights).
- Focus on rotator cuff and scapular strengthening, progressing to weights.
- Increase ROM and flexibility, progress to overhead exercises.

Supracondylar Fracture

Most common fracture type in children, usually due to falling.
Two types: Extension type (posterior displacement) and flexion type (anterior displacement).

Supracondylar Fracture Complications

Brachial artery injury (Volkmann's ischemia)
Nerve injury (median, ulnar, or radial nerves).
Stiffness
Heterotopic calcification (Myositis ossificans)
Mal-union (cubitus varus or valgus)

Supracondylar Fracture Treatment

Non-displaced: Immobilization with a long-arm cast or splint.
Displaced: Closed reduction with percutaneous pinning; open reduction and internal fixation are sometimes required.

Supracondylar Fracture Rehabilitation

Phase 1 (0 to 6 weeks): Gradual return to ROM of the elbow, wrist, fingers, active elbow exercises.
Phase II (6 to 12 weeks): Passive ROM, active elbow exercises with resistance.
Phase III (> 12 weeks): Isotonic exercises for strengthening, progress to more challenging exercises, full ROM.

Volkmann's Contracture

Deformity of the hand, fingers, and wrist caused by a brachial artery injury after supracondylar fracture.
Characterized by decreased blood flow leading to muscle damage and shortening.
Pain, pallor, pulselessness, paresthesias, and paralysis (5Ps).

Volkmann's Contracture Treatment

Prevention is key.
Intra-compartmental pressure over 30 mmHg necessitates an urgent fasciotomy
Post-surgery, aggressive therapy and tendon slide, neurolysis, and extensor transfer.
Aggressive passive stretching, ROM exercises, and muscle strengthening are needed.

Post-Traumatic Ossification

Usually results from impact causing damage to the periosteum and surrounding muscle
Bone grows within the muscle forming a painful calcification.
Treatment focuses on RICE principle, stretching, and strengthening.

Mal-union Supracondylar Fracture Management

Most commonly results in cubitus varus deformity.
Management involves corrective supracondylar osteotomy.

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Description

Test your knowledge on non-operative and surgical treatment options for shoulder instability and elbow fractures. This quiz covers rehabilitation protocols, surgical indications, and specific intervention techniques. Enhance your understanding of effective management strategies in orthopedic care.