Rehabilitation After ORIF of Elbow Dislocations

Rehabilitation After ORIF of Elbow Dislocations

Cynthia Watkins, PT, DPT, CHT

Charles L. Getz, MD

Dr. Getz or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Mitek and Zimmer; serves as a paid consultant to Cayenne Medical; serves as an unpaid consultant to Zimmer; has stock or stock options held in OBERD; and has received research or institutional support from Integra, Rotation Medical, and Zimmer. Neither Dr. Watkins nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.


Elbow joint stability is dependent on a highly congruent skeletal articulation and collateral ligaments. Dislocations of the elbow are relatively common, being the second most commonly dislocated major joint. Most simple elbow dislocations are managed with closed reduction, a brief period of immobilization, and early protected rehabilitation. Elbow dislocations associated with fractures of the radial head and the coronoid are complex injuries that are much more likely to require surgical intervention.

Relevant Anatomy

The elbow is stabilized by both the bony congruency of the joint and the periarticular soft-tissue structures. The soft-tissue structures on the medial side (Figure 19.1) are the medial collateral ligament (MCL) complex and the flexor pronator mass. The lateral (Figure 19.2) side soft tissues include the lateral collateral ligament complex (LCL) and the extensor and supinator muscular complex. The primary restraint to valgus instability is the radial capitellar joint, while the MCL is a secondary stabilizer that becomes the primary stabilizer if the radial head is removed. The bony congruency of the ulnar trochlear articulation is the primary restraint to varus stress, with the LCL being a secondary stabilizer.

Supination and axial loading of the forearm causes the ulna and radial head to rotate away from the distal humerus, with the radial head translating posterior to the capitellum and the lateral ulna rotating away from the lateral trochlea. The lateral ulnar collateral ligament (LUCL) is the primary stabilizer to prevent this instability pattern, known as posterolateral rotatory instability (PRLI).

Most elbow dislocations occur as a result of a fall onto an outstretched arm. The forearm is forcibly supinated and axially loaded. In addition, the valgus-carrying angle and slight degree of flexion convert the axial load into a valgus thrust. This mechanism results in injury of the stabilizing structures around the elbow. O’Driscoll described the stages of elbow instability as beginning with a failure of the LUCL, with progressive disruption of the anterior and posterior capsule. In severe cases, the medial ulnar collateral ligament (MUCL) is also injured. This unlocks the forearm from the humerus, and allows the radial head to dislocate behind the capitellum.

In cases of complex instability, the radial head is driven into the capitellum and the coronoid into the trochlea before the forearm is fully disengaged, resulting in various degrees of fracture of the radial head and coronoid in addition to the collateral ligament injuries. The terrible triad injury pattern consists of an elbow dislocation, radial head fracture, and coronoid fracture.

PRLI is a relatively rare late sequelae of traumatic elbow dislocation or subluxation. It occurs when the LCL complex fails to heal sufficiently to prevent the forearm from rotating away from the humerus, resulting in either recurrent frank dislocations or subluxations of the elbow. Varus posteromedial rotatory instability (VPRI) is caused by a varus load, which results in failure of the LCL under tension and fracture of the medial ulna joint line due to compression of the coronoid against the medial aspect of the trochlea.

Operative Treatment

Simple Elbow Dislocations

For the majority of patients with simple elbow dislocations, a brief period of immobilization followed by protected early range of motion (ROM) will result in a favorable outcome. In rare cases, the elbow will not be stable even with the elbow in 90° of flexion and the forearm pronated. These patients require operative stabilization of the elbow.

Figure 19.1 Illustration of the medial elbow ligamentous complex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehensive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.)

A small number of patients will continue to have radiographic findings of instability at 7 to 14 days or clinical findings of instability at 14 days, thus will be considered for surgical stabilization. In the majority of these cases, the LCL and common extensor origin are found torn away from the lateral epicondyle, and can be anatomically repaired either with sutures through bone tunnels or with suture anchors. If the LCL is torn midsubstance, a ligament reconstruction with a tendon graft may be required (Figure 19.3). Uncommonly, the MCL will also require repair or reconstruction after the lateral repair. If the elbow continues to have instability after both sides of the elbow are addressed, an external fixator is applied to maintain the reduction.

Figure 19.2 Illustration of the lateral elbow ligamentous complex. (Reproduced with permission from Gramstad G: Anatomy of the shoulder, arm, and elbow, in Boyer MI, ed: AAOS Comprehensive Orthopaedic Review 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2014.)

Ideally, fixation of all of the injuries will be secure enough to start earlier rehabilitation. However, extensive repairs or swelling may require a delay in the initiation of therapy. Wound healing and infection prevention is the highest priority, then joint stability, and finally ROM after complex elbow repairs.

Stabilization surgery can be done through a posterior incision with full-thickness skin and subcutaneous flaps raised to allow access to the lateral and medial sides of the joint. Alternatively, separate direct lateral and medial incisions can be used. The laterally based incision requires less soft-tissue dissection and may lead to less wound healing problems than a posterior incision. The potential need for future additional surgery is also a consideration when planning the surgical approach. A lateral incision may be preferred if future surgical contracture release is planned, while a posterior incision would be preferred for later elbow replacement.

Complex Instability: Fracture Dislocations

Complex instability falls into two main catagories, terrible triad injuries and VPRI. Terrible triad injuries involve fractures in addition to the ligamentous injuries, as described for simple elbow dislocations. Surgery is recommended when the fractures of the coronoid or radial head would require intervention on their own. Surgery is also recommended if the joint is not congruently reduced or the elbow demonstrates clinical instability at greater than 45° of flexion.

Surgery to address terrible triad injuries requires repair of types II and III coronoid fractures, radial head repair or replacement, and repair or reconstruction of the LCL. MCL repair often may be required to stabilize the elbow as well as application of an external fixator. Management of coronoid fractures can be difficult especially if there is comminution. Although the coronoid is most easily accessed from the medial side it can also be reached from the lateral side if a radial head replacement is required. Coronoid fractures can be fixed with a variety of techniques, including screws, small plates and screws, and transosseous sutures. The decision for a single posterior incision or separate lateral and medial incisions is based on surgeon preference. These injuries often include extensive soft-tissue injuries, and swelling can be a problem. Wound healing problems can be a major complication of surgery for these injuries.

VPRI may include subtle injuries and require operative intervention when the trochlea is not congruent and/or the radial capitellar joint is gapped on an anterioposterior elbow radiograph. Computed tomography (CT) is used to assess the joint alignment in suspected cases, as these injuries are often difficult to assess with plain radiographs. The coronoid fracture is addressed through a medial approach to the elbow by elevating the flexor carpi ulnaris muscle (FCU) anteriorly. The ulna nerve is identified and protected during this approach. The LCL requires a separate lateral approach to repair or reconstruct the ligament. If fixation is tenuous, an external fixation will be applied to offload the repaired joint and ligaments, and protect the reduction.

Figure 19.3 A–C, Illustrations of reconstruction of the lateral ulnar collateral ligament through an extended Kocher’s approach. (Reproduced with permission from Morrey BF. Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4(3):117–128, and with permission from the Mayo Foundation for Medical Education and Research, Rochester, MN.)

Postoperative Rehabilitation

Although there is no “one-size-fits-all” approach to rehabilitation after operative fixation of elbow instability injuries, there are general principles that can be applied and utilized in individual cases. The initial postoperative management focuses on preventing and decreasing swelling, managing pain, and protecting the repair. The primary rehabilitation goals after surgical treatment of elbow dislocation are restoring joint mobility while protecting the surgical repair, preserving elbow stability, and eventually restoring function. Increases in ROM should not be gained at the expense of joint stability. Restoring a functional arc of motion is essential to enabling the patient to return to normal activities. While normal elbow ROM has been measured as 0° to 140° of flexion and extension, and supination/pronation 80° to 85°, the functional ROM to complete most activities of daily living (ADLs) has been established as 30° to 130° (flexion/extension) and 50°/50° supination/pronation, although some common tasks may require higher degrees of flexion and forearm rotation. It is important to educate the patient early about the expected ROM losses, especially elbow extension. A loss of 15° of elbow extension is not an uncommon sequela of even simple elbow dislocations.

Patients are splinted in the operating room and placed in a sling. The splint rests the soft tissue to help reduce swelling and protect the repair. The splint is typically discontinued 7 to 10 days after surgery. The splint can be replaced with either a custom-molded orthoplast removable splint, or a prefabricated brace, which can be removed for hygiene and permit early ROM exercise while protecting the repair (Figure 19.4).

Gentle active and active assisted exercises are typically initiated within the first 7 to 10 days after surgery. Active range of motion (AROM) rather than passive range of motion (PROM) is advocated to take advantage of the compressive stabilizing forces of the muscles surrounding the elbow. The patient is encouraged to remove the orthosis and perform these exercises at frequent intervals throughout the day. As the bone and soft tissues begin to heal, the ROM can be progressed and light functional activities can be initiated. Strengthening is begun once the joint is declared stable by the physician. In general,
the elbow has enough healing to tolerate strengthening around 8 weeks after surgery. Comminuted coronoid or radial head fractures may need to be protected for a longer duration.

Figure 19.4 Photograph of posterior elbow custom splint.

Dependent on the amount of soft-tissue trauma, there may be substantial swelling and edema in the first 14 days postoperatively. Capsular thickening and co-contracture of the brachialis muscle develops within days of the injury, leading to restricted movement of the elbow, especially with extension. Edema management can include elevation, retrograde massage, and the use of light compressive dressings and sleeves.

Pain also contributes to stiffness and muscle guarding. The therapist needs to distinguish between the normal level of pain associated with the injury and surgery versus pain from nerve irritation. Care must be taken to monitor the ulnar nerve on the medial aspect of the elbow for irritation/instability. Symptoms will include tenderness to palpation of the medial aspect of the elbow and paresthesias in the ring and small fingers. Uncontrolled neuritis and neuropathy with associated pain can lead to elbow contracture as well as reflex sympathetic dystrophy and chronic regional pain syndrome (CRPS). Prolonged ulnar compression can also lead to muscle atrophy or wasting of ulnar innervated muscles, including the hand interossei.


Protection ROM Edema Management Scar Management Pain Management HEP Functional Goal
Long-arm orthosis; hinged brace AAROM in protected arc Elevation, retrograde massage, compressive dressings Scar massage, silicone sheets, desensitization TENS, IFC, ice, medications as prescribed by physician Elbow AAROM in protected arc, AROM to unaffected joints Light use of affected hand while wearing protective orthosis
AAROM = active assisted range of motion, AROM = active range of motion, ROM = range of motion, IFC = interferential current therapy, TENS = transcutaneous electrical nerve stimulation.

Pain management techniques, including medication, transcutaneous electrical nerve stimulation (TENS), biofeedback, and relaxation techniques may be employed to decrease pain and increase the ability to participate with the therapeutic exercises.

The patient is encouraged to use the affected arm for functional activities, within protected guidelines, throughout the rehabilitation process. For example, if in a splint, the patient may still be able to use the affected hand as a helper for ADLs. When a patient has a weight limit on lifting, it is still beneficial to use the elbow for unweighted ADLs. Since the function of the elbow is to position the hand for functional activities such as dressing, bathing, and eating, patients are usually highly motivated to progress toward these goals.

Authors’ Preferred Protocol

Phase 1 (Inflammatory Phase, 0–2 Weeks) (Table 19.1)


  • Protect the repair

  • Decrease edema

  • Decrease pain

  • Influence scar formation/remodeling

  • Prevent contracture


  • Custom-fabricated long-arm orthosis with elbow in 90° of flexion and neutral forearm (radial head fracture) or pronated forearm (LCL repaired)

  • Hinged elbow brace

Oct 13, 2018 | Posted by in ORTHOPEDIC | Comments Off on Rehabilitation After ORIF of Elbow Dislocations
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