Elbow fracture

[WendyRobinson]

Chad is a 10Y 7M old, male neutered lab. He has historically been obese, weighing in at around 115 lbs. The owner has managed to get him down to 92 # since his elbow fracture. He is still heavy but so much better.

Chad presented for a Rehab consultation on 8-31-22 following R elbow fracture and surgery. Chad had an acute injury/fracture to his R elbow in early May 2022 after falling out of a two story window.  Chad had surgery at a local veterinary clinic with a board certified surgeon for a comminuted right elbow fracture of right lateral condyle and Olecranon. Chad has not been doing any Rehab since the initial surgery. Chad had weekly modified RJ bandage change with weekly bandage changes for 10 weeks following surgery.   Recheck radiographs were performed on 7-26-22 ( 12 weeks post-op) showed static implants, incomplete healing of the condylar fracture with minimal new bone growth, suspect loss of reduction of the olecranon fracture, sclerosis of subchondral bone with degenerative joint disease . Owner just started water walking last week for short duration (~ 5 min) but he gets tired quickly.  He has gone 3 times this week.  He is only walking several hundred feet at a time.  
He currently has a grade 3/4 R TL lameness.
Orthopedic exam - bilateral TL antalgic gait with R TL being worse than L. Off weighting to back legs and off R TL in standing. He weight bears on the medial aspect of R TL paw causing rotation of MCP joints and digits. Digits and MCP joints are hypomobile in flexion and rotation. Central nails (3+4 ) worn with wear on dorsal surface, nails 2+5 too long. He has mild hyperextension of R carpal joint in standing with a Marked decreased ROM in flexion. The right Elbow joint has bony thickening and mild effusion present. He has discomfort and crepitus with ROM.
The right elbow has decreased ROM in flexion and markedly decreased ROM in extension ~ 110 degrees.  He has decreased shoulder ROM in flexion and extension but comfortable through ROM. He has marked muscle atrophy of forearm extensor muscles and flexor muscles, carpal flexors tight.  Marked atrophy of biceps m and triceps m and of supraspinatus m and infraspinatus m on R TL.
His L TL digits are splayed and flattened with hyperextension of MCP joints and hypomobility of MCP joints and digits in flexion and rotation. He has moderate hyperextension in standing of his L Carpal joint. Bony thickening with effusion on dorsal aspect is present and there is decreased ROM and crepitus in flexion. 
He has a fair amount of compensatory neck and back tightness and soreness.

I am looking for ideas for Rehab and improving function of his R TL and overall comfort. I am concerned about the overall health of the elbow joint and the incomplete healing of the fractures. I am concerned that further engagement of the triceps may cause further distraction of the olecranon fracture.
The tools I have available at the clinic are my hands, acupuncture, laser, Piezowave, Assisi loop, e-stim.
I am ordering a Therapaw carpal support wrap to support his L carpal joint.
Are there any good support options for the elbow joint?
Any ideas would be wonderful.
Thank you so much
Wendy Robinson :

[lehughes]

Awww.... Poor Chad!

Okay... So my thinking goes first to Pain Management.
I would want to ensure that this dog has a good multimodal pain management strategy inclusive of pharmaceuticals and whatever else the own is willing to put on board - Fatty Acids, CBD, Magnesium...

Then, we look at what is the most practical Exercise for this dog. I think you are correct with UWT. I would add simply standing in the water and lifting legs. So you can still do the 5 minutes of walking in the water and slowing building up. But perhaps a few minutes of standing could also be beneficial.
On the same train of thought, do the owners have a harness (i.e. Help em Up Harness)? If they use the shoulder strap attachment (or make their own using thick leashes) - they can help Chad to walk longer / farther and support some of his weight.
Beyond that, I don't think you will practically be able to engage in more exercise / different exercises. I'd say walking or static balancing. Those are all you should focus on right now.

Therapies... anything for pain management and healing. Laser, Assisi, Acupuncture all sound great.
You could dial your estim down to 2Hz and put it around the elbow and use it like a TENS. To have a greater impact, I would structure your in-clinic appointments to be Modalities first, UWT second. This way you get better bang for your buck with the exercise, if the joint feels more comfortable before you begin.

I would also look into finding things / ways that the owner can engage in pain management at home as well. Home Assisi Loop? Cheaper LED or Laser to rent? Home Massage?

All in all, I think the NOW plan ends up just being simple. Instead of looking at ALL of the dysfunctions, you figure out what makes the most sense now. I don't know of a good elbow support system... Yes, you could get a bracing company to make something rigid, but they tend to support Medial-Lateral instability, and would be clunky and cumbersome... which would inhibit Chad from wanting to use the leg.

So, my advice is, Don't worry about making everything looks normal right off the bat - you can't. Focus on the number one problem(s) that can help make the other areas better.

I hope this helps!

Cheers,

Laurie

[WendyRobinson]

Thank You so much for all of your wisdom

Wendy Robinson

[WendyRobinson]

Thank You so much for all of your wisdom

Wendy Robinson

[WendyRobinson]

Thank You so much for all of your wisdom

Wendy Robinson