Treating Complex Elbow Injuries: 6 Clinical Reasoning Considerations

Elbow injuries involving multiple structures as the result of a traumatic event are described in the literature in a variety of ways, including:

• Complex elbow dislocation
• Complex elbow instability
• Complex traumatic elbow injuries
• Traumatic elbow dislocations

Regardless of the term used, recent studies propose the initiation of early rehabilitation for mobilization to minimize functional impairment if surgeons can achieve restoration of articular congruity and stability.^{1, 2}

The Challenges of Treating Complex Elbow Injuries

Although receiving this population early in the wound-healing process is ideal, many complex factors can limit this from occurring. These complex factors can be related to the injury itself or the client. The difficulty with treating this population is that each injury is unique and requires a high degree of clinical reasoning from the clinician throughout the continuum of care to optimize outcomes and return patients to meaningful occupations promptly.

The clinician needs to collaborate with the entire healthcare team throughout the continuum of care to gain an understanding of how the structures are healing to apply the appropriate amount of stress to maximize surgical outcomes, maintain independence with activities of daily living, and ensure progress toward the patient’s goals.

Applying Clinical Reasoning and Evidence-Based Practice

Regardless of when in the wound-healing process or in which setting the patient is being treated, the treating clinician must possess a high degree of clinical reasoning and implement evidence-informed practice to progress the rehabilitation plan appropriately. The clinician must stay informed on current evidence to guide clinical decision making.

Due to this population being at risk of chronic instability, post-traumatic arthritis, and poor functional outcomes if a dislocation is involved, getting the facts beyond the diagnosis is essential.¹ There is a lack of high-level studies in this population regarding optimal rehabilitation treatment and progression to optimize outcomes. Until higher level studies are published, clinicians are tasked to make clinical decisions throughout the continuum of care based on the following:

1. Information that is communicated by the surgeon

The clinician must continue communication throughout the rehabilitation process to gain information on the healing of the structures involved, findings on follow-up radiographs, and presence of intrinsic versus extrinsic limitations.

2. Symptoms the patient is presenting with

These might include persistent edema, pain, scar adherence, and decreased sensation or hypersensitivity.

3. What wound-healing stage the patient is in

Sometimes patients must be immobilized due to the nature of the injury, and the clinician may receive them later in the wound-healing process. Additionally, patients may have other medical conditions or complications, such as infection, which can delay the healing of structures.

4. Expert opinion

There are algorithms and treatment considerations available in the literature that can assist clinicians with the clinical decision-making process.

5. Biomechanical studies

These demonstrate optimal positions exercises should be performed in to increase the stability of the elbow while decreasing stress to healing structures.

6. Patient factors

Patient-centered care is of the utmost importance in addressing the Triple Aim of Healthcare and progressing toward the vision statements of rehabilitation practitioners. A comprehensive and holistic approach is essential for a return to meaningful occupations. MacDermid posits that evidence-based practice means clinicians should not exclude treatments when there is only low-level evidence but should change their practice once effective treatments have been identified.³

Treating complex elbow injuries and progressing the rehabilitation program can be overwhelming for a clinician inexperienced in managing this population. Regardless of what setting you practice in or how many years of experience you possess, mentorship and/or referral to a certified hand therapist is recommended to optimize outcomes by providing timely and appropriate interventions throughout the continuum of care.