Treatment of Simple Elbow Dislocation Using an Immediate Motion Protocol
Treatment of Simple Elbow Dislocation Using an Immediate Motion Protocol
Abstract & Commentary
Synopsis: The treatment of elbow dislocations with a period of immobilization may be more harmful than helpful.
Source: Ross GR, et al. Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.
Treatment of elbow injuries in the adult remains a clinical challenge. In general, the typical treatment of joint injury has included some period of early protection by immobilization. However, many physicians and physical therapists have presented evidence that this period of immobilization may be more harmful than helpful. This may be particularly true for elbows, where immobilization may be especially detrimental.
The focus of this study was the issue of elbow immobilization. Twenty consecutive subjects suffering from simple elbow dislocation were treated "prospectively" since 1987 with a protocol that included immediate early motion. Elbow dislocations with concomitant fractures and/or those requiring surgery were excluded. Evidence for inclusion included prereduction radiographs on all but three subjects. Patients were seen daily in the athletic training room for the first two weeks. Daily pretreatment and post-treatment measurements of range of motion (including flexion and extension) and circumferential measures of arm and forearm were obtained by the same individual. No a priori evidence of this individual’s reliability was reported. The protocol included typical treatment modalities such as ice and electrical current along with range of motion and progressive strengthening exercises. In addition, each patient wore a compression wrap at times when he or she was not in treatment and was instructed to perform active, painfree range of motion and other functional activities "during short intermittent breaks, throughout the day." The subject pool description was 19 males and one female, with an age range of 19-24 years. All injuries occurred during athletic endeavors. Range of motion averaged -4° (extension) to 139° (flexion). All patients achieved "full or near full" (within 5°) range of motion. This "final" range of motion occurred, on average, 19 days after injury with a range of 3-60 days. It should also be noted that "normal" arm size was achieved at 6.5 days post-injury, indicating diminished effects of disuse atrophy.
Comment by Clayton F. Holmes, EdD, PT, ATC
Elbow injuries remain a challenge clinically. This study is further evidence that immobilization may do more harm than good. This is particularly enlightening because, while these elbow dislocations did not have concurrent fractures, they are usually clinically dramatic, with considerable swelling and ecchymosis. The clinical presentation may beg for immobilization but clearly, according to this study, that would not be prudent.
As Ross and colleagues themselves state, there are limitations to this study. For example, while the protocol was undertaken "prospectively," this is a somewhat inaccurate description. A study cannot have an experimental design unless it is prospective. However, the whole purpose of a prospective design is to randomize subjects into two groups, which was not done in this study. Ross et al state that this was not done due to the low number of simple elbow dislocations over time. Clearly, the number of such cases could not have been known prospectively. Second, while one individual took all clinical measures, there was no mention of establishing reliability of this individual a priori. Nevertheless, none of these limitations diminishes the message of limiting immobilization after these injuries. Ross et al do make one disclaimer: "The high success rate may be due in part to the excellent patient motivation and nearly unlimited resources for rehabilitation." The study was done in a relatively controlled environment at the U.S. Naval Academy, and Ross et al are concerned that it may not generalize well to a more traditional health care system. While this may in part be true, there is evidence that some patients do well with less supervision.1 In addition, it should be noted that the level of supervision could be performed by a physical therapist, today’s reimbursement systems not withstanding.
Reference
1. Schenck RC, et al. A prospective outcome study of rehabilitation programs and anterior cruciate ligament reconstruction. Arthroscopy 1997;13(3):285-290.
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