organised swelling

This is just a note of something a physio on my prac called me in to see on one of his patients because he felt it was of particular interest. The patient was a 78 year old lady post fractured shaft of humerus. She had been immobilised for a six week period finishing 3 weeks prior to my seeing her and had not been referred for physio so had literally just sat with her arm in a collar and cuff for that time. When I saw her she had this huge collection of tissue around her distal humerus, elbow and proximal forearm. She had a significant biceps contracture with 20 degree lack in active and passive extension. I was just amazed at this extra tissue, it wasn't soft and fluid like regular extra articular swelling but it was palpable in the axtra-articular tissue. It was hard but not quite as hard as bone and since the patient has no pain on palpation you could sink quite firmly into it and differentiate it from the neighbouring bones. The fracture site was more proximal but the swelling had just tracked distally and acumulated and organised into this fibrous lump in places protruding up to 4cm from where the skin should have been. The wrist and hand luckily had been spared as the arm was immobilised in elbow flexion with the hand sitting near the contralateral shoulder. The management the physio had undertaken was massage, ultrasound and active extension. The physio felt that over the last 3 weeks this had been successful with a slight softening of areas of the tissue and an increase in elbow extension range. He was however doubtfull that full recovery would be possible. Interesting to see I thought although quite dissapointing that it had occured given that it could have been prevented, or at least decreased, you would think by proper swelling management and movement within restriction during the 6 weeks.