Open Fractures: Recovery Challenges and Surgical Options

Q: Open Fractures: Recovery Challenges and Surgical Options

Hello： In terms of elbow function, flexion is more important than extension; while extension affects appearance, insufficient flexion can lead to difficulties in daily activities such as brushing hair and washing the face. <br>Therefore, the primary goal of joint manipulation is

Open fracture

Hello Dr.
Lee, I had an accident on August 21, 2009, where I fell from a height and landed on my right elbow, resulting in an open fracture of the ulnar and olecranon.
After undergoing reduction surgery and being in a cast for four weeks, I did not start rehabilitation until October 12, when I discovered that my elbow had become stiff (unable to fully extend and could only flex to 90 degrees).
On October 23, I underwent a joint manipulation procedure.
Although the orthopedic surgeon was able to achieve a range of motion from 0 to 130 degrees under anesthesia, after waking up, I could only bend my elbow to 100 degrees and still could not fully extend it.
Currently, I am actively rehabilitating, but I feel that progress is minimal.
I am considering undergoing a second joint manipulation procedure soon, especially to address the inability to extend.
The orthopedic surgeon mentioned that my autonomic nervous system is very sensitive, and my extremities are cold, which causes the range of motion to quickly decrease again.
Therefore, the plan is to apply a cast to keep my elbow extended for two days immediately after the second joint manipulation, and then to use a splint at night while sleeping.
This method is intended to force the elbow to stay extended.

I have a few questions:
1.
How long should I wait between the first and second joint manipulation procedures? Can joint manipulation be performed repeatedly?
2.
Is it feasible to apply a cast immediately after the second joint manipulation? Will I lose the ability to flex my elbow after the cast is removed?
3.
If I still cannot regain normal function in terms of flexion and extension, are there any final options for treatment? Thank you for your patience in reading this.

rory, 30~39 year old female. Ask Date: 2009/11/04

Dr. Li Wenlin reply Orthopedics

Hello: In terms of elbow function, flexion is more important than extension; while extension affects appearance, insufficient flexion can lead to difficulties in daily activities such as brushing hair and washing the face.
Therefore, the primary goal of joint manipulation is to increase the angle of flexion, while the angle of extension is secondary.

1.
There is no specific timeframe required between the first and second manipulation procedures; it generally depends on the progress made during rehabilitation after the first procedure.
Personally, I prefer to observe for at least two to four weeks.
If there is no improvement, a second joint manipulation can be considered.

2.
After the joint manipulation, a cast is typically applied immediately, usually at the maximum flexed position, and it is not kept on for too long—generally a few days to one or two weeks—before being removed.
Rehabilitation should begin immediately after the cast is removed, so there is no need to worry about being unable to flex the elbow after the cast is taken off, as it will not be on for an extended period!
3.
Rehabilitation is a crucial component.
Many orthopedic patients who have undergone fracture surgery require assistance from rehabilitation professionals, so active rehabilitation is very important.
Of course, if conservative treatment fails, surgical intervention may be considered to address the underlying causes of elbow stiffness.
However, I believe this will not be necessary, as proactive rehabilitation combined with one or two joint manipulations will certainly lead to success.
Wishing you a speedy recovery!

Reply Date: 2009/11/04

More Info

Open fractures, such as the one you described involving your right elbow and ulna, present unique challenges in recovery and rehabilitation. An open fracture is characterized by a break in the bone that is accompanied by an open wound in the skin, which can increase the risk of infection and complicate the healing process. In your case, it seems that you have undergone surgical intervention, including reduction and fixation, followed by a period of immobilization in a cast. However, the stiffness and limited range of motion you are experiencing are common complications following such injuries.

Understanding Your Situation
1. Recovery Challenges: After an open fracture, the healing process can be prolonged, especially if there are complications such as stiffness or joint contractures. The fact that you are experiencing difficulty in fully extending your elbow and achieving a normal range of motion is not uncommon. The stiffness can result from a combination of factors, including the initial injury, the surgical procedure, and the period of immobilization.

2. Surgical Options: You mentioned the possibility of a second joint manipulation (arthrolysis) to address the stiffness. This procedure can be beneficial in cases where conservative measures, such as physical therapy, have not yielded satisfactory results. However, it is essential to consider the timing of this procedure. Generally, a second manipulation should be spaced out to allow for adequate healing and to minimize the risk of further complications. The specific interval can vary based on individual circumstances, but a common recommendation is to wait at least several weeks to a few months after the first procedure, depending on the recovery progress.

Addressing Your Questions
1. Interval Between Surgeries: The interval between your first and second joint manipulation should be determined by your orthopedic surgeon based on your healing progress and the degree of stiffness. Continuous manipulation without allowing adequate healing can lead to further joint instability or complications.

2. Post-Manipulation Casting: Applying a cast immediately after the second manipulation to maintain the elbow in a straight position can be a viable strategy to promote extension. However, there is a risk that once the cast is removed, the joint may revert to its previous state of stiffness if not adequately rehabilitated. It is crucial to follow a structured rehabilitation program post-cast removal to regain mobility.

3. Final Options for Recovery: If you continue to experience limitations in your elbow's range of motion despite surgical interventions and rehabilitation, there are additional options to consider. These may include:
- Physical Therapy: A tailored physical therapy program focusing on stretching and strengthening can help improve function.

- Joint Mobilization Techniques: Manual therapy techniques performed by a skilled therapist can assist in regaining motion.

- Surgical Release: In cases of severe stiffness, a surgical release of the soft tissues around the joint may be necessary to restore function.

- Functional Bracing: In some cases, a functional brace can be used to support the joint while allowing for some movement.

Conclusion
In summary, your situation with an open fracture and subsequent stiffness is complex and requires careful management. It is essential to maintain open communication with your orthopedic surgeon and rehabilitation team to determine the best course of action tailored to your specific needs. Regular follow-ups and imaging studies may be necessary to monitor the healing process and adjust your treatment plan accordingly. Remember, recovery from such injuries can be a gradual process, and patience, combined with a proactive approach to rehabilitation, will be key to regaining full function of your elbow.

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