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This is Nikki, one of our specialists, senior physiotherapists who works specifically with us, an upper limb. Very knowledgeable. He's going to answer any of your questions for all those things. You know, when you're filling out all the physio forms you go, I've got no idea what I'm doing. I'm making it up. This is the point we get to ask, I think, learn a little bit from her. Um This is, we don't know any physiotherapy really do. We would just try and pick it up and make it up as we go along. So we're all in the same boat. I'm still in that same boat and so we're learning hi there. Nice to meet you all. Um I'm hoping to get you standing up and doing a few movements and things because I'm sure you will half asleep by now from all this um this lectures all afternoon. Um My background's actually mostly in sport. I started at the hospital a year ago, so I'm getting much more involved in um postoperative care, immediate postoperative care than, than I have been for quite a couple of years. It's lovely to be from this perspective where I actually see it kind of hot off the press. I've been working closely with Miss Fisher and Mr Mall. Um So any surgical questions, I'll definitely ask these guys, but hopefully on the physio side, I can help you. Um I think you've done loads of, of anatomy already. Um I'm, I'm quite fascinated by the elbow because of the, it's called a, it's, it's called um a uniaxial joint. But actually, it's much more complex than that because the super pronation, it's very important to function to get the pronation going. Um So um from an anatomical point of view, we're thinking when we, when we get somebody for, for physiotherapy, we're thinking Super Nation pronation and flexion extension from the get go. We don't wait with one. We get, we get going on all. Um Right. Can you um go to the next slide? Um I'm not great with the technology. So Charlie is making sure I get to the right um to the right slide. Um Nothing really else extra on here because you've already done all of this stuff. Let's go to the next slide. OK. Charlie, are you projecting any? I don't see any, you can't see any slides. Oh, we can see them. Is that, can anybody see? I don't think you've shared your screen yet. Charlie, let me look at uh hang on, let me just try again. What about now? Yeah. Yeah. Yeah. Yeah. Yeah. It just restarted the same thing, but There you go. Ok. So I think if, if, if you guys were thinking when you've just done surgery on a patient and you're sending them to us, we all need to be on the same page as to, um, what, how quickly can we get this moving? How quickly can we get this strong? How quickly can we get this back to normal? But what do we have to not do so that we don't stuff it up before we get there. So I think if you, when you were referring to a patient, uh a patient to us, um um what's really important is, is what is safe and what isn't safe. So, precautions are really important. Um The, the surgeons always give us a weight bearing precaution and they say to us, can they weight bear or can't they weight bear? And you would think that's only in the lower limb, but in the upper limb, it's quite applicable as well. So, um do, are you very familiar with the terms active, passive and resistant movement, easy or not? Ok. Everybody, let's stand up, step away from your screen a little bit. If we did active elbow flexion, we can see more people, active elbow flexion, let's see some active elbow flexion. Perfect. Ok. What about active elbow extension? That's better. Who's the person in the um, yeah, so if you, if you're standing and letting your arm go down, you're probably doing more passive elbow extension if you think about it, but if you did it like that you're getting some elbow extension or if you didn't want to stress into abduction, that would be a little bit more active elbow extension. Because if you're standing and letting your arm go down to your side, that's more of a passive elbow extension. So passive elbow flexion, Charlie and I were actually one of his colleagues has said before, a really nice way of getting passive elbow flexion would be lying flat on your back with your arm. Can you see me on the bed here? Probably not. If I lay flat, am I, am I, are you gonna be outpatient? No or not? And they see so far? Yeah. Yeah, they see me. So if I had my arm here, I could then get very nice passive elbow flexion. And we were talking about how to get good range even when you've got a ligamentous injury. And that would be a really nice way of working with your patients. So, um think about telling the physio, do you want it active, passive or resisted, what would resisted extension look like? And I have some resistant extension. Perfect, resisted flexion. That's it good, right? Um So that's important to let us know um if the physiotherapist, you shouldn't be giving the physio having to give the physiotherapist that much information, they should know what we need to do per protocol. But um for you to have an idea of, of when would resisted movement be safe. So we would be thinking about muscle attachments associated with the surgery. Those would be, that would be very important for you to tell us. So normally we do, we don't do much resistance until six weeks. Sometimes we don't do any resistance until 1212 weeks. Those are the important, um, especially with a muscle repair. Um, resistance from 12 weeks would be more typical. If you haven't done a muscle repair, then resistant a little bit earlier would be safer. Um, right, use of the sling is really important and this is where you guys can probably make the biggest difference to the patient is, patients are terrified most of the time. So when the person who did the surgery says to you, you can take your arm out of the sling and use it for, for gentle everyday things. It makes an enormous difference to the patient. The last thing they want to do is to be in trouble when they come back. And someone says, why the heck did you take the sling off? So I think from what I heard, I heard the tail end of the last talk that, um, the, the, the surgeon talking said that from nine days, if you're not getting some movement, you're in trouble. Um, we try very hard to see patients. Um, we sometimes see them a week POSTOP, we often only see them two weeks POSTOP if we really unlucky, we see them at four weeks or five weeks. POSTOP is the first time they come to us as physios. So you guys can make a big difference by saying you can take your arm out the sling. I often say to the patient, just take your arm out the sling and when you're sitting, just rest your arm and your lap. If you've got even a ligament instability, if you're using the body as a, um, a strutt, you could easily loosen the sling here, you could allow the hand to come down into their lap. I'm gonna pretend I'm sitting and there they sit, sit watching the teddy teddy with their elbow, not fully flexed. That makes a heck of a difference. Um, no, normally the first day or two or even the first week or so painful that they can't even think about doing that. But somewhere around the first week, 10 days they feel that they actually can do that. Another important thing that I haven't actually put in the presentation is swelling of the hand, the hand swells very quickly if, if it isn't moved and, and if we're only getting to see them a little way down the line, if you can just tell them to pump their hand, also, make sure that the sling often you see a sling that sort of ends here and then the hand is hanging out the sling in the most awful way. So you want the sling to be tucked in so that the whole of the arm up to about the base of the little thing is, is supported. And if you see someone wearing a sling with half their arm out of it, remind them to get the sling on, on properly because you get a lot of wrist swelling. We, I can't say it would definitely cause um chronic regional pain. Um uh yeah, chronic regional pain syndrome. But, but you, you do, you want to avoid situations where the hand is in an awkward position, swollen and unmoving for a long period of time. Um So sorry, complex regional pain syndrome. My words are deserting me. So that's an important thing that you guys could do. Think about the elbow extension, think about the hand, the hand function. Um Most of the time it's pretty safe for the patient to work within the sling like that. If you had a biceps repair, you might have to be a bit careful if they were forcefully turning their palm up, you would be putting a little bit of load on the, on the, on the biceps if I'm right. So, so generally with most surgeries, you could happily let the patient work a little bit with super pronation in the sling except for a distal biceps repair. You do get those guys that are still trying to work a screwdriver in their sling or whatever they're trying to do that that would be a very bad idea. Um, ok, let's go through anything else. Oh, the other thing is if, if the, if the surgeon, if that's the first person they chat to but even if the physio, but whoever says to them, we really would like you to have your arm almost fully moving by just after six weeks, they start thinking, ok, I need to start getting there. If, if nobody says to them get moving, they assume they're gonna stay absolutely dead still until the next time they see somebody which could be at six weeks or, or four weeks. So giving the patient a little bit of goal and saying to them, we're hoping to have you sort of halfway to straight by the time you come back to us, um, empowers them a little bit to know where they're going. Ok. Can you do the next one? Ok. Um I think we've skipped one go one back. Oh, no, that's right. Ok, because I've, I've shortened my notes, um, using the hand for, for ADLs. Um I would say if somebody came to me in a sling and they were a weak POSTOP, I wouldn't be asking them to wash their face just yet, but you can quite easily do your buttons. You can, you can work within a sling and do your buttons quite well. And that's something that I say to the patients start getting on and doing your buttons as soon as you can, it starts, um, it stops the, the, um, ignoring of the hand, it stops the neglect of the arm that, that it sets in quite quickly that you see, patients actually forget that they have another arm. So, just involving them in every day, little things would be good. By the time they get to about four weeks I would really want them to be doing small little movements. So, even like, um, they, they, I guess they wouldn't be cutting their meat but they might be pushing the food gently onto their fork. They might be, um, uh, they would definitely be involved in dressing. So they would be that the, the operated arm would be slid into a sling, then you would get the other arm. And does everybody know that? So if you, if you're going to be dressing with a patient, you would put the operated arm in first and you would take the operated arm out last when you're undressing because everyone that probably makes sense. But probably another question, how many of you tell that to patients and explain, that's what to do. Yeah, I can see it. It's not your job, but to be honest, yeah, that's the point. These are things you don't get told or talk to patients sometimes come with really horrible, like a fungal infection under the armpit because they honestly haven't moved their arm away from their side since the doctor put it in the sling in hospital maybe two weeks ago. So, if you were, if you were not exactly sure exactly what not to do and to do, if you gently allowed the arm down to the side, as far as it would go, when most, um, elbow surgeries you're not gonna, it's not gonna go all the way down to start with. But if they did that and you lean slightly away from the body, you can easily get in under the armpit without doing any harm. If you wanted to put a sleeve on, you would use a batton shirt, a batton or a, or a, a shirt with a, a zip is much better than one to go over the head. You snide the sleeve up over this arm and then you put it into the other arm and then you bring this arm back up here and then it could help with the buttons. If you were taking it off, you'd take the left side off first if you had a right side surgery and you would take the, take the sleeve off like that. Does that make sense? That would be something very useful for you guys to be able to say to your patients as well. Um, ok, so ADLs move frequently. So if I give patients an exercise program, I say to them to move at least 4 to 6 times a day, that doesn't mean that for the rest of the day, they haven't moved their hand at all. I want them to be moving their hand. I ask them to do hand pumps every hour. I asked, I say to them, they can come out of the sling as often as they like to lay their hand in their lap. If they're comfortable to do it. They're often quite uncomfortable being locked up in the sling. I just say to them, if you're going to be moving around, attach your sling again and, and secure your sling, don't move around the house with your sling off. Um, especially in the first couple of days because that's where they might trip and fall. Once we get to about 3 to 4 weeks, I probably would say they can go around without the sling. Um, would you even say less than 3 to 4 weeks? Yeah. As soon as they feel comfortable and they've not got that loss of balance that you're talking about. Yeah. If they're at home and they're in a safe environment, then I'm happy for it to be. So, so it could even be earlier to when the patient is comfortable. If the patient was a fracture that hadn't been fixed with an, or if you wouldn't be as quick as we're talking about, you probably would wait till about four weeks. Um, and I probably still wouldn't let the walk around at home if they had an unoperated. So, a conservatively managed fracture, I probably would get them to do exercises many times a day, 4 to 6 times a day. But walk around with the sling on, um, in between exercises. I don't know if you'd agree with that. So, the Oros are a lot more secure than the, than the, um, non operated fractures, which are few and far between, except with old people, with old people. We often end up going conservative with them. Um, and then you would, you would, um, want them in the sling when they're moving around, especially because their balance is not always perfect. The other thing to remember. So, um I'm thinking about, um, maybe a, so we've got a, um, an orif of an elbow and this is a young person. He fell off his bike, he fractured his elbow. There's no reason that he can't do a shoulder flexion movement, he can keep his hand in this position. But shoulder flexion often you find patients with elbow problems get really stiff shoulders and we get all the complications afterwards of, of a stiff shoulder or a stiff wrist. So don't forget the other joints. Um You can say to the patient you're allowed, you can lean forward, you can even lean forward in the sling and get your, get your shoulder moving a little bit by doing that in the sling. Um, wrist we've, or hand we've talked about, don't forget the wrist, move the wrist up and down, move the wrist side to side. Um The one thing where I would be cautious is if you're thinking and I think I did hear this is what the other surgeon was talking about. Um If you've got a repair of the lateral collateral ligament, if you took your arm into abduction, the relative weight of your forearm would cause a stress on the collateral ligament. So that would be the one, the one operation if, if you had a repair of the ligament, I think twice before I give the patient something to do. But generally a flexion movement in the sling is quite a safe movement to do. So if you weren't sure and you just did that, you would still be safe, that's different to that or that where you're going to get some stress. Has anyone got a question about that or is everybody happy? Is that all right? OK. I think the key thing there is you are showing supporting the arm so that it's not putting those forces across it, isn't it? When I mentioned, did he think about this V stress? That's because if you have your arm outside trying to do things like that, that's actually putting quite a lot of a movement across your elbow across, maybe what you've reconstructed or when you've damaged those structures, that's not good. And there is evidence around that I think it's stuck with, isn't it that avoiding bear stress? So, but yes, I appreciate that. If you're really wide, then maybe you can't get your elbow neutral, but it's better if you're, it's time to think about where the structures are and what's been damaged, what you've repaired and how forces get put across those, then a neutral plane up and down or when you're supine holding things, those allow you to work some of those flexors, extensors without results. I think it's kind of the convert to what Nicky was saying about. If you've had an elbow injury, there's no reason you can't support your elbow to do your shoulder movement so that your shoulder doesn't get stiff. It conversely you have to think about. Ok, well, if I move my shoulder, I abduct my arm. What effect is that having on the elbow? So patients don't think about that and half the time we don't think about that, but it has a huge effect. So the number of patients who come back to my clinic who, who've had an elbow, whatever, and their shoulder is really stiff and they've gone on to develop a frozen shoulder because they haven't been moving their shoulder. We all think about stiffness in the elbow, but we don't necessarily think about the effect of not doing something with the other joint. Yeah. And, and then also, um, uh, complex regional pain syndrome. I haven't seen it often but I've seen it a couple of times and it's often very fearful patients, um, patients that are sometimes mentally, maybe a little bit more complex and, and I always I always think when I'm working with a patient, I think to myself, are they a cowboy or are they, are they conservatively? I call it a ninny, but it's not the right thing to say. What's the right word in England to say somebody who is a scaredy cat? A scary cat. It's precious. That's the word for somebody who's a scaredy cat or somebody that's a cowboy. If they're a cowboy, I teach them to hold back. If they're, if they're a scaredy cat, I encourage them because I think they're never gonna do something to themselves to hurt themselves. They're so scared. But I try and almost look at the personality and I don't necessarily give the same instructions to every personality because some people, they will, they've had a biceps repair but they go out and they carry their shopping. Those are the kind of people that you want to terrify them. Who I did a BP from there on and two weeks later he was moving microwaves around the kitchen. I know are cowboys and that's a great word for them. Yeah. Absolutely. So, they don't know, they've got no idea what goes on inside them and they've got no idea what the doctor has fixed or the surgeon has fixed. So, so by assessing their personalities, I think you can, you can get a better handle on what you want them to do. It's not just 11 thing fits all. Ok, let's go to the next one. I hope I'm not going to slowly, am I of the time? Ok. Um, the one thing that I've learned particularly is flexion. I have seen 11 chappy that struggled a lot with flexion, but he had a strange personality. Mostly flexion will come back because we have to eat and we have to touch our faces. So we end up getting flexion extension is the movement that we really concentrate on first. What's also quite interesting is, um, I'm sure you've seen it with or if you've ever experienced it yourself. Um, a week or two or three, even after six weeks, post any injury. If you have moved in one direction, it becomes more difficult to move in the other direction with healing tissue. Um, we call the word, do you learn hysteresis as a word, the ability of the tiss more than that the ability of the you to change. So if you are giving somebody exercises and you give them a whole bunch of flexion and extension exercises, so a whole bunch of bending and straightening exercises, there's a good chance that not all of them will be done or not, all of them will be done effectively. So we would really concentrate on an extension exercise first because that's the one that really goes wrong with the elbow. Um That's the one that we lose mostly flexion, we can get back even if we're a little bit delayed. So getting out of the sling is probably the most important thing. You can tell the patient, I've had one patient who somehow got the idea that his hand had to be up here. And I think it had to do with swelling on the hand and they were, somebody was thinking about, don't let the hand swell. It was an absolute disaster because by five weeks he could, he could hardly even get to 90 never mind further than that. So we definitely don't want people sitting up here in flexion. We do want them moving their hand. Um We're happy for them to move through the range. We don't want them stuck up in a flexed position um because we need to get the extension right. Um Supination pronation, I've already mentioned this is probably not something you might come across, but I often find that some patients are more comfortable doing their extension in neutral. Some patients are a bit more comfortable in pronation. It doesn't really matter in the early days. It doesn't really matter where the hand is just start getting the movement. If you've got a biceps repair, you want to be a little bit more careful of working in Super Nation because that puts the biggest load on flexing the the the using the biceps to flex. Um But mostly you could really happily be between anywhere between neutral and Super. Does anyone know what normal Super Nation is in pronation? Normal range of motion that you're expecting. So 80 degrees of um circulation 8585. Yeah, perfect. II often find if I look at because I'm always looking at what the other side is with a patient. II seldom find people can get to 85 or 90. To be honest, I would say probably 80 is is reasonable, um, maybe 8085 pronation. So I hope do you guys all look at the other arm because you get stiff people like me that I definitely can't get to 90 degrees. There's no ways I can get to 90 degrees or even 80. And then um so so, but to have an idea of what you're looking for would be a a good idea. Um What about risk flexion extension? Is everyone comfortable with normals? So, so 90 degrees is not a normal amount of of risk flexion. II almost never seen hyper mobile patients have risk flection. But if you just look at your own risks, you'll find that probably around about 70 degrees is a reasonable amount on my risk, probably 60 degrees. Um So maybe get used to looking at everyone. Just look at your wrists, tell me what ranges you are on your wrists, not with over pressure, Rami just active. So if you squish your hands together, that would be with overpressure. If you just flex them, that would just be active. Oh Jose has got quite a lot of range. What have you got you've got quite a lot of range. Ok. Extension. Probably mostly on about 70. Yeah. Ok. Can you make a side advance on your dog? I'm Charlie. Right. Um, I teach patients to touch their arms. They're often terrified of touching anywhere near the cut. Um, sometimes you get them at six weeks and they still haven't touched anywhere near the cuts. They don't touch their arms. They're terrified that if they do something, they're gonna damage something underneath, especially the scaredy cats. So I often say to them, II would never do, I would never do soft tissue treatment within the first two weeks of, of surgery. I think that's crazy because there's so much bleeding and bruising. I think one would just make it worse. But it's, it's ok. I sometimes say to them touch your arm if it's a little bit sore r over the area that's sore, it will soothe it. They don't have to go in with a deep massage in physio. I sometimes would use some soft tissue treatment, but that would be probably way more past four weeks. Five weeks when the tissue is a little bit more um robust. What's really important that you could tell them is to touch the scar, touching the scar is important. So let them get past the stage of bleeding as soon as the stitches are out or the stitches should be dissolved, get them to start touching the scar. Normally with little circular movements on the skin. Um, I wouldn't say before. 10 days. You agree? Yeah. Do you want a bit longer than that? 10 to 14 days? Depends on where the scar is. Yeah. And true. If the scar is open don't do, we don't do scar massage yet, but we do start touching sooner. And you'd think as soon as it's, and it doesn't have to be, I would never do that to a scar. I would never pull the skin apart. It's about putting your fingers onto the scar and moving it as if you're moving the tissue separate to the tissue below. And that helps quite a lot with, with not getting a bound up adhes area. Um, so we say from 14 days on, I think that would be safe. Um, ice after exercise. I wouldn't do this even within the first. You could, you could actually do it within the first two weeks. You could do ice. I would do no heat until at least 10 days if not two weeks afterwards. If there's any sign of inflammation or infection, definitely no heat. Um And I don't think this is something you would tell the patient, but I might say to the patient if they're really struggling with movement, do you exercise after a shower? So that you're nice and warm or take a really mild hot pack or a, or a bean bag? Not overly hot? And I always say to them, remember your skin over the scar is raw, it's not robust, it can't withstand normal heat. So, so don't, don't put the, put the any heat over the scar, but put it over the area and, and heat up the area that's tight. You could, you could always put it on the bicep. If your scar was further down and heat often helps the patients to move. One very important thing I want to say is that um we don't have good timelines on our referrals. So you can say urgent on your referral. That's another very important thing to put on your referral actually. Is it urgent? Normally anything post surgical, you should put urgent because if you don't put urgent, it means it could be two months, three months down the line that it gets dealt with. So anything surgical that you need seen within, I'd say eight weeks put urgent. Um we have set up a lot of see and treat um clinics now in the hospital so that we can see the patients when the surgeon has seen them on the day that the patient comes, it cuts out transport problems. It means that we've got a very direct line to speak to the surgeon to make sure that we're doing what they want us to do. Um If there's a question from the patient, we can come back and we can reassure. But those I think those see and treat clinics are critical and particularly for the elbows and I have to say that in the shoulder clinic or upper limb clinic that we have on a Thursday. Um, it's, it's mostly elbows that we end up seeing and it makes total sense because if you miss the boat on an elbow, you're in deep trouble. If you miss the boat on a shoulder, you can normally get it back, but an elbow, it's almost like you've got, you've got a little window and if you miss it, you'll be lucky if you get it right, you probably won't get it right. So you can't make mistakes with elbows from a mobility point of view. Other joints are quite a bit more forgiving. Um but elbows aren't forgiving at all. So early mobilization, getting them to the physio bending over backwards to make sure that, that they get seen from your side and from our side is absolutely critical. Um You can't, you can't, you can't get it back if you don't, how do you go next? Very briefly saying that it will come in the other talks. But essentially all the treatments that we do and offer is if we can't move it because we're worried about something, we have to do something to make it stable so we can move it a summary. So if for whatever reason, you're a little bit worried about that you stay in a cast or something, I actually know the treatment for any other thing is make it stable. So you can move. Which is, that's exactly what a physio wants to hear. The last thing you want to do is to mess up a surgeon's work. Um, and when I was checking with Miss Fisher on the notes that I had and, uh, we were talking about, it's gonna come up just now it's gonna talk, uh, talk about an orf or an elbow fracture. The reason the RF was done was to allow the, the patient to move. So if you don't move the patient, you may as well not have done the surgery. I mean, unless it's completely not a line, but if you're gonna fix it, it's so that the movement can happen. So then your job is to make sure that you refer to physio and you highlight how urgent it is. Our job is to make sure that our, our waiting lists aren't too long and that we prioritize on elbows. Um A lot of our patients are only seen every six weeks or every eight weeks. Elbows, we try and see every 23 or four weeks because it's that critical in that little window that we've got. Um So what do I need to know from the surgeon? This is something that maybe might be worth jotting down on your, on your referral, um, active versus active, assisted versus passive movement. Um That's important for me to know weight bearing precautions. Um How long the surgeon wants me to do whatever they said. I must do so. So are we talking about three weeks? II, usually look at when the patient is gonna be followed up. And that gives me a good idea of, of, of the timelines that the, that the surgeon is thinking of. It's not always like that, but you could think in your mind. Um, four weeks would be, you've, you've just about missed the boat. If you haven't got the patient moving by four weeks, you've missed the boat. Six weeks, you should be well on your way to, to having the elbow moving 12 weeks, it should be pretty much done and dusted that you've got the movement back. Um And if you think about that, it fits with the, with the, with the bone and soft tissue healing times. So that's why it's set up like that. Um So that you haven't got beautiful scarring that's so scarred that it, it doesn't move. I'm thinking of the soft tissue, you can get a wonderful strong fix by three months. But if you haven't taught the tissue to be mobile, then you've, you've missed it and it's pointless to have strong tissue that doesn't move. So those time periods are really important and you telling us if you're the surgeon, you've got to tell us when we're gonna look to the next stage, often you would do an an X ray at six weeks and you would check on the healing and that would give you the confidence to give us the instructions to go to the next stage. So it's very useful for you to write. Patient will be X rayed at six weeks. It tells us that you've got, um, you've got information you need to get about the bone before we move on to the next stage, which might be resistant movement or the next stage that we do. Does that make sense? Um If you've got further imaging or investigation planned, it gives us a little bit of a hint. Um It's probably more applicable to the shoulder, but if the referral says pending MRI, um then I know that there's probably more that you perhaps want to investigate from a soft tissue point of view. Um That alerts me to go back to maybe more of the letters and find out what is, what is the bigger picture with this. So any little bits of information like that are, are useful. And then the last thing is when you're gonna follow up with the surgeon, the one other thing I would add there, which I haven't and I said just now was right urgent on it. Your referral must say urgent. If it's post surgical, it must say urgent. Um We would never, so I'll give you an example. It's about achilles, but it's, it's still applicable achilles go into a boot and they have um surgery for they, they're in the boot for 10 weeks and then at 10 weeks, we get them out of the boot to start rehab. But we still call those people urgent because if you don't call them urgent, I mean, a physio is not gonna take someone out the boot just because they were told it's urgent. If the referral says in the boot for 10 weeks, that's what it will be. But if you, if you don't put urgent on your referral, it will be put in the pile that's gonna be dealt with closer to the three month mark. And the problem then is you get, or the problem closer to the 10 week mark, you get delays and then your patient only gets seen at perhaps 4.5 months. It's a little bit of an NHS. Yeah thing. But we've, we've got to do it like that. Ok. Next one. Um ok. So then does anyone need to stand up and stretch, stand up and stretch? I think it's late stri for, you couldn't see Joe's house? And so we know. Yeah, well done. There you go. Come on, Jose, there you go. Good. Right. Um Fractures around the elbow. Um That, that are um open reduction, internal fixation. We, we really, we, we trust your surgery um and we will get you out of this to get the patient out of this thing as early as possible and get, get them moving. There's not a lot of, there's not a lot of stuff that can go wrong with getting moving. If it's just a fracture. Um, I guess if you aggressively, um, gave a lot of overpressure you might in the early days of surgery cause some problems. So, I would say active movement would be the safe one to do for the first four weeks. Um, yeah, there's not, there's not too much on the other surgeries. There are things that can go wrong. You definitely wouldn't be doing resistance. You wouldn't encourage a patient to carry their shopping. Um Within four weeks of having an RF that would be, that would, would be overdoing, asking them to be active. Um The conservative ones, I've been learning quite a lot about because it's quite terrifying as a physio to be told that at two weeks, you can start getting this patient moving even though you know that there's no or this is conservative management. And you just think to yourself what if I move the bones? But that's why we need good instruction from the doctor. So M Fish was saying to me, um that last point in an older person with an intraarticular fracture because you need to start moving the, moving the fracture or moving the, the, the the joints so that you can mold the joint surfaces that even from 2 to 4 weeks, you could actually get them moving. So the cast would be on, settle the pain, settle the soft tissue and then start to get them moving. Um Physios are we are well, trained to, to say if there is excessive pain in the area of the fracture, we will come back to you and say there's a problem. This is not, this is, this is not working. Um It's, I think getting a relationship with your physio and your surgeon where you, you trust the surgeon's decision and the surgeon knows that you'll come back to them if it's not panning out as expected is the best way to get these things to do. Well, um being overly conservative, one can actually get away with it in other joints, but in elbows, we can't. So we've actually got to communicate a lot and know what the other one is wanting. Um So that we can get the patient moving quickly. Um, a distal humerus fracture, I saw one the other day, I think they'd been in a pop until five weeks. Mr Mulligan said to me perhaps the, the, the it wasn't his patient. It was another patient, but it was pretty difficult to start getting range of motion at five weeks. Um And I think the problem then is you, you almost are required to do over pressure to be able to try and make up for lost time, creating over pressure on a fracture that's only five weeks healed in an elderly person is a bit debatable because ii guess that the bony healing time, we haven't had full bony healing time. So we create a problem for ourselves if we, if we do pop them for too long, I don't know what you think. But, but I think that could create more problems because then we've got to, we've got to push them a little bit harder to get right, or accept a poor result from a mobility point of view. So, would you even say 34 weeks? Just humorous? I think I'm generally a little bit more aggressive. Um And so I think that my bottom line, as I was saying to Nicky is whatever we're doing, the whole point is to get the joint moving. So if you don't think that this patient is going to manage without a cast, then you probably need to think about fixing them, even if they're elderly. The whole point is you need to get them moving. So I think stiffness is much harder to deal with and the complications of early mobilization. Um So I'm, I think I'm probably on the aggressive side of movement rather than conservative blitz just because I trust what the physios are going to do to get them going. And that's the whole point of doing it and you know, what can go wrong if we don't. So we can, can you go to the next I should learn? Is it just the purple button? Not OK. I'm not going to go into too much detail. You'll be very grateful. I had about three slides on elbow replacements like the nitty gritty of every single approach. And Fisher said to me, I think you should keep it a little bit simpler. Um It's not, it doesn't have to be as complicated as that. So, suffice it to say that there are different approaches and, and different techniques done with a, with a uh um an elbow replacement, a total elbow replacement. And you can imagine that if you remove the triceps to do the surgery or you didn't remove the triceps to do the surgery or you split the tri triceps to do the surgery. That's got pretty huge implications from a physiotherapy point of view with active extension because you would be very cautious with active extension on a triceps that actually had been removed and res sutured. You would be much more cautious than perhaps one that had been split or not detached. So I would say if it comes to a total elbow replacement, I would want the surgeon to be very specific either with what technique they did or with, um, what, uh, what they want me to do when it comes to the triceps. Give me a, give me a hint as to and then, and then even thinking long term at what point can I start resisting this tricep? If it's a triceps off approach, I would say it's probably closer to three months. If the triceps wasn't disturbed, I would say you might even start around six weeks. You might start with some resistant movement. So what's interesting about surgery also. It's sometimes not just about what happened on the inside, it's what had to be cut to get to the inside. And that's quite important to let your physio know. Um, so, um, no flexion with elbow flex. So if you, if you, if you worked on elbow flexion with the elbow at the side, the arm is stable and it's safe. You don't want a weight to hang down straight from a straight arm. It's very tempting to improve elbow extension. It's quite tempting to hang a weight from the hand. It's sometimes something I think it's, um, it's, it's just to make sure you guys are awake. Um If, if a weight hangs from a hand, it's quite tempting because it does help to get better extension. Um, but the problem with that, um, Miss Fisher was explaining is that you actually could either pull the prosthesis out of the humerus because remember that it's got to grow in before it's secure. Um Or if the, if the prosthesis isn't connected top piece to the bottom piece, you might pull the bottom piece out relative to the top piece. If there isn't a, a hinge II, you guys know more about that. But, um, that's what you would be wanting to, to avoid, would be a weight hanging from a straight arm. You definitely wouldn't want to be pushing up, pushing up, would put some leverage on the, on the ulnar part of the attachment and could cause ulnar fracture. Um The other thing you wouldn't want to do is if you, if you did have a patient that had really good flexion, um I mean, I don't know why you do this as a physio because you should be spending your time on something more important than end of brain flexion early on. Um But, but if you think about that, you're gonna overstretch the triceps and that would also be a risk. Um The notes for, for our protocols actually say six weeks driving. But I don't think I've ever heard one of the surgeons saying you can drive at six weeks. They normally say you've got to be able to perform an emergency stop. So you've got to be able to have your hands at 10 to 2 and you've got to be able to control the car. And to be honest, I don't think there are many patients at six weeks that could do that. So sometimes a precaution is to say you won't, you won't bust the bone at six weeks, but you might kill the child that runs across the road at six weeks. So the driving decision is actually uh a lot about competence to manage the task. It's not just about the, the nitty gritty of whether the bone can take the stress. Um I think um I use that line of what would you do if a child ran out in front of the car and if you felt like if you're able to make the emergency maneuver to get out of the way, then you're safe to drive. But if you weren't, then you shouldn't be driving and most people don't want to knock a child over. I mean, it says a lot about a person if they say, yeah, that's fine. But yeah, normally that's a good kind of idea for them as to whether or not they're safe to drive. I think giving timelines is good because it gives somebody something to work towards, but sometimes it can have a negative effect like that. So they say, well, you said I could drive at six weeks. Like Nicky said, not many people are driving at six weeks, whether they have an elbow RF, whether they have proximal humerus RF, whether they have a shoulder replacement, an elbow replacement. So six weeks for driving is one of those really annoying timelines that we give patients, but actually just say to them you'll be able to drive and you can hold onto the steering wheel, make an emergency maneuver and get out of the way of a child that runs in front of the car. And then people understand that a bit clearer. I'm just thinking practically a triceps, um a an elbow replacement would be a very good opportunity for you to say to the patient. Ok. There's three little things I want you to do until you see the physio. Number one, I want you to get out of your sling and lay your hand in your lap. Um, when you are watching the TV, or at rest, number two, I want you to pump your hand open and closed a lot. So you don't get a lot of swelling and you can happily move your, your hand palm up and palm down in your sling until you get to see the physio. I'm just thinking of a sort of a practical little, what would you do in a, in a total elbow replacement? Ok. Let's go to the next one. Is it that one? That one that don't worry, ra radial head replacement? I've actually seen loads of those lately. Um We're really seeing a lot of, of them. Um You would be careful with strong resistant flexion um because of the area of the attachment of the, of the flexor of the elbow. Um Miss Fisher was saying to me that I wouldn't have thought about this is that normally if somebody's injured their radial head, they've probably injured their lateral collateral ligament. And so you would be thinking about with the patient. I don't, I don't do this with the patient. Luckily. So I don't think I've harmed anyone. But um the, the point is that think about the, the, the other injuries that might have happened. So you'd be avoiding abduction of the shoulder. Um If, because is that right? Because the likelihood of a lateral collateral ligament is there or we've had to, you know, so in the process of getting the radio head in, we might have disrupted it and it's just putting a lot of stress on that side of the elbow and you want to try and avoid that as much as possible. I think we might end that in. We're busy with our protocol. We've done all our protocols of the shoulder. If anyone's interested, we'll be getting a whole new set of protocols out, but we'll do the ones we'll get on with the elbow ones now that we've done this talk and I think we'll include that as one of the precautions. Um One of the other things to think about. Um it's not your job to think about, but our job is to help to mold the joint. So the reason we move is not just to not lose range, but it's actually to think about the cartilage and that, that moving the joint and allowing um not just not to have adhesions, but, but the reason we got into the shape that we got, I think developmentally is because the joints moved against each other. So, so it helps to lubricate the joint and to assist the joint by. So even if it's a small amount of movement, II think super pronation is one of those ones where it's a small amount of movement, there's not a lot of leverage on it, but you can get a lot of of, of effective, um, nutrition to the joint and, and improvement. Ok. We're almost done. Um, biceps repair. A very important one to protect, um, the patients often end up quite stuck in flexion. So, letting them know that they can take their arms out. I would, this is probably a, uh, a population of surgeries that have quite a few cowboys unless they're an old man that was chopping wood or doing something like that. You, you get a lot of the really big bulky gym guys and they just can't wait to get back and, and train again. So these are the guys, we probably, I'm really strict about saying we don't go back to doing weights until three months. Um They try and find all sorts of ways to try and train around the precautions. Um But you really don't want any resistance because of the repair. Um I do find that they are quite sore with full pronation. I think it's the, I think it's the maybe the air of the button but or the end of is it stretching it? Um So they often don't have full pronation. Um I do use a but I often do active assisted flexure um pronation super in the beginning because biceps is very active in super. So I normally taught them, teach them to do that. Active assisted. Um One can very effectively use gravity to, to get the arm down and something that one of my colleagues did that. I like a lot if, um, this Fisher would be the anchor. So, working like this when you've got a biceps repair is actually quite safe because you're contracting the triceps, you're causing some straightness. So I wouldn't be doing this at two weeks, post, post surgery. But it's quite a nice way to get those crazy gym people that can't wait to get any muscle contracting. It's something that they can do. It's working towards extension. I would not do that with the weight because the problem with the weight is in order to get into a position, you often end up having to go through a position to get into the right position to work on triceps. So I don't let them even get hold of a dumbbell because things can go wrong. But if you think about a, a the band, the, the flexion is actually assisted flexion because the band is pulling them up, the downward movement is the resistant part and then they're not going to be doing that with their biceps. So, um, after six weeks, you could use a little bit of gentle overpressure to get full range. Generally, we work on active, but we get going early. If you get going early, then you get better results. It's a lot of reassurance. It's a lot of telling them that they will feel a little bit uncomfortable and a little bit numb around the top of their forearm. I find if you, if you educate the patient, um, they, they work with you a whole lot more and tell them why it's important to move triceps repairs. I haven't seen any yet in this hospital. Charlie was saying that I think I stitched one back home once they got off. I think I've done two. So they're not much less than biceps, but they tend to be more of a kind of avulsion injury. So, so I would say if you were going to give some some quick advice to a biceps repair, you would say try and get your arm out, the sling, I'd say at least six times a day, let the arm hang down at your side side, allow it to slowly go into that position. If you are uncomfortable, you can hold it with your hand. Um They can definitely do hand pump. I would, I would say to, to that, that population if you are gonna move your hand, move it with the help of your other hand, don't do this alone in the first couple of weeks and then from then on the physio can, can help them. And that's it I think. Is that the last one? Sorry? I thought I'd be half an hour and I've kept you for a whole hour. Um Oh, terrible tr sorry. Um So terrible tr would be a multitude of injuries together. Um Because of the damage that happens to the capsule. We really struggle with stiffness. On this one, but on the other hand, you also can't rush in and get moving really early because because of the structures that have to heal so often, it will be um a fracture of the radial head, a fracture of the conoid and the medial or lateral um ligament disrupted. I actually was reading about it. You seldom repair the medial. You mostly repair the lateral. Yeah. So you may have a, a ruptured medial that is gonna heal conservatively, whereas the lateral is surgically repaired. Um, get the move the elbow moving. I normally get pretty precise instructions from the surgeon. Um The last one I saw, I think I saw him at about three weeks. Um And um, and we did get him moving as quickly as we could good, but he did stiffen up quite a lot. Um So when I saw him at five or six weeks, um but I'm seeing him almost every two weeks. So on a patient like that, I'm gonna see him really often. So as soon as I'm allowed to do something from the surgeon's point of view, we get on and do it. Um No shoulder abduction, same as before. Um I checked with Miss Fisher. I'm a bit of a, a scaredy cat. So I normally load from a little bit later. I'm not a cowboy. No, you're not a cowboy. But if, if the, if the surgeon gives you the confidence you can start loading it from six weeks quite happily. And that often gives the patient, if the patient is allowed to do something with their arm, the range gets better because they're actually allowed to do daily stuff when you're not allowed to do anything with your arm. That's when you, it takes long to get better, but lots of stiffness because of the capsule. I think that's it. Yeah. All right. Sorry guys. That was exhausting. It was very, very helpful. Certainly, I think Nikki was quite nervous that she was going to be speaking to a bunch of registers, but I explained to her that we don't understand what the physios do. We just normally send range of movement or strengthening. None of us really know specifics about what we're asking for. So, and I still write that now because I know Nicky knows what it means. Yeah, I think that's the thing you've got to then set up a relationship with the surgeon. Otherwise physios can be afraid if they're not empowered. So, being empowered, working closely with your surgeon and understanding what they've done and what they want and then you can actually get on and do it and, and, and get the patient better quicker. So, having a good working relationship, I think is a very important. Absolutely. I think, I think um, all it's an orthopedics are multi disciplinary, but certainly in a, we are very, very reliant on people like Nikki and our occupational therapist as well. To get our patients going. So we couldn't do our job if she wasn't around. So we thought it was super important that you guys had her input and understood what she's doing from a video perspective. So, thank you, I'll add one other thing as well and that is that hopefully you guys will have gleaned a few bits from it that you won't inadvertently tell patients the wrong stuff so that they may feel different by the time they get busy. You know, I say, well, I don't really know what to say. Just say the sling don't do anything, protect it. Physics will get to you in three months time or whenever it might be, although we do the referrals at the right time that will happen sooner. So there's little bits of confidence and knowing a few things to say. And what do I do about this and just having heard it a few times, generally I pick things up over the years. I wish I had a bit more pick them up soon, should I say so that you can give the right information? You can always sing on the same hymn sheet. Well, just, you know, if you're not sure there is absolutely no shame in asking the bus if they haven't told you what they want as POSTOP instructions. Just because the worst thing you can do is say, get going and then actually they didn't want them to because they might not be quite so cowboy as I am all the other way around. Don't do anything, but actually they should be. Does anyone have any questions you want to put to our resident physiotherapist or are you all done at five o'clock? Let's just bring this out. Still there. Thank you for listening. So, at tentatively, I appreciate it. Cool. All right, we'll let you all go and uh enjoy the rest of the evening. Thanks guys. Bye.