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REHABILITATION

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ity and strength at the expense of stability and comfort,

but clinicians must consider mobility and stability of
equal importance and not strive for progress in one
while sacricing gains in the other. Range of motion
(ROM) is initiated as early as possible within safe
parameters to prevent the development of stiffness. In
cases where fractures and dislocations are considered
unstable, ROM should not be ignored, but rather delayed or performed in a protective position.7 The following guideline outlines appropriate treatment to
restore joint motion and function after elbow fractures,
while avoiding damage to repaired and injured structures. The phases of wound healing are correlated to
treatment so that techniques are used appropriately to
augment healing and avoid inammation.

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The elbow joint consists of three bones: distal humerus,

olecranon, and radial head. Elbow trauma can result in
a simple one-bone fracture or a complex fracture/dislocation involving a combination of bones. These injuries
vary by the bones and structures involved and the
extent of the injury. Elbow dislocations occur in isolation or along with a fracture. Both fractures and dislocations often include concomitant soft tissue injury, such
as ligament, muscle, or nerve. Seven percent of all fractures are elbow fractures,1 and one third of those involve
the distal humerus. The mechanism of injury is a posterior force directed at the exed elbow, often a fall to an
outstretched hand, or axial loading of an extended
elbow. Thirty-three percent of all elbow fractures occur
in the radial head and neck by axial loading on a
pronated forearm, with the elbow in more than 20
degrees of exion.2 Radial head fractures are often associated with ligament injuries. Radial head fractures
that are associated with interosseous membrane disruption and distal radial ulnar joint dislocation are
termed Essex-Lopresti lesions. Twenty percent of elbow
fractures occur in the olecranon as a result of direct
impact or a hyperextension force.3 When the radial
head dislocates anteriorly along with an ulnar fracture,
the result is a Monteggia fracture. Another common fracture location along the proximal ulna is the coronoid
process.4

ANATOMICAL OVERVIEW

The elbow joint is composed of three complex articulations: ulna-humeral, radio-capitellar, and proximal
radio-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 ligaments, plays a major role in the stability of the elbow
joint by preventing dislocation. The joint is highly congruent and has limited joint play. The elbow is particularly prone to contracture and stiffness because of the
high congruity, multiple articulations, and the close relationship of ligaments and muscle to the joint capsule.6
Types of xation range from rigid to tenuous. Rigid
xation allows early active and passive motion with
minimal pain. Stable xation allows early protected
motion, and tenuous xation requires delayed protected
mobilization.7,8

REHABILITATION OVERVIEW
General rehabilitation goals are to restore motion and
strength for optimal function while protecting injured
and repaired structures and preventing joint stiffness.
The trend in rehabilitation has been toward early mobility with less immobilization. The greatest challenge
facing therapists is determining the balance between
mobility and stability. Often, attention is given to mobil-

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 surgeons
preference, therapists experience, and the patients
needs. The protective splint is worn for as long as 2 to
8 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 are
immobilized in 90 degrees of elbow exion, with the
forearm in neutral rotation (Figure 7-2). Olecranon and
proximal ulna fractures may be immobilized, with the
elbow in 60 to 75 degrees of exion, the forearm in
neutral, and the wrist in slight extension (Figure 7-3).
Complex radial head fractures/dislocations and radial
head replacements may be immobilized in up to 120
degrees of exion to stabilize the radial head (see
Figure 8-2).
Motion
Active and active-assistive ROM is initiated as soon as
stability of the fracture is achieved via xation or bone
healing. The elbow splint is removed for the performance of exercises three to four times daily. The patient is
instructed in elbow ROM as tolerated, within the safe
prescribed arc, that is, 12 days postoperatively, if rigid
xation is achieved. If the xation or joint is considered
stable, a program of early-protected motion is begun (see
Chapter 8). In cases of tenuous xation and joint instability, protected motion is delayed. Elbow exion and
extension is performed with the shoulder resting on a
towel 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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Greater
tubercle

Head

Coronoid
process

Head of
radius

Humerus

Intertubercular
groove
Radial
tuberosity

Lateral
epicondyle

Deltoid
tuberosity
Nutrient
foramen

S
L

Medial
epicondyle

C
B

Trochlea

Lateral
epicondyle

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Coronoid
fossa

Humerus

Coronoid
fossa

M
I

79

Elbow Fractures and Dislocations

Olecranon
process

Semilunar
notch

Lesser
tubercle

Capitulum

Radius

Ulna

Radius

Medial
epicondyle

Ulna

Coronoid
process
Radial
notch
Radial
tuberosity

A
Capitulum

Styloid
process
of radius

Trochlea

Greater
tubercle

Head

Anatomical
neck
Surgical
neck

Styloid
process
of ulna

Olecranon
process

Head of
radius

Coronoid
process

Neck

Medial
epicondyle

Radial
tuberosity

Humerus

Ulna

Radius

A
C

Olecranon
fossa

Coronoid
process

Trochlea

Styloid
process
of ulna

Lateral
epicondyle
Olecranon
process

Radial
neck

Ulna

Lateral
epicondyle

Olecranon
fossa

Radial
head

Medial
epicondyle

Humerus

Styloid
process
of radius

B
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.)

Radius

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Posterior elbow shell at 90 degrees.

F I G U R E 7-3

Posterior elbow immobilization splint in 60 to 75

degrees.

stable should not be exed beyond 90 degrees, until

fracture union is achieved. Fractures that involve triceps
rupture/reattachment follow tendon-healing precautions. Active elbow extension and active and passive
elbow exion beyond 90 degrees is contraindicated for
the rst 3 weeks to avoid tension at the repair site.

Precautions
Specic precautions apply to particular fractures. Radial
head fracture dislocations are least stable in combined
elbow extension and forearm supination. Extension is
limited to 75 degrees and progressed slowly, as the joint
becomes more stable. Olecranon fractures that are un-

Troubleshooting
Complications of these surgeries include risk of redislocation and failure of xation. Any unusual symptoms
are reported to the surgeon for further investigation.
Joint stiffness in the uninvolved joints is common and
should be monitored closely and treated accordingly.

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the elbow exed to 90 degrees. Shoulder, wrist, and

forearm ROM, and active and passive stretches are
performed to the forearm exor and extensor muscle
groups to avoid muscle tightness. Tendon gliding exercises are performed to avoid tendon tightness and joint
stiffness.

Postoperative Phase I: Inammation/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

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

PRECAUTIONS

TREATMENT STRATEGIES
Protection 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

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

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 exercisesall planes
Avoid use of sling or posturing in the sling position

Elbow ROM

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Only 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

POSTOPERATIVE PHASE II: FIBROBLASTIC/

FRACTURE STABILITY (WEEKS 2 TO 8)

Phase II may commence as early as day 1, if fracture and

joint stability is achieved.

Splinting
In the early part of this phase, the protective splint is
removed frequently for exercises and light, functional
activities. The splint is gradually weaned during the day
so that by the end of this phase, the splint is worn for
sleep and protection. The splint is usually discharged by
the sixth postoperative week.

Motion
Controlled stress to the healing tissue is most effective
during the broplastic phase. The goal is to achieve
maximum active and passive elbow ROM. Communication with the surgeon is imperative to dene precautions and establish realistic goals. When signicant
stiffness presents at an early stage, static progressive
splinting is considered with the approval of the physician. Early joint stiffness is treated with serial static or
static progressive elbow mobilization splints. These
splints are described in detail in Chapter 9. When
splints are provided in this phase, the joint is held at the
active end range for a prolonged stretch. Passive end
range stretch is delayed until phase III to avoid an
inammatory response. Treatment sessions begin with
moist heat followed by an elbow exor, extensor, and
forearm compartment stretch (Figure 7-4). Applied force
is steady and prolonged to gain tissue length. Passive
stretching is applied to the point of discomfort. Total

FIGURE

7-4

Moist

heat

applied

at

end

range

elbow

extension.

end range time (TERT) is emphasized over several repetitions.9 At no point should motion be forced. Forced
motion can damage tissue or trigger an inammatory
response.
Precautions
Specic precautions apply to each fracture type. Combined elbow extension and supination are contraindicated for radial head fracture/dislocations. Elbow
extension is increased gradually as the joint becomes
more stable. Elbow ROM exercises are performed with
the shoulder in slight external rotation in cases with
lateral ligament involvement to avoid stress to the
healing ligament. For olecranon fractures with concomitant triceps repair, aggressive elbow exion is avoided.

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Troubleshooting
Signicant pain at end range with a hard end feel may
indicate heterotopic bone formation and warrant reevaluation by the surgeon. Elbow stiffness is a common
complication 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 that

sometimes, even with the best therapy and compliance,
stiffness is inevitable because of the nature of the injury
and the length of immobilization required to achieve
stability. In these situations, it is important to give the
patient hope. The patient needs to be aware that further
procedures (see Chapter 9) are available to increase
elbow 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

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

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PRECAUTIONS

TREATMENT STRATEGIES
Protection

Use thermoplastic splint for travel, sleep, or at-risk activities

D/C sling, avoid posturing in sling position

ROM Program

Edema Control

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

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: SCAR

MATURATION AND FRACTURE
CONSOLIDATION (WEEK 8 TO MONTH 6)
The primary goal in this phase is to achieve maximum
ROM, increase strength and endurance, and resume
normal activity. There are no longer precautions that
limit motion. If stiffness persists, capsular stretching,
soft tissue mobilization, joint mobilization, and low load
prolonged 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-

Elbow Fractures and Dislocations

cises are progressed to progressive resistive exercises

(i.e., elastic bands, pulleys, and free weights). Functional
retraining and work conditioning is performed in this
phase.
Troubleshooting
Complications of elbow fractures include reex sympathetic dystrophy, heterotopic bone formation, malunion,
nonunion, nerve compression, exion or extension contractures, and joint stiffness.6 If any of these are suspected, the patient should be referred back to the
surgeon for further evaluation.

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Postoperative Treatment Phase III: Scar Maturation and Fracture Consolidation (Week 8 to
Month 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 STRATEGIES
ROM 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

83

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

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1. Jupiter, J., Morrey, B. Fractures of the Distal Humerus in Adults.

In Morrey, B. (Ed). The Elbow and Its Disorders, 3rd ed. WB
Saunders, Philadelphia, 2000, p. 293.
2. Morrey, B. Radial Head Fractures. In Morrey, B. (Ed). The Elbow
and 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. WB
Saunders, Philadelphia, 2000, p. 365.
4. Regan, W. Coronoid Process and Monteggia Fractures. In
Morrey, 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). The

Elbow 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 Greens Fractures
in 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):525539.
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 on
Improving Passive Range of Motion. J Hand Ther 1994;7(3):
150157.