Post op ... ??

[Immortal25]

Just wondering, if one has a fracture but only did surgery a month later...and thus the healing stage of the fracture is counted starting from the day of incidence or the day of operation? Thanks all... a bit confused with this.

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[smshaffe]

surgery day because they moved the bone during the surgery. but, if the surgery was a stabilizing one such as with screws or other hardware the fracture should be stable enough that you don't have to worry about healing timeframes in most cases.

[Immortal25]

Thanks for the reply. I see...it is indeed a stabilizing one as the case had a displacement fracture of the olecranon and a metal plate was inserted. Thing is he has a extensor lag/lack of about 30 degrees. What physiotherapy treatment can be done for this? Is joint mob good? Doing exercises for the past 2 weeks seems to have only increased ROM by about 5 degrees...
I've started giving strengthening exercises as well. Stretching don't seem to do much as he constantly feels end range pain. Thing is, after extension (as much as tolerated), as he goes for flexion, he feels pain at the op site which is the posterior elbow region. That pain is caused by the metal plate though isn't it?
I suppose, the most important question now is, can he reduce the lack/lag(both flex and extend)? And by how much? And what's the best treatment for this?
I always find treating elbows to be a real pain as most patients end up with lag/lack...
Thanks all.

[smshaffe]

Was it just a fracture or a fracture dislocation? if it was just a fracture, mobilize all you want. if there was a dislocation be more careful. how long ago was the surgery? if it was 1-3 months you'll have a much easier time stretching than if it was longer.

the pain could be caused by anything but i would put the plate low on the list. surrounding soft tissue is more likely tight and dysfunctional.

i would say that for a stiff elbow mobilization is the best way to increase the range. i would do both physiological and accessory mobilizations. physiological would include having the patient work into extension on their own or with you doing it. if this causes pain, what kind of pain is it? we can brake it down into a few likely types.

- first, superficial pain that is a "stretching" pain. this could be good. you can test this by holding the extension position of the elbow joint and then pulling the superficial tissue together on the elbow (either front or back side). if this changes the pain/stretch without moving the elbow joint it is a superficial stretch and i wouldn't worry about it. stretch both physiological and accessory mobilizations.

- second, deep (likely joint capsule) stretch. again move the patient into extension and hold the point in the range when the pain starts. then, create a joint gapping or distraction force whereby you move the proximal forearm backwards away from the anterior surface (in supination). if the capsule is tight this will separate the joint, stretch the capsule, and make the tissue pain increase. this will probably have a significant stretching sensation and should feel tighter to both you and the patient compared to the other elbow. this means you should mobilize it (there are lots of good ways). i would do both physiological and accessory mobilization in this case.

- third, sharp pain on extension. do the same distraction technique as described in the paragraph above. if the distraction decreases the pain it may insinuate that something in side the joint such as the cartilage is getting pinched and is therefor painful. i'd stick to accessory mobilizations like distraction and avoid end range stretching if necessary.

you may want to heat it before you mobilize. but, if you don't work into that extension lag with physiological and accessory mobs the lag will never go away. don't worry about the fracture, it is sure to be solid if the surgeon did a good job.

[tailoool]

would the Pt feels pain when doing active resisted exercise? find out the muscle proble;
then try to control the olecranon movement when asking the Pt to do the action again. to see if the pain reproduced? if no pain, the pain is possibly produed by the Joint problem. then try the MWM method.