Haley Libs

Condition: Elbow Dislocation 4 Weeks s/p Elbow Contracture

Condition Description: An elbow dislocation occurs when one of the articulating joint surfaces
of the forearm separate from the humerus. The elbow is the second most commonly dislocated
large joint in adults, but the most common large joint dislocation in children. Seven of every
100,000 individuals will suffer from an elbow dislocation; the demographic at the highest risk
for elbow dislocation is adolescent males.1 Elbow dislocations typically occur from a traumatic
accident, including falling on an outstretched hand, motor vehicle accidents, sports injuries and
overuse. Following a fall on an outstretched hand, damage to the soft tissue surrounding the
elbow typically occurs, laterally to medially, in a sequential pattern, beginning with damage to
the lateral collateral ligament complex, resulting in a posterolateral rotary subluxation and
ending with damage to the medial collateral ligament complex, resulting in a posterior elbow
dislocation.2 Elbow dislocations vary in severity and dislocation direction. The three
classifications for elbow dislocation are simple, complex and severe. 3 An elbow dislocation is
classified as a simple dislocation if there is no major injury to the bone following dislocation. A
classification of a complex elbow dislocation is given if there is significant injury to both the
bones and the ligaments. Finally, a severe dislocation is when there is damage to the nerves
and blood vessels surrounding the elbow. The six different elbow dislocation directions are
posterior, postero-lateral, radial (Nursemaid’s elbow), ulnar, anterior and divergent.

Immediately following elbow dislocation, the patient may experience swelling, pain, weakness
at the joint, bruising, decreased range of motion, and the arm may appear deformed. 3
Succeeding acute trauma, a non-surgical or surgical procedure is necessary to stabilize and
reduce the elbow joint. The non-surgical approach calls for a closed elbow joint reduction
followed by temporary immobilization in 30 degrees elbow flexion for 7 days. Surgical repair is
necessary if a closed reduction is not possible or a joint re-dislocates. 4 Surgery is also deemed
necessary if the joint is unstable or has an associated elbow fracture.5 Following reduction of
the elbow joint, the patient may experience reduced elbow ROM and strength, reduced grip
strength, potential neurovascular symptoms in the distal forearm, pain and laxity of the
collateral ligaments, as well as elbow flexion contracture.6 However, the most common
complication following a simple elbow dislocation is elbow stiffness and loss of range of motion,
due to immobilization and static splinting of the arm following reduction. Immobilization that
extends beyond 25 days may lead to a flexion contracture of at least 30 degrees. 7 Structures
within the elbow that may contribute to contracture include the anterior capsule, collateral
ligaments and surrounding musculature. Early ROM is necessary to reduce the risk of
contracture following reduction. Elbow dislocations are not typically reoccurring. However,
inadequate immobilization of the elbow following injury, as well as failure of the lateral
collateral ligaments leads to joint instability and may play a role in reoccurrence of the
condition.8

Scenario: Ryan is an 18-year-old, healthy male who was playing football and fell on an
outstretched hand, with his elbow hyperextended and his shoulder slightly abducted. Following
the fall, he felt extreme pain at his right elbow. His elbow appeared swollen, bruised and
deformed. After an X-ray, the doctors confirmed that Ryan had suffered a simple posterior
 Haley Libs

elbow dislocation. Surgery was not required, but a gentle reduction maneuver, followed by
immobilization of the elbow at 30 degrees elbow flexion (supported by a sling) was conducted.
Today, 4 weeks post injury, the patient is complaining of pain on the medial and lateral aspects
of the elbow, as well as difficulty extending the elbow to reach for objects in front of him. The
patient has also reported difficulty grasping heavier objects, such as glass mugs and heavier
food items from the cupboard. Ryan has been referred to an outpatient occupational therapy
clinic to address his decrease in functional range of motion following immobilization. Ryan is a
son, older brother, teammate and student. When Ryan is not in school, he helps his mom
around the house to complete household chores and takes care of his 3-year-old little brother.
He has stated that he enjoys throwing football with his brother in the backyard but has been
unable to since his injury. The patient has stated he wants to get back to playing football,
cooking with his mom and participating in class activities.

Standard Ideal Alignment: Elbow Anatomy: Carrying angle

Posture From the anterior view, the zero position of the During full elbow extension, the
upper limb is a position in which the glenohumeral elbow demonstrates a valgus angle
joint and forearm are positioned in midrange. In due to the oblique articulation
this position, muscle activity is minimal, and the between the trochlea of the humerus.
origins and insertions are in a resting orientation. This angle is known as the carrying
angle. The normal carrying angle in
In order for the elbow to be in proper alignment, adults is averaged to 17.8 degrees for
the scapula must be in a neutral position, meaning both men and women when
there is no protraction/retraction, elevation nor measured radiographically.5 Meaning,
depression. The humeral head should sit centered the forearm is slightly abducted from
in the glenoid fossa with no internal rotation nor the body when the elbow is in full
elevation. Distally, the wrist is positioned in a elbow extension.
slightly extended position with the palm facing
inward toward the body medially. Thus, the Dynamic movement:
forearm is neither pronated nor supinated in the The elbow allows for two axes of
resting position. The resting position of the movement: flexion-extension and
ulnohumeral joint is 70 degrees of flexion and 10 pronation-supination. Movement
degrees supination.9 While the radiohumeral joint does not occur in a single plane at the
holds a resting position in full extension and full elbow, as slight rotation and medial-
supination.9 lateral motion occurs during elbow
flexion and extension.5 During
From a lateral view, the ear, shoulder, lateral supination and pronation, the radius
elbow, posterior hip, anterior knee and lateral rotates around the ulna.
malleolus should all be in line. This plumline is a
reference for normal standing posture. Any Symmetry:
deviation from the plumline is considered a fault in From the anterior view, both
standard posture. shoulders should be at an equal
height and both hands should extend
down to the side at the same length.
 Haley Libs

Skeletal Skeletal Anatomy: Simple Posterior Dislocation

Imbalance With enough force, the trochlea of the humerus can Analysis: Below is an x-ray of a simple
displace over the coronoid process of the ulna, posterior dislocation. During a simple
leading to a simple posterior dislocation. In the case posterior dislocation, the olecranon
of a simple posterior dislocation, there is not an process of the ulna is pushed into the
associated fracture to the surrounding bony olecranon fossa of the humerus while
segments. However, there may be significant laxity the trochlea of the humerus is
of the ligaments and torn tissue. Thus, a simple dislodged over the coronoid process.10
reduction maneuver and immobilization at 30 In the case of a simple posterior
degrees of elbow flexion is required to allow the dislocation, there are no associated
associated structures to heal. fractures, as reflected in the image
below.
Flexion and extension at the uniaxial hinge joint are
afforded by the articulation between the trochlea of
the humerus and the coronoid and olecranon of the
proximal ulna. During full elbow flexion the
coronoid process of the ulna rolls onto the coronoid
fossa of the anterior distal humerus. During full Figure 1: Henry, K., & Jones, J. (n.d.). Case 1: Posterior [Digital image]. Retrieved
May 18, 2020, from https://radiopaedia.org/articles/elbow-dislocation

extension, the olecranon process rolls into the

olecranon fossa of the posterior distal humerus. Contracture Radiographic Analysis:
Shortening and tightening of the anterior capsule, Below is an x-ray of an adhesion on
collateral ligaments or surrounding musculature the anterior capsule of the elbow.
following immobilization prevents the movement of Shortening and hardening of the
the olecranon on the humerus. This leads to a anterior capsule results in loss of
resting fixed, flexed position and hindered elbow extension and a fixed flexed
movement at the uniaxial hinge joint. Articular position. Thus, limiting the ability of
malalignment following elbow dislocation, as well the olecranon process to roll onto the
as, intra-articular adhesions may lead to decreased posterior trochlear notch.
range of motion and subsequent contractures.

Figure 2: Nobuta, S. (2018, August 01). Figure 1 B Elbow with adhesion of the
anterior capsule. Arthrogram. Retrieved June 03, 2020, from
https://www.researchgate.net/figure/B-Elbow-with-adhesion-of-the-anterior-
capsule-Arthrogram-revealed-no-infiltration-of_fig2_51398228

Muscle Structures w/ description: Progression:

Imbalance Biceps Brachii: The biceps brachii is one of the Following the simple reduction
major forearm flexors and forearm supinators. This maneuver, the arm is temporarily
muscle originates at the coracoid process and immobilized in 30 degrees of elbow
 Haley Libs

supraglenoid tubercle and inserts on the radial flexion for seven days. However, this
tuberosity. Immobilization at 30 degrees of elbow may extend up to three weeks leading
flexion for an extended period of time may result in to potential contracture. After
shortening of the biceps brachii. Adaptive immobilization, the patient may
shortening of the biceps brachii will lead to experience decreased ROM of the
decreased elbow extension. Supination and elbow, as well as weakness of the
pronation may also be affected. under-used muscles. For example,
elbow flexors such as the biceps
Brachialis: Forearm flexor that originates on the brachii and brachioradialis may
anterior humerus and inserts on the tuberosity of become shortened due to prolonged
the ulna. The brachialis muscle is likely to be immobilization. The triceps brachii
shortened following immobilization in the flexed muscle may become lengthened and
position. weakened due to lack of use and
immobilization. Therefore, elbow
Brachioradialis: This muscle originates on the extension, as well as supination and
anterior humerus and inserts on the tuberosity of pronation are likely to be affected.
the ulna. The brachioradialis is likely to be
shortened following immobilization for an extended Adaptive Shortening:
period of time. When the arm is immobilized in 30
degrees of elbow flexion, the forearm
Triceps Brachii: The triceps brachii will be flexors (biceps brachii, brachialis, and
lengthened/weakened following immobilization in brachioradialis) become shortened.
30 degrees of flexion. The triceps brachii originates While the triceps brachii becomes
at the shoulder joint, then crosses the elbow and lengthened due to the prolonged
inserts on the olecranon of the ulna. This is the flexed position. The anterior capsule
primary elbow extensor. Thus, elbow extension will also becomes shortened, contributing
be weakened. to decreased ROM and subsequent
elbow flexion contractures.
Medial Collateral Ligament: Composed of the
anterior, posterior and transverse bundle. Following
immobilization, this ligament is likely to shorten
and weaken. This may be dangerous, as this
ligament prevents against valgus force.

Radial (lateral) collateral ligament: Stabilizes the

lateral aspect of the elbow and extends from the
lateral epicondyle to the annular ligament.
Extended immobilization may cause the radial
collateral ligament to shorten, as well as weaken.

Annular ligament: Ligament that holds the radial

head within the radial notch. Prolonged
immobilization may lead to shortening of the
annular ligament, resulting in decreased supination
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and pronation of the forearm.

Anterior capsule: One of the most common elbow

joint contracture sites. The anterior capsule will be
shortened following prolonged immobilization.
Compensations Posture Description:
 Increased motions such as scapular The inability to fully extend the arm
protraction and scapular elevation will and loss of forearm supination and
increase tightness of the pectoralis minor pronation alters the client’s
muscle, leading to a rounded shoulder movement patterns. Proximally, the
position. client will demonstrate increased
trunk movement to compensate for
Trunk the decreased elbow extension in the
 Increased trunk flexion. affected extremity. An increase in
 Increased trunk rotation. scapular protraction and elevation
 Increased lateral flexion when reaching for may lead to increased tightness of the
objects. pectoralis minor muscle, resulting in a
rounded shoulder posture. Increased
Proximal load will be put on the shoulder as the
 Increased scapular protraction and elevation client attempts to manipulate items
to compensate for decreased elbow within his environment (grabbing
extension. items from the fridge, assisting little
 Over-use of shoulder (flexion, abduction, brother in performing his nighttime
extension) to compensate for decreased routine). Pain and inability to supinate
elbow extension. and pronate may lead to decreased
 Decreased supination and pronation of the use of the right upper extremity,
forearm results in increased glenohumeral resulting in further stiffness and
internal rotation. weakness.

Distal
 Decreased elbow extension, supination and
pronation.
 Decreased forearm rotation at the DRUJ will
lead to increased supination at the hand and
fingers.
 Pain when gripping heavier objects at the
medial and lateral epicondyle will decrease
use of the affected extremity.
Occupations11 Education- Writing, placing books in locker. The following occupations are
affected for Ryan:
Leisure- Throwing football with brother and playing Education- The patient demonstrates
football at school. the inability to write and lift books
into his locker using his right upper
 Haley Libs

IADLs- meal preparation, home management, child extremity. The patient has difficulty
rearing. manipulating a lock, due to shortened
and weakened muscles that produce
ADLs- LE dressing, toileting, eating, brushing teeth. pronation and supination. Ryan is
unable to grasp a backpack with his
Social participation- Playing football with friends. dominant hand.

Leisure- Ryan is unable to participate

in overhead activities such as
throwing a football with his brother
and friends due to decreased elbow
extension.

IADLs- Ryan is unable to extend his

elbow to reach for heavier objects in
the fridge due to pain when grasping
heavier items and decreased active
elbow extension range of motion. The
decrease in forearm supination and
pronation hinders Ryan’s ability to
perform simple meal preparation
activities, such as pouring milk. Ryan’s
inability to fully extend his dominant
arm effects his ability to perform
household chores such as taking out
the trash, vacuuming and doing
laundry.

Child rearing- Ryan has difficulty

performing care-giving tasks, such as
getting his brother dressed in the
morning and assisting him in his
nighttime routine (i.e. brushing teeth
or taking a bath).

ADLs- Decreased active elbow

extension range of motion in the
affected extremity decreases Ryan’s
independence in performing pants
management during LE dressing and
toileting.

Social participation- Decreased social

participation due to inability to
 Haley Libs

participate in football.

Occupation Adaptation
Education- Ryan is unable to write at
this time, however, Siri allows Ryan to
complete assignments using his voice.
Ryan is unable to pick up his backpack
with his dominant hand, therefore, he
will have to use his unaffected
extremity. The therapist will provide
education on proper positioning of his
backpack to decrease risk of further
injury (Both straps on back to ensure
even load).

Leisure/social participation- Although

Ryan is unable to perform overhead
elbow flexion tasks (i.e. throwing), he
can still go to the field with his friends
and engage in conversations with his
teammates. Ryan and his brother may
take up a new sport such as soccer,
until his elbow extension range of
motion is within normal limits.

IADLs- If necessary, the therapist will

teach Ryan one handed techniques.
Ryan will have to reach for heavier
objects in the fridge with both upper
extremities until the dominant upper
extremity has returned to full
strength and motion. Equipment such
as kitchen scissors and an electric can
opener may be used until the
patient’s active range of motion and
strength has returned.

Child rearing- Ryan may have to

modify his brother’s morning and
nighttime routines. Ryan may help his
3-year-old brother get dressed with
the use of a dressing stick. Adaptive
equipment such as a toothbrush with
a curved handle will allow Ryan to
 Haley Libs

help his brother brush his teeth

without excessive forearm pronation.

ADLs- For pant management, Ryan

may use adaptive equipment such as
a dressing stick. Ryan will be educated
on the figure 4 pattern to adapt
donning and doffing pants. Adaptive
equipment, such as built-up,
elongated or curved handles may be
used to decrease active supination
and pronation range of motion at the
forearm when brushing teeth or
eating.

Assessments Impairment Based- Self- Report-

 Goniometry12- Assesses joint range of  American Shoulder and Elbow
motion, as well as muscle length. Surgeons (ASES)13- Consists of
Goniometry may be used to assess changes 19 questions that help
in muscle length and range of motion at the measure elbow function.
elbow joint following contracture. Components of the
 MMT12- Manual muscle testing of all joints assessment include pain,
of the upper extremity will be conducted to function and satisfaction. The
assess weakness in surrounding therapist’s assessment of
musculature. Specifically, MMT will be motion, strength, and stability
performed for musculature connected to are also utilized in this
the shoulder, wrist and hand. If pain is assessment.
established, MMT will be discontinued.  PSFS14- The PSFS enables
 Ulnar nerve compression (elbow flexion) patients to identify functional
and Tinel’s sign12- A common entrapment limitations when performing
site of the ulnar nerve is at the elbow. The daily tasks. The patient selects
ulnar nerve compression test and Tinel’s 3-5 functional activities that
sign will help rule out ulnar nerve injury. are restricted by their injury or
condition. The PSFS has been
Performance Based: validated for a number of
 Box and blocks16- Assessment that is musculoskeletal conditions.
frequently used for neuromuscular  DASH14- The DASH is a 30-item
conditions. The test assesses activities of questionnaire that assesses
daily living, dexterity, coordination and functional ability of the upper
upper extremity function. A higher score on limb. The items are centered
the assessment indicates greater gross on functional tasks, symptoms,
manual dexterity. In order to increase the as well as social, work, sleep
demands of the elbow, the board can be and overall capability. This
 Haley Libs

placed further away from the patient. assessment has been validated
 Push-off test14- Assessment of patient’s for upper limb disabilities,
ability to weight bear through the upper including elbow conditions.
extremity (specifically, through the elbow).  UEFI15- The UEFI is composed
This assessment assists in assessing of 20 questions that help
occupational limitations, as well as joint assess functional use of the
pathology. Numerous studies have shown upper extremity. Within the
that the push-off test is linked to function assessment, the patient is
and work limitations in those with elbow asked to rank level of difficulty
and wrist conditions. when performing household
 Functional impairment test- hand, neck, chores, work activities, lifting a
14
shoulder arm - Used to assess gross motor bag of groceries, washing hair,
activities of the upper limb. Although this pushing on your hands, driving
assessment has been validated for severe and participating in hobbies.
and mild shoulder conditions, validation
studies for elbow conditions have yet to be Observation12-
completed. Subtasks include reaching at a  Carrying angle- Assess for
specific height, and prolonged manipulation changes in carrying angle due
at a height. to recent elbow trauma.
 ABILHAND17- The ABILHAND has been  General posture of upper
validated for neuromuscular disorders and is quadrant- Assess for internal
used to measure manual ability of those rotation of the humeral head
with upper extremity impairments. This and deviations from neutral
measurement quantifies the adult’s ability alignment of the forearm.
to complete activities of daily living that  Trunk alignment- Assess for
require the use of their affected upper thoracic and cervical flexion as
extremity. Tasks included in this assessment well as the forward head
including manipulating fasteners, meal position.
preparation, cutting fingernails, hammering  Scapular alignment – Assess
a nail, wrapping gifts and more. for scapular mal-alignment
 Minnesota Rate of Manipulation Test 14, 18
such as scapular protraction,
Similar to the box and blocks assessment, internal rotation or depression
this test can be administered at a distance  Swelling and deformity at
to increase the demands of the elbow. This elbow.
large board test assesses gross motor
movement quality and hand dexterity.
During the placement and displacement
test, the participant is asked to put blocks
into the holes with one hand as quickly as
possible.

Impairment Based and Self-Report:

 Timmerman-Andrews Elbow Score13-
Assessment used to assess elbow stiffness
 Haley Libs

and pain following trauma. Objective

measurements include elbow flexion
contracture, forearm pronation and
supination and total arc of elbow motion.
Subjective categories include activity level,
locking, swelling and pain.

Therapy Therapeutic Procedures: Occupation based activities:

interventions  Static Progressive splint - In order to
19
 Locker/backpack simulation:
promote improved, end range elbow Patient will participate in the
extension, as well as induce growth of the following activity two times to
shortened tissues surrounding the elbow, promote increased
the therapist will customize a static independence in school
progressive extension turnbuckle splint for participation. The activity
the patient. The device will be applied at focuses on active elbow
night, with serial increases in end-range flexion, elbow extension and
tension. The therapist will certify end-range forearm supination and
positioning is without pain, to ensure pronation. The patient will be
patient adherence. asked to bring in his school
 Elbow extension stretch21,22 - To further bookbag, along with one light
stretch and lengthen the anterior book. Patient will perform the
musculature (biceps brachii, brachialis and following sequence: 1) Using
brachioradialis) of the upper arm and proper body mechanics,
ligaments of the elbow, the patient will patient will pick up bookbag
participate in an elbow extension stretch. (filled with 1 book) from the
During this exercise, the patient will be ground. Patients forearm will
positioned in a seated position with the be supinated, and patient will
forearm supinated and a towel roll under contract the elbow flexors to
the proximal and distal humerus. The bring the backpack to his
patient will be asked to relax the upper waist. 2) Patient will carry his
extremity to allow for a stretch. Patient will book-bag to his “locker.”
perform activity 2 times for 5 minutes. As Patient will slowly and in a
the patient’s range of motion increases, they controlled manner extend the
can add a 2.5 lb weight to the wrist to elbow and place the backpack
increase the end range stretch. This activity on the ground. 3) Patient will
20
can be adapted to use a band as well . then use the affected upper
Note: This activity will be included in the extremity to unlock locker
home program. Patient’s will be asked to combination.4) Patient will
hold this position 3 sets of 5 minutes, 3 grasp book from bookbag with
times throughout the day. affected upper extremity and
 Isometric exercise for triceps brachii: place it in his locker. Note: In
Patient will perform 10 sets of 5 second order to perform this task in
elbow extension holds with resistance from the clinic, the patient will bring
therapist in order to improve strength of the his own backpack and lock.
 Haley Libs

triceps brachii without moving the joint. The patient will perform the
 Strengthening of the triceps- Patient will same activities, but the lock
perform 3 sets of 10 elbow extension will be locked on a cabinet
exercises to improve strength of the within the outpatient clinic.
weakened triceps brachii muscles. Grade Therapist will educate patient
down: Patient may perform elbow extension on proper lifting mechanisms
exercises with the arm resting on a table. for picking up a backpack.
Grade up: Patient may perform elbow  Football with little brother- In
extension exercises while lying supine and order to promote increased
the shoulder abducted to 90 degrees independence in leisure
(working against gravity). activities such as playing
 Pronation and supination with weighted football with his brother and
dumb bell or hammer- Patient will perform friends, the patient will
2 sets of 10 supination and pronation participate in a football
exercises with a hammer, in order to throwing activity with his
improve active forearm supination and brother. In a standing position,
pronation range of motion. the patient will use his
 Stretching of pec minor: Patient will opposite hand to support the
perform 3 sets of 30 second pectoralis minor distal end of the humerus on
door stretches to decrease rounded the affected extremity. With a
shoulder posture that is observed due to small football in hand, the
compensatory motions. patient will be asked to
 PAMS- Patient will heat the elbow to perform three elbow (triceps
improve tissue extensibility at the elbow extension) extensions with the
prior to activity. Patient will heat at the football in hand. On the third
beginning of session for 10 minutes (Note: extension, the client will
patient may heat while simultaneously release the football and send
performing prolonged elbow extension it to his brother. The focus of
stretch, if no inflammation is present22). the exercise will be on slow
After the cessation of exercise, the patient and controlled elbow
will perform 10 minutes of icing with an extension movements to
icepack in order to decrease inflammation improve strength of the
and decrease pain. triceps brachii muscle. Patient
will perform 5 sets of 3
repetitions. Note: In order to
perform this task in a clinic,
the therapist will ask the
patient to bring his own
football.
 Meal preparation - Patient will
improve active elbow
extension by grabbing various
food items from a refrigerator.
Patient will be asked to
 Haley Libs

remove six items from the

refrigerator, using active
elbow extension. To work on
forearm supination and
pronation, patient will be
asked to poor three cups of
“milk” into a cereal bowl. The
aforementioned activity will
increase Ryan’s independence
in IADLs such as meal
preparation, as well as
improve active elbow
extension and forearm
supination and pronation.
Note: If there is not a fridge
within the outpatient facility,
the therapist will place grocery
items in a cabinet placed at
chest height. Patient will have
to open the cabinet and grab
one item at a time from the
cabinet. In order to grade up
the task, the therapist will
place the objects on a higher
shelf, requiring the patient to
perform increased elbow
extension.

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