What makes an elbow injury complex?
Is it the number of structures involved in the injury? The severity of the damage? Or is it the amount of clinical reasoning required to appropriately treat the injury?
Although various terms may be found in the literature describing these types of injuries (for example, complex elbow dislocation, complex elbow instability, complex traumatic elbow injuries, and traumatic elbow dislocations), research has demonstrated that these injuries can lead to significant long-term disability. Therefore, the rehabilitation process must be a collaborative effort between all members of the health care team and the client to maximize outcomes and allow a return to meaningful occupations, health, and well-being.
The Initial Evaluation
The first step in the rehabilitation process is the initial evaluation. This process can start in various settings, ranging from inpatient to outpatient, with the possibility of seeing these clients for the first time in different stages of the wound healing process.
Regardless of setting and stage of wound healing, you must consider many factors that accompany these injuries, which involve multiple structures within the elbow. This involvement of multiple structures in the elbow is consistent in the literature, defining what constitutes a complex elbow injury despite the use of the various descriptive terms.
What Does the Literature Say?
Jones and Jordan state surgical treatment aims to achieve a stable/functional joint to allow early comfortable range of motion and to minimize long-term sequelae.1 Fusaro, et al., posit that the basic principles of a rehabilitation plan are as follows:
- Contain the effects of immobilization
- Avoid excessive stress to healing tissues
- Satisfy specific clinical criteria before progressing to the next phase of rehabilitation
- Based on current evidence2
Proposed algorithms on how to optimally manage these injuries are published in the surgeon and therapy literature to assist with the clinical decision-making process in diagnoses such as “terrible triad” injuries.3 The difficulty with treating this population is that each injury is unique and requires a high degree of clinical reasoning as each treatment will vary based on client and surgical factors.
6 Questions to Ask the Referring Surgeon
When receiving a referral for a patient with this type of injury, there are many factors the you must consider before establishing a treatment plan. Collaborating and communicating with the referring surgeon is vital to avoid excessive stress to the affected structures.
You must be prepared to ask the appropriate questions to the referring surgeon and not just go by the diagnosis on the prescription. Having answers to the following questions is ideal before evaluating the client:
- What was the date of the surgery?
- What structures were involved and surgically repaired?
- What is the stability of the elbow and what are the ROM limitations?
- Were there any associated nerve injuries or repairs?
- What were the radiographic findings for fracture stability and joint alignment? Was a “drop sign” present?
- Were there any other findings of the case that I need to know?
6 Questions to Ask Yourself
After obtaining the surgical information, there are questions you, as the treating therapist, should ask yourself:
- What stage of the wound healing process is the client in?
- What ROM do I need to perform and educate the client on depending on the client’s wound healing phase?
- What can I teach the client to prevent uninvolved joint stiffness and muscle weakness that will hinder future use of the upper extremity? What problems do I anticipate?
- Does the client have any factors that will limit healing or participation in therapy? These might include PMH, cognitive status, socioeconomic factors, psychological factors, or other environmental factors.
- What ADL modifications do I need to instruct the client on to maximize independence while still protecting healing structures?
- Are there any insurance or financial limitations that may affect the client’s ability to attend therapy sessions or carry over the home program?
The Biggest Question You Should Ask
Finally, you must ask yourself, regardless of practice setting, if you have adequate knowledge and experience in a patient with this injury. Timely and appropriate treatment is essential to optimize outcomes.
This may be the most crucial question you should ask. If the answer to this question is no, then reaching out to or referring your client to a Certified Hand Therapist is encouraged to gain mentorship and guidance throughout the continuum of care.
The answers to these questions will assist you in providing the foundation for a comprehensive evaluation addressing all the areas of need for your clients who are in this situation. Watch the MedBridge course “Complex Elbow Injuries Part 1: Evaluation Considerations” to learn more about other factors that can hinder successful outcomes.
- Jones, A. D. R. & Jordan, R. W. (2017). Complex elbow dislocations and the “terrible triad” injury. The Open Orthopaedics Journal, 11, 1394–1404.
- Fusaro, I., Orsini, S., Stignani Kantar, S., Sforza, T., Benedetti, M. G., Bettelli, G., & Rotini, R. (2014). Elbow rehabilitation in traumatic pathology. Musculoskeletal Surgery, 98(Suppl 1), 95–102.
- Pipicelli, J. G., Chinchalkar, S. J., Grewal, R., & Athwal, G. S. (2011). Rehabilitation considerations in the management of terrible triad injury to the elbow. Techniques in Hand and Upper Extremity Surgery, 15(4), 198–208.