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Olecranon Fracture Posts

Back in the cast – More Physiotherapy

So with the new cast in place I began another week of plaster physiotherapy and .

At this stage is pain is now bearable. The main source of the pain still transpired to coming from the inside of my arm. Nowhere near my elbow. On certain movements, especially when doing the tricep stretch over my head, there would be a very sharp pain, right in the centre of the arm if I wasn’t careful to support the arm with my other hand. This was proving to be quite worrying as I didnt know that I WASNT doing any damage.

I was reassured by my consultant when the cast was changed, that I didn’t need to hold the arm like porcelain china outside of the cast. The K-wires and rods inside my arm are specifically placed to produce tension across the fracture site if any forces that would normally produce movement go through the arm. Save falling on the arm, there is little I’m actually going to be able to do to move the fracture currently due to the metalwork

Reassurance = doing more

Being told I can carefully do more greatly helped me to push on with the physiotherapy, being careful to do all of the stretch up to the point of very mild discomfort, but crucially nothing further than that. I was also able to continue using the PowerBall as often as possible – it was really positive over time to feel the improvements in my grip and the ability to move my hand improving.

I really feel that using the PowerBall has been a massive help. In moving the ball back and forward to keep it spinning, you can visibly see your biceps, at the top of the cast, moving. So I know at least I’m trying the keeping one section of my arm muscles mobile when the cast hopefully comes off a the end of the week.

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Fist to work the lumbricals

 

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Extension of the wrist, working further recruit the extensor muscles of the forearm

 

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Flexion of the wrist Physiotherapy , working the flexor muscles of the forearm

 

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Physiotherapy to extend the fingers, working the extensor muscles in the forearm

Plaster on, plaster off?

Now I say hopefully have the cast removed at the end of the week, as its not just a simple, right times up, whip it off.

The cast WILL be taken off at two weeks post op to allow review of the surgical wound, but the question is, will it have to go back on again?

This will be determined to some degree by the check x-ray performed after the cast has been removed. If the fracture site looks to be healing well then the question comes what to do?

In medicine, and particularly in the GP surgery we try to reach a shared management plan with the patients. This can sometimes be challenging, let me explain a frequent scenario;

The most important thing in determining the management plan for a patient is that its their body, and as long as their decision is informed it’s not for the doctor to over rule them. If you have a patient, with diabetes that is very poorly controlled. It is there choice not to take their medications. You can’t force them on them. As long as they understand that by not treating their diabetes, if they get an infection in their foot, for example, which the diabetes makes more likely the consequences could be much more significant than normal. An infection in a diabetic, which is harder to treat due to them not taking their medication, if it isn’t cleared up, can potentially spread to the bone, leading to amputations or death.

If that patient has had this explained to them, you can’t make them do the right thing, its their call.

Making the decision

Now on the other side of the shared decision making, is when there is no right answer.  There are equal risks and benefits to both options, and this can be difficult for both the patient and the doctors. The patient wants to make the best choice, but the doctor explains that there are significant, and potentially different down sides to each option, there is no best option. Here the patient can frequently say “what would you do?” that, is always a hard question to answer, as the risk is not yours to shoulder.

If the healing of the fracture was good, I would be faced with a similar, no right option  choice.

If the fracture is ok. There are several options

  1. Cast comes off– which means I can start real physiotherapy, and get moving my arm faster, reducing the loss of power, and hopefully getting back to full movement sooner
    • But, the fracture is VERY new soft bone, so its quite possible I could damage it, especially if I try to move too much.
      • To say move too much sounds relatively daft. – just don’t do it! Although sometimes accidents happen- I dropped my phone, and instinctively tried to reach out to catch it – full force with the RIGHT arm. Now it was in plaster, so it didn’t really move far, but that doesn’t mean that the tricep didn’t give a REALLY hard tug on the fracture, demonstrated by much yelping coming from me!
      • Too much, even slight, movement at the fracture site might cause the healing to slow, or worse non-Union, where the bone fails to join, so that’s not exactly a risk free choice
  2. Cast says on – this means I basically can’t hurt myself, and I’m well protected, giving the fracture the best possible stability in order to heal. There is not is hard and fast rule as to when the cast comes off, normally its expected 2-3 weeks post op. Keeping it on for the longer 3 weeks would be decided if the fracture repair wasn’t quite as advanced as hoped at the 2 week post op checkup X-ray.
    • Here the downside of keeping the cast on is rehabilitation of the muscles will take longer, and the chance of getting full range of movement is less.
    • Putting that into perspective, it’s expected that ~90% of people will have some permanent reduction in range of movement, and likely a permanent 10% loss of power in the arm, getting out of the cast asap and engaging fully with physiotherapy can help maximise to rehabilitation.

A TOUGH CALL

There is no right or best answer here. Frankly the risks and benefits of both options are about equal. There is no real additional guidance that can be given – assuming there are no other confounding factors – an example would be if I was elderly with a risk of falls, or a patient suffering from anorexia meaning fracture may not heal as quickly, then the balance would go in favour of keeping the cast. As it was I wanted it off as soon as possible and to hit physiotherapy as hard as I could.
The desire to get out of the cast and into physiotherapy intensified in the final two days prior to the consultant review, as I could feel and increasing stiffness in my arm when doing my over the head stretches. That feeling was a little worrying!
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James Gill

Author of TitaniumGeek, which started after smashing off my RIGHT elbow. Feel free to drop me a line about sports tech, medicine, or frankly anything that you want to chat about!!