Chapter 7 Elbow Fractures and Dislocations

Aviva Wolff, OTR/L, CHT

The elbow joint consists of three bones: the 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, and one third of those involve the distal humerus. The mechanism of injury is a posterior force directed at the flexed 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 flexion. 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. 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.

Anatomic Overview

• The elbow joint is composed of three complex articulations: ulna-humeral, radio-capitellar, and proximal radio-ulnar.

• The joint capsule is thin, translucent, and has an exaggerated response to injury.

• 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.

• Types of fixation range from rigid to tenuous.

1 Rigid fixation allows early active and passive motion with minimal pain.

2 Stable fixation allows early protected motion.

3 Tenuous fixation requires delayed protected mobilization.

Rehabilitation Overview

• General rehabilitation goals are to restore motion and strength for optimal function while protecting injured and repaired structures and preventing joint stiffness.

1 The trend in rehabilitation has been toward early mobility with less immobilization.

2 The greatest challenge facing therapists is determining the balance between mobility and stability.

3 Often, attention is given to mobility 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 sacrificing gains in the other.

• Range of motion (ROM) is initiated as early as possible within safe parameters to prevent the development of stiffness.

1 In cases where fractures and dislocations are considered unstable, ROM should not be ignored, but rather delayed or performed in a protective position.

• 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 inflammation.

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

GOALS

• Protective immobilization

• Edema and pain control

• Full ROM in uninvolved joints

• Active/active assisted ROM (A/AAROM) of elbow within safe parameters

• Awareness and understanding of repair process and precautions

• Independence in home exercise program (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 STRATEGIES

Protection Options

• Custom thermoplastic splint

1 Adequate padding over the olecranon, medial/lateral epicondyles, and ulnar styloid

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