heterotrophic ossification of elbow

[Janice]

My husband is status post 3 months elbow dislocation and radial head implant. He still has limitations with pronation and supination both are 45 degrees active range of motion. elbow flexion is 130, and extension is 15 degrees. doctor has recommended arthroscopic surgery as he has noted heterotopic ossification and feels this may be limiting pro/sup movement. Questions: Is it too early to do this?, will he have to have this done again?, what would be recommended for active and passive ROM following procedure? I don't want to cause increased inflamation in elbow yet I would like a lot more ROM than 45 degrees. At least functional ROM.

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[emad]

Hello Janice ;

The point is the 3 months period which is not short ,i assume you are speaking about following radial head prothesis surgery.

I like to clear when i speak about range of motion in assessment and re-assessment i write wjat is lost , for example elbow extension -45 for me means the patient loses of elbow extension function .

I like to know what had been applied as manual and physical Therapy ,i am sure no reason for being afraid of mtion because of inflammation following 3 months , movement is important at least in related areas as shoulder ,thracic and hand to mantiain neural mobility . Is there pain complaint ?

Cheers
Emad

[Janice]

Extension of the elbow is -15 degrees. Therapy began 10 days after surgery for A/PROM to forearm for pro/supination, AROM for elbow ext ( MD wanted us to becareful with this due to severity of dislocation. ) & AAROM for elbow flexion. Has maintained 130 flexion, -15 ext. Pronation and supination have been difficulty to progress from the beginning. Pain has been minimal and has gradually tried to use is c ADL tasks, this is not his dominant UE. He has received iontophoresis c acetic acid over the radial head area for scar tissue, and heat and ice to arm as needed for pain and stiffness. 4 wks s/p surgery strengthening was initated at the elbow and forearm, and shoulder. Shoulder ROM is good, Hand ROM is within normal limits with tightness at end range for ext and flexion. Last week he did a lot of driving and thus has had increased pain and some numbness in hand (dorsum - radial nerve). It has decreased overtime and we have put a hold on strengthening and used ice for inflamation. Surgery for scoping elbow is scheduled for this Thursday, however, I am going to call nurse to tell her of increased pain and inflamation and nerve involvement. His job he has to perform a lot of typing and computer usage and needs more pronation. He is begining to have c/o pain in hand at PIPJs which I believe is due to compensatory movement of his hand to pronate. Shoulder also gets agravated at times (like impingement) due to having to internally rotate while typing to achieve full contact of fingers with the keyboard. Will Heterotopic ossification continue to be a problem even after surgery and should he wait to have this procedure done?

[emad]

Hello again Ja;

I assume you are NOT a physiotherapist !

First of all pain and numbness complaint means neural Sensitivity from over actiivity or stress or exercise as well of course mis-dealing with upper limb from the patient , which ought to have recieved good explanation /education regarding what could increase or decrease the complaints as pain and numbness ,certainly this includes how to sleep , postions taken to avoid stress over the Radial you mentioned above , however it is quite simple problem with just rest and simple ,designed neural motions every thing goes well .

In addressing manual Therapy ,just easy handling is good way to success ,we do not have to be aggrressive in applying stretching and strenghing , the patient is not going to play heavey sports , just daily normal life is enough .the point the MD stressed in advising is good .

I think the patient needs just time of simple ,well-designed manual therapy to avoid aggrvating pain and very important recieving well education regarding what to do and what not to do , time of activity ......just not stressing long times .

As for your question :

Will Heterotopic ossification continue to be a problem even after surgery and should he wait to have this procedure done?

Take care , i am just giving advice through online discussions , which means i have not seen or touched the patient .But personally , i do not like invasive surgeries repitation , just once .......This is question must the MD replies well for , why and what will happen ? what expected ?............

The pronation and supination limitation is normal thing in such problem and little progress in obtaining function in pronation and supination is ordinary issue ...................Surgery at all does not help gaining fuction ....except in one case the MD expects that there is bony issues around the head which hinder the ROM ......

Cheers
Emad

[Janice]

never said I was a physiotherapist. I am an occupational therapist and have been working in the outpatient field for 10 yrs. I simply asked a question regarding HO, not about manual therapy. If you will re-read my thread i acknowledged why he was having pain and numbness. the MD said there was HO around the shoulder of the prothesis and he felt like this was limiting movement. I feel like the MD is very knowledgable as he is the president of the American Orthopaedic Society for Sports Medicine, authored several books, and many other credientals. I simply wanted some other medical opinion about HO and the nature of it. Cheers, janice

[emad]

Well ;

As for HO , i think it is easy for you to collect reliable knowledge regarding from Internet just search for up to date articles in PDF you will find much .

Just i searched quickly to find out the following :
http://www.jaaos.org/cgi/content/abstract/12/2/116
http://www.emedicine.com/radio/topic336.htm

from 2006 http://www.emedicine.com/pmr/topic112.htm

and a good PDF article attached above .

Of course , you are OT knows that we are just searching for knowledge basing the search on the reilable diagnosis of the MD .I will try to read as possible from the links above then give my view .I think if the case is Myositis ossificans it is better to let that resolve by itself , i saw before around 3 patients with Myositis ossificans just anterior to the elbow aspect ,with rehabilitaion the extension gained very well , the flexion was blocked by the Myositis ossificans ,i refused to apply any aggressive procedures at that time ,i saw one child from them after 6 months .The bony ossification resolved alone .and the flexion ROM was fully function .

Hope my views are not causing problem for you ,just collect knowledge then decide !!

Cheers
Emad

[rafeekmk]

thank you for the great link.... PDf attachment

[PhysioP]

Hay, sorry to hear about your husband. Thought I would just put in my 2 cents...

HO can turn into a very chronic and life dibilitating condition if not properly treated. Bone scans are essential in assessing the maturity of the HO, and invasive treatments should only be under taken once it is sure to have reached this stage.

HO can also be provoked further by local irritation and inflammation. I once had a client with HO who's condition became severely life affecting due to constant irritation (man refused to stop certain ADL's). This is sometimes what makes HO such a large problem in people with TBI's. Therefore, it is probably a good idea to talk to your therapist about exercises / stretches which cause the least irritation to the bony mass.

In your situation, I would double check with your MD to ensure that it is the appropriate time to undertake surgery. If the HO has not reached maturity, continue with the therapy until it has and then assess the ROM / functional limitations and decide on further treatment from that point.

Far from everything is known about HO, and this information is just off the back of my skull, so please, as allways, consult your doctor before acting on any information provided Thanks!

[mark456]

I think the patient needs just time of simple ,well-designed manual therapy to avoid aggrvating pain and very important recieving well education regarding what to do and what not to do , time of activity ......just not stressing long times .
i saw before around 3 patients with Myositis ossificans just anterior to the elbow aspect ,with rehabilitaion the extension gained very well , the flexion was blocked by the Myositis ossificans ,i refused to apply any aggressive procedures at that time ,i saw one child from them after 6 months .The bony ossification resolved alone .and the flexion ROM was fully function .

mark456

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