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 When pain is no longer a barrier to treatment:
HYPOAESTHESIAS OF THE HAND IN THE ULNAR
NERVE DISTRIBUTION  PREs on UE x 10 reps x 3 sets (di ko sure to)
 Concomitant fx REFERENCE
 Myositis ossificans
 Degenerative changes in the joint  Physiopedia

RED FLAGS VOLKMANN ISCHEMIC CONTRACTURE

 Hx of CA  Deformity of the hand, fingers, and wrist which
 Fever occurs as a result of a trauma such as:
 Palpable enlarged mass 1. Fx
 LOM in undiagnosed condition 2. Crush injuries
 Excessive swelling 3. Burns
 S/Sx of systemic infection or CA 4. Arterial Injuries
 Significant unexplained elbow pain c no previous Following this trauma, there is a deficit in the
films arterio–venous circulation in the forearm which
 Loss of normal shape (unreduced dislocation) causes a decreased blood flow & the hypoxia can
 Unexplained deformity lead to the damage of muscles, nerves, and
 Red skin vascular endothelium. This results in a shortening
 Hx of non–investigated trauma (contracture) of the muscles in the forearm
 Unexplained significant sensory or motor deficit ANATOMY
SURGERY
 The bones are an important factor in a
 Elbow stiffness & pain Volkmann’s contracture. The humerus of the
upper arm is often involved in VIC.
PT MANAGEMENT  Fx of the supracondylar ridge causes a deficit in
 Splinting: 45 to 90 degrees of elbow flexion for 3 the circulation of the brachial artery – it is caused
days to 3 weeks by the blocking of the circulation & deficit in
 AROMEs on Upper Limb x A/P x 10 reps x 2 sets supply of blood that the muscles and nerve
malfunction. There is a contraction of the muscles.
 Effleurage on Upper limb x 5 mins
 The muscles which are usually involved are the
 Ice pack on Upper Limb x 15 – 20 mins
flexors of the wrist. Yet there is also a
When the patient no longer requires immobilization: contracture occur in the extensors of the wrist,
but this is less common.
 Gentle AROMEs and PROMEs in a pain-free range 1. Superficial Muscles:
targeting the entire UE  Pronator Teres (median nn)
 Multi-angle isometric activities &  FCR (median nn)
Proprioceptive Nuclear Facilitation patterns
 FCU (ulnar nn)
for the elbow help decrease pain, increase
 FDS (median nn)
ROM, and begin to target strengthening
components in the preliminary stages of  Palmaris longus (median nn)
recovery 2. Deep Flexors:
 FPL (median nn)
 Pronator Quadratus (median nn)
 FDP (median nn)

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 EXAMINATION
EPIDEMIOLOGY/ETIOLOGY  The findings are specific as described in clinical
presentation subheading above
 The incidence of VIC is low. It counts 0.5%, which
 The deformity in this condition can be divided into
means it is a rare disease
different levels of severity
 The intracompartimental pressure occurs when 1. MILD
there is a bulging caused by a trauma. Thus, there
 Flexion contracture of 2 or 3 fingers c
is not enough space for muscles, nerves, and
no or limited loss of sensation
blood vessels that lie within this fascia. This
2. MODERATE
results in vascular defects and defects on nerves.
 All fingers are flexed and the thumb is
 Possible causes can be animal bites, fx of the
oriented in the palmar orientation. The
forearm, bleeding disorders, burns, excessive
fist in this case can remain permanently
exercise and injections of medications at the
in flexion & there is usually a loss of
forearm
sensation in the hand
CHARACTERISTIC/CLINICAL PRESENTATION 3. SEVERE
 All muscles in the forearm (flexors and
 5 P’s: extensors) are involved. This is a
 Pain serious limiting condition
 Pallor  An objection test to evaluate the ischemia and the
 Pulselessness pressure in a muscle compartment is an invasive
 Paresthesias test. It measures the absolute pressure in the
 Paralysis compartment of the muscle. This is also called the
 Special Findings: Intracompartimental Pressure Monitoring (ICP)
 Bleach view at the level of the skin
DIAGNOSTIC PROCEDURES
(Pallor)
 The wrist is in palmar flexion  ICP can be measured by several means including:
 Clawed fingers  Wick Catheter
 Pain occurs with passive stretching of  Simple Needle Manometry
the flexor  Infusion Techniques
 Palpation of the affected region creates  Pressure Transducers
persistent pain (Pain)  Side–ported Needles
 It is possible that the pulsations cannot  Critical pressure diagnosing compartment
be felt in the swollen arm, mainly in the syndrome is unclear
distal part (Pulselessness).  Different authors consider surgical intervention if:
 There are also neurological limitations  Absolute ICP >30 mmHg
noticeable from the muscles that pinch  Difference between diastolic pressure
the neutral pathways, there is a and ICP >30 mmHg
decreased sensation (Paresthesia) and  Difference between MAP and ICP >40
there is an observable motor deficit mmHg
(Paresis)
MANAGEMENT
DIFFERENTIAL Dx
 Prevention is the best Mx in this condition. Often
 Pseudo–Volkmann’s Contracture times, the Mx require the surgical and physical
therapy intervention for a better outcome.

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  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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