Elbow Wrist & Hand Surgery & Post-Op Rehab

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  1. Total Elbow Arthroplasty: Indications
    • End stage arthritis (usually RA)
    • Comminuted intercondylar fx in patients ≥ 70yrs old
    • Severe bone destruction
    • Progressive loss of extension > 60°
  2. Total Elbow Arthroplasty: Complications
    • Infection
    • Posterior elbow dislocation
    • Radial head impingement
    • Proximal ulna fx
    • Hardware failure

    ~1/3 pts will sustain major complication w/in 5 years
  3. UCL Reconstruction: General Rehab Guidelines
    • Week 1: Immobilized at 90° elbow flexion; perform hand/wrist ROM and grip exercises
    • Week 2: Ext increased gradually; may use arm for light ADLs
    • Weeks 3-8: Work on ROM; begin isometrics and light db exercises
    • Weeks 4-6: Discontinue brace
    • Week 10: Simulate throwing motion, chest passing
    • Weeks 12-14: Throwing w/ weighted ball, swing golf club
    • Week 16: Begin 25rep x 2sets throwing program on flat ground QOD, gradually increase distance from 45' to 150'
    • Month 6: Begin throwing off mound at 50% effort
    • Month 7: Begin throwing breaking balls on flat ground
    • Months 8-10: Begin practicing in game conditions
    • Months 11-12: Return to competition
  4. Ulnar Nerve Transposition: Cubital Tunnel Syndrome
    • Ulnar nerve separated, retaining as much of the accompanying blood supply as possible
    • Reattached anterior to medial epicondyle 
    • Elbow flex no longer places nerve on stretch
    • Multiple surgical approaches possible (Subcutaneous Transposition, Intermuscular Transposition, Submuscular Transposition)
    • Splinted for a few weeks post-surgery 
    • PT referral emphasizes ROM and strengthening
  5. Ulnar Nerve Transposition: Subcutaneous Transposition
    • Ulnar n. positioned anterior to medial epicondyle beneath subcutaneous tissue
    • Held to muscle fascia w/ fasciodermal sling
  6. Ulnar Nerve Transposition: Intermuscular Transposition
    • Ulnar n. freed and laid across the flexor-pronator mm group
    • Gutter cut in muscle for the nerve
    • Facia sutured over the nerve
  7. Ulnar Nerve Transposition: Submuscular Transposition
    • Origin of flexor-pronator mm group released
    • Ulnar n is transposed deep to the muscle layer
    • Requires splinting for 3-6 weeks
  8. Carpal Tunnel Release
    • Cut of transverse carpal ligament
    • Tissue around the median n. may be excised 
    • May be performed endoscopically or open
    • Typically excellent outcomes
  9. Carpal Tunnel Release: General Rehab Guidelines
    • Recovery time ~2 weeks for incision healing (unless significant weakness is present)
    • Strengthen any weakened muscles and improve function
    • Stretching to improve mobility of wrist/fingers
    • Scar management
    • Ergonomics assessment/simulation to optimize prolonged postures
    • Education regarding ergonomics and carpal tunnel compression
  10. MCP Arthroplasty
    • Joint replacement w/ RCL construction to reduce ulnar drift
    • Static night splint for 12 weeks w/ wrist in 20 degrees extension and MPs in full extension
    • Avoid key pinching for 12 weeks
    • Radial walking at 2 weeks (no pushing w/ 5th digit)
    • Soft putty for grip strengthening at 6 weeks
  11. MCP Arthroplasty: Complications
    • Recurrent ulnar drift
    • Lack of full extension
    • Prosthesis fracture
    • Volar subluxation of the proximal phalanx
    • <10% failure rate
  12. Tenosynovectomy: Trigger Finger Release
    • Excision or resection of a tendon's sheath
    • Tendon remains intact and in place
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Elbow Wrist & Hand Surgery & Post-Op Rehab
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