Chapter 07

IIHAND

REHABILITATIONAVIVA WOLFF, OTR/L , CHT

S E C T I O N

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7Elbow Fractures and

DislocationsAVIVA WOLFF, OTR/L , CHT

C H A P T E R

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The elbow joint consists of three bones: distal humerus,olecranon, and radial head. Elbow trauma can result ina simple one-bone fracture or a complex fracture/dislo-cation involving a combination of bones. These injuriesvary by the bones and structures involved and theextent of the injury. Elbow dislocations occur in isola-tion or along with a fracture. Both fractures and dislo-cations often include concomitant soft tissue injury, suchas ligament, muscle, or nerve. Seven percent of all frac-tures are elbow fractures,1 and one third of those involvethe distal humerus. The mechanism of injury is a poste-rior force directed at the flexed elbow, often a fall to anoutstretched hand, or axial loading of an extendedelbow. Thirty-three percent of all elbow fractures occurin the radial head and neck by axial loading on apronated forearm, with the elbow in more than 20degrees of flexion.2 Radial head fractures are often as-sociated with ligament injuries. Radial head fracturesthat are associated with interosseous membrane dis-ruption and distal radial ulnar joint dislocation aretermed Essex-Lopresti lesions. Twenty percent of elbowfractures occur in the olecranon as a result of directimpact or a hyperextension force.3 When the radial head dislocates anteriorly along with an ulnar fracture,the result is a Monteggia fracture. Another common frac-ture location along the proximal ulna is the coronoidprocess.4

ANATOMICAL OVERVIEWThe elbow joint is composed of three complex articula-tions: ulna-humeral, radio-capitellar, and proximalradio-ulnar (Figure 7-1). The joint capsule is thin,translucent, and has an exaggerated response to injury.5

The radial head, along with the medial and lateral liga-ments, plays a major role in the stability of the elbowjoint by preventing dislocation. The joint is highly con-gruent and has limited joint play. The elbow is particu-larly prone to contracture and stiffness because of thehigh congruity, multiple articulations, and the close rela-tionship of ligaments and muscle to the joint capsule.6

Types of fixation range from rigid to tenuous. Rigidfixation allows early active and passive motion withminimal pain. Stable fixation allows early protectedmotion, and tenuous fixation requires delayed protected mobilization.7,8

REHABILITATION OVERVIEWGeneral rehabilitation goals are to restore motion andstrength for optimal function while protecting injuredand repaired structures and preventing joint stiffness.The trend in rehabilitation has been toward early mo-bility with less immobilization. The greatest challengefacing therapists is determining the balance betweenmobility and stability. Often, attention is given to mobil-

78 C H A P T E R 7 Elbow Fractures and Dislocations

ity and strength at the expense of stability and comfort,but clinicians must consider mobility and stability ofequal importance and not strive for progress in onewhile sacrificing gains in the other. Range of motion(ROM) is initiated as early as possible within safeparameters to prevent the development of stiffness. Incases where fractures and dislocations are consideredunstable, ROM should not be ignored, but rather de-layed or performed in a protective position.7 The fol-lowing guideline outlines appropriate treatment torestore joint motion and function after elbow fractures,while avoiding damage to repaired and injured struc-tures. The phases of wound healing are correlated totreatment so that techniques are used appropriately toaugment healing and avoid inflammation.

POSTOPERATIVE PHASE I: INFLAMMATION/PROTECTION (WEEKS 0 TO 2)Splinting

In phase I, therapy focuses on protection of repaired or injured structures. Healing structures are protected in a brace, cast, or custom-molded thermoplastic splint to maintain alignment and prevent deformity.Splint designs vary and are based on the surgeon’s preference, therapist’s experience, and the patient’sneeds. The protective splint is worn for as long as 2 to8 weeks postoperatively, depending on the stability of the fracture/joint and the severity of the injury. The position and angle of immobilization is based on the type of fracture. Distal humeral fractures areimmobilized in 90 degrees of elbow flexion, with theforearm in neutral rotation (Figure 7-2). Olecranon andproximal ulna fractures may be immobilized, with theelbow in 60 to 75 degrees of flexion, the forearm inneutral, and the wrist in slight extension (Figure 7-3).Complex radial head fractures/dislocations and radialhead replacements may be immobilized in up to 120degrees of flexion to stabilize the radial head (see Figure 8-2).

Motion

Active and active-assistive ROM is initiated as soon asstability of the fracture is achieved via fixation or bonehealing. The elbow splint is removed for the perform-ance of exercises three to four times daily. The patient isinstructed in elbow ROM as tolerated, within the safeprescribed arc, that is, 12 days postoperatively, if rigidfixation is achieved. If the fixation or joint is consideredstable, a program of early-protected motion is begun (seeChapter 8). In cases of tenuous fixation and joint insta-bility, protected motion is delayed. Elbow flexion andextension is performed with the shoulder resting on atowel roll against a wall (see Figure 4-4). Forearm ROM,if permitted, is performed with the arm at the side and

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79C H A P T E R 7 Elbow Fractures and Dislocations

Head

Intertuberculargroove

Deltoidtuberosity

Nutrientforamen

Greatertubercle

Lessertubercle Coronoid

process

Radialtuberosity

Styloid processof radius

Styloid processof ulna

Lateralepicondyle

Medialepicondyle

Coronoidfossa

TrochleaCapitulum

A

OlecranonprocessSemilunar

notch

Lateralepicondyle

Medialepicondyle

Radialtuberosity

Humerus

Radius

Ulna

Coronoidfossa

Coronoidprocess

Trochlea

Capitulum

Radialnotch

Head ofradius

Radius Ulna Humerus

A

A

B

B

C

C

S

L M

I

Head

Anatomicalneck

Surgicalneck

Greatertubercle

Coronoidprocess

Coronoidprocess

Radialtuberosity

Styloid processof radius

Styloid processof ulna

LateralepicondyleMedial

epicondyle

Olecranonfossa

Trochlea

B

Olecranonprocess

Olecranonprocess

Lateralepicondyle

Medialepicondyle

Radialhead

Radialneck

Humerus

Radius

Ulna

Olecranonfossa

Head ofradius

Neck

RadiusUlna Humerus

A

A

C

B

B

C

S

L

I

M

F I G U R E 7-1 Elbow joint. A. Anterior view. B. Posterior view. (From Thibodeau and Patton [Eds].Anatomy and Physiology, 5th ed.)

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stable should not be flexed beyond 90 degrees, untilfracture union is achieved. Fractures that involve tricepsrupture/reattachment follow tendon-healing precau-tions. Active elbow extension and active and passiveelbow flexion beyond 90 degrees is contraindicated forthe first 3 weeks to avoid tension at the repair site.

Troubleshooting

Complications of these surgeries include risk of redislo-cation and failure of fixation. Any unusual symptomsare reported to the surgeon for further investigation.Joint stiffness in the uninvolved joints is common andshould be monitored closely and treated accordingly.

F I G U R E 7-2 Posterior elbow shell at 90 degrees. F I G U R E 7-3 Posterior elbow immobilization splint in 60 to 75degrees.

Postoperative Phase I: Inflammation/Protection (Weeks 0 to 2)

GOALS• Protective immobilization• Edema and pain control• Full ROM in uninvolved joints• A/AAROM of elbow within safe parameters• Awareness and understanding of repair process and precautions• Independence in HEP

PRECAUTIONS• Exercise only within safe prescribed arc• Monitor pressure areas over posterior aspect of elbow from prolonged splinting• No passive manipulation or stretching• No aggressive motion, which can cause inflammation and pain• Avoid neurovascular compromise

TREATMENT STRATEGIESProtection Options

• Custom thermoplastic splint• Adequate padding over the olecranon, medial/lateral epicondyles, and ulnar styloid

Pin and Wound Care for ORIF/CREF• Solution of 50% hydrogen peroxide and sterile water daily to pin sites• Standard sterile wound care procedures to ORIF• Use of nonadherent dressing with minimal bulk to allow for early motion

the elbow flexed to 90 degrees. Shoulder, wrist, andforearm ROM, and active and passive stretches are performed to the forearm flexor and extensor musclegroups to avoid muscle tightness. Tendon gliding exer-cises are performed to avoid tendon tightness and jointstiffness.

Precautions

Specific precautions apply to particular fractures. Radialhead fracture dislocations are least stable in combinedelbow extension and forearm supination. Extension islimited to 75 degrees and progressed slowly, as the jointbecomes more stable. Olecranon fractures that are un-

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POSTOPERATIVE PHASE II: FIBROBLASTIC/FRACTURE STABILITY (WEEKS 2 TO 8)Phase II may commence as early as day 1, if fracture andjoint stability is achieved.

Splinting

In the early part of this phase, the protective splint isremoved frequently for exercises and light, functionalactivities. The splint is gradually weaned during the dayso that by the end of this phase, the splint is worn forsleep and protection. The splint is usually discharged bythe sixth postoperative week.

Motion

Controlled stress to the healing tissue is most effectiveduring the fibroplastic phase. The goal is to achievemaximum active and passive elbow ROM. Communi-cation with the surgeon is imperative to define pre-cautions and establish realistic goals. When significantstiffness presents at an early stage, static progressivesplinting is considered with the approval of the physi-cian. Early joint stiffness is treated with serial static orstatic progressive elbow mobilization splints. Thesesplints are described in detail in Chapter 9. When splints are provided in this phase, the joint is held at theactive end range for a prolonged stretch. Passive endrange stretch is delayed until phase III to avoid aninflammatory response. Treatment sessions begin withmoist heat followed by an elbow flexor, extensor, andforearm compartment stretch (Figure 7-4). Applied forceis steady and prolonged to gain tissue length. Passivestretching is applied to the point of discomfort. Total


end range time (TERT) is emphasized over several rep-etitions.9 At no point should motion be forced. Forcedmotion can damage tissue or trigger an inflammatoryresponse.

Precautions

Specific precautions apply to each fracture type. Com-bined elbow extension and supination are contrain-dicated for radial head fracture/dislocations. Elbowextension is increased gradually as the joint becomesmore stable. Elbow ROM exercises are performed withthe shoulder in slight external rotation in cases withlateral ligament involvement to avoid stress to thehealing ligament. For olecranon fractures with concomi-tant triceps repair, aggressive elbow flexion is avoided.

F I G U R E 7-4 Moist heat applied at end range elbow extension.

Postoperative Phase I: Inflammation/Protection (Weeks 0 to 2)—cont’d

Edema/Pain Management• Elevation, correct positioning, cryotherapy, light compression wrap (Ace bandage), safe early

active ROM

Uninvolved Joint ROM• Hand: tendon gliding (full composite flexion to DPC), thumb all planes• Wrist: MD approval required, gravity eliminated flexion, extension, deviation• Shoulder: in supine, wearing splint, AAROM exercises—all planes• Avoid use of sling or posturing in the sling position

Elbow ROMOnly appropriate for stable fractures/dislocations and within limits of repaired structures

• Removal of splint to allow early active-assisted ROM exercises• Exercise only in safe prescribed arc, in gravity-eliminated or gravity-assisted positions• Forearm pronation/supination if permitted

CRITERIA FOR ADVANCEMENT• Clinical union at fracture site or stability via surgical fixation• Joint stability throughout full arc of motion at ulna/humeral and radio-ulnar joints

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Troubleshooting

Significant pain at end range with a hard end feel mayindicate heterotopic bone formation and warrant reeval-uation by the surgeon. Elbow stiffness is a commoncomplication of trauma to the elbow. To avoid stiffness,strict adherence to the home program is imperative.Compliance and commitment to the home program are


crucial for a good outcome. It should be noted thatsometimes, even with the best therapy and compliance,stiffness is inevitable because of the nature of the injuryand the length of immobilization required to achievestability. In these situations, it is important to give thepatient hope. The patient needs to be aware that furtherprocedures (see Chapter 9) are available to increaseelbow motion and function farther down the road.

Postoperative Phase II: Fibroblastic/Fracture Stability (Weeks 2 to 8)

GOALS• Maximize active/passive ROM of the elbow and forearm in a pain-free range• Control of edema and inflammation• Decrease scar adherence• Increase distal strength and proximal stabilization strength• Improved muscle-tendon unit length• Return to light, functional tasks with use of involved extremity

PRECAUTIONS• Full arc active/passive ROM with MD approval• Monitor response to ROM: avoid inflammatory episodes and/or exacerbation of pain• No dynamic elbow splinting• Monitor for early forearm and/or elbow joint contractures• No grade III or IV joint mobilization• No resistive exercises or activities

TREATMENT STRATEGIESProtection

• Use thermoplastic splint for travel, sleep, or at-risk activities• D/C sling, avoid posturing in “sling” position

ROM Program• Active, active-assisted, and gentle passive ROM exercises, against gravity• Emphasize total end range time (TERT) over several repetitions• Gentle distraction, grades I & II joint mobilizations only• Use of moist heat before exercising, heat on stretch• Contract/relax exercises• Biofeedback and/or NMES

Edema Control• Cold pack, retrograde massage, moist heat before retrograde massage, light compression

wrapping or sleeve, overhead ROM exercises

Scar Management• Scar massage and silicone gel sheeting following removal of sutures/staples and complete

closure of the wound• Decrease scar adherence with cross-friction massage at scar interface• Deep muscle massage to flexor/extensor muscle groups• Compression sleeves (Tubigrip) to minimize hypertrophic scarring

Light, Functional Activities• Restoration of normal movement patterns and encouraged use of extremity for light ADL• Encourage functional splinting (holding phone to increase flexion, swinging arm while walking,

and/or using keyboard)• PNF patterns encouraged

CRITERIA FOR ADVANCEMENT• Evidence of radiographic union or confirmation by MD of fracture, joint, and repaired

structures to withstand resistance/stress

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POSTOPERATIVE PHASE III: SCARMATURATION AND FRACTURECONSOLIDATION (WEEK 8 TO MONTH 6)The primary goal in this phase is to achieve maximumROM, increase strength and endurance, and resumenormal activity. There are no longer precautions thatlimit motion. If stiffness persists, capsular stretching,soft tissue mobilization, joint mobilization, and low loadprolonged stretch via static progressive splints are used(see Chapter 9).

Graded strengthening begins when the fracture union is stable and soft tissue is healed. Isometric exer-


cises are progressed to progressive resistive exercises(i.e., elastic bands, pulleys, and free weights). Functionalretraining and work conditioning is performed in thisphase.

Troubleshooting

Complications of elbow fractures include reflex sympa-thetic dystrophy, heterotopic bone formation, malunion,nonunion, nerve compression, flexion or extension con-tractures, and joint stiffness.6 If any of these are sus-pected, the patient should be referred back to thesurgeon for further evaluation.

Postoperative Treatment Phase III: Scar Maturation and Fracture Consolidation (Week 8 toMonth 6)

GOALS• Full functional ROM• Full functional strength and endurance• Full participation in all functional activities, work, and leisure

PRECAUTIONS• Hard end feel indicating a bony or hardware block; notify MD• Failure of hardware, joint incongruity• Nonunion or malunion• PRE is contraindicated if patient is unable to isolate specific muscle group

TREATMENT STRATEGIESROM Program

• Focus on end range parameters and quality of motion• Continue previous exercises; goal: passive ROM = active ROM

Strength and Endurance• PRE to all muscle groups• Free weights, wall pulleys, Thera-Band, weight well, MULE, BTE, PNF patterns with resistance

Splinting Program• Continue splinting program overnight and intermittently during the day• Upgrade splint parameters to passive end range position• Continue functional splinting throughout the day

Return to Function• Encourage return to ADL, work, and leisure activities• Activity analysis• BTE

CRITERIA FOR DISCHARGE• Achieved full or functional ROM and strength• Returned to previous level of function• Independence in home exercise program and splinting program• Progress has plateaued, and status has not changed over 6 weeks

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References

1. Jupiter, J., Morrey, B. Fractures of the Distal Humerus in Adults.In Morrey, B. (Ed). The Elbow and Its Disorders, 3rd ed. WBSaunders, Philadelphia, 2000, p. 293.

2. Morrey, B. Radial Head Fractures. In Morrey, B. (Ed). The Elbowand Its Disorders, 3rd ed. WB Saunders, Philadelphia, 2000, p.341.

3. Cabanela, M.F., Morrey, B. Fractures of the Olecranon.In Morrey, B. (Ed). The Elbow and Its Disorders, 3rd ed. WBSaunders, Philadelphia, 2000, p. 365.

4. Regan, W. Coronoid Process and Monteggia Fractures. InMorrey, B. (Ed). The Elbow and Its Disorders, 3rd ed. WB Saunders, Philadelphia, 2000, p. 396.


5. Morrey, B. Anatomy of the Elbow Joint. In Morrey, B. (Ed). TheElbow and Its Disorders, 3rd ed. WB Saunders, Philadelphia,2000, p. 13.

6. Hotchkiss, R. Fractures and Dislocations of the Elbow. In Rockwood, C., Green, D.P. (Eds). Rockwood and Green’s Fracturesin Adults, 4th ed. Lippincott-Raven, Philadelphia, 1996, p. 929.

7. Barenholtz, A., Wolff, A. Elbow Fractures and Rehabilitation.Orthop Phys Ther Clin North Am 2001;10(4):525–539.

8. Hotchkiss, R., Davila, S. Rehabilitation of the Elbow. In Morrey,B., Nickel, V.N. (Eds). Orthopedic Rehabilitation. Churchill Livingstone, New York, 1992, p. 157.

9. Flowers, K.R., LaStayo, P. Effect of Total End Range Time onImproving Passive Range of Motion. J Hand Ther 1994;7(3):150–157.

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