Rehabilitation following elbow fractures or dislocations emphasizes restoration of mobility, stability, and muscle performance.
The functional arc of motion required to perform most activities of daily living (ADLs) is 30 to 130 degrees of flexion and 50 degrees each of supination and pronation.
The most common complication of elbow fractures and dislocations is elbow flexion contracture. The exact pathology of elbow contracture is unclear.
The therapist must thoroughly examine the intrinsic and extrinsic structures and customize the therapy to address the specific problems that may be encountered during the healing phases of each structure.
Optimal rehabilitation of the elbow after injury or surgery requires careful timing and progression of therapy during the physiologic phases of tissue healing, balancing appropriate tissue stress to increase motion and function without provoking inflammation and compromising the healing structures.
The upper extremity is a functional unit, with the elbow serving as a link placing the hand in space and as a stabilizer for power and fine-motor function. The elbow must be mobile, stable, strong, and pain-free to enable independent function in ADLs, work tasks, and recreation. Rehabilitation after an injury to the elbow must include restoration of these essential functions.
The elbow is a trochleoginglymoid joint. At the distal humerus, the trochlea articulates with the ulna, and the capitellum of the distal humerus articulates with the head of the radius. The three bones form three articulations of the elbow: the radiohumeral, the ulnohumeral, and the proximal radioulnar joints. The elbow has 2 degrees of motion: flexion–extension and supination–pronation. The highly congruous articular surfaces of the elbow joint provide static elbow stability with assistance from the joint capsule and the collateral ligaments. The elbow flexor and extensor muscles contribute to dynamic stability.
The normal arc of elbow flexion and extension is approximately 0 to 140 degrees, plus or minus 10 degrees, with supination and pronation being 80 degrees and 85 degrees, respectively. The functional arc of motion required to perform most ADLs is 30 to 130 degrees of flexion and 50 degrees each of supination and pronation.
Restricted motion of the elbow after fracture or dislocation may result in significant functional limitation. Range of motion (ROM) deficits in flexion are typically more functionally limiting than deficits in extension. This is because elbow flexion has greater functional value to the patient in a ratio of approximately 2 to 1. However, the patient’s vocational and avocational needs ultimately should define the therapeutic goals of rehabilitation.
There is no standard for normal elbow strength except for comparison with the uninvolved side. Generally speaking, the dominant extremity is 5% to 10% stronger than the nondominant limb, and males are two times stronger than females. In standard muscle-testing position, the isometric strength of the elbow flexor group is approximately 30% to 40% greater than that of the extensor muscle group. Supination strength is approximately 15% greater than pronation. ,
The most common complication of elbow fractures and dislocations is the elbow flexion contracture. The exact pathology of elbow contracture is unclear. Reported reasons for loss of motion include prolonged immobilization, soft tissue trauma, intra-articular trauma, and heterotopic bone formation. Electron microscopy reveals that joint capsule tissue specimens from joint contractures appears as dense, hypertrophic collagen fibrils with extensive cross-linking. The hypertrophic tissue can be 3 to 4 mm thick and can tether elbow extension and block flexion. The muscle belly of the brachialis muscle lies in intimate contact with the anterior joint capsule. With traumatic injury, a hematoma forms, which can cause adherence of the brachialis to the anterior joint capsule, thereby limiting flexion and extension of the elbow.
Goals of Elbow Rehabilitation
The goals of elbow rehabilitation following elbow fracture or dislocation include (1) restore function by restoring motion and muscle performance, (2) influence scar remodeling and prevent joint contracture, and (3) restore or maintain joint stability. Treatment is coordinated for the involved tissues through the progressive stages of healing without damaging the healing structures. The therapist must focus on minimizing joint stiffness and muscle weakness to maximize functional outcome without losing fracture reduction or joint stability. The therapist must be attentive to potential complications and, when possible, minimize or prevent them. These complications include ankylosis, instability, nerve injury, and ectopic ossification.
The stages of healing overlap, and their duration may vary depending on the location and severity of the fracture, concomitant soft tissue injuries, and the patient’s age. The therapist should be aware that the method of fixation influences the type of bone healing and the fracture healing time. Primary bone healing occurs with compression plate fixation. Secondary bone healing occurs with callus formation and the use of casts, rods, and internal or external fixation devices. Secondary bone healing is faster than primary bone healing.
Fractures and dislocations of the elbow may cause trauma to several intrinsic and extrinsic tissue structures. The intrinsic structures are bone, ligament, and joint capsule. The extrinsic structures are the muscle, tendon, nerve, and skin. The therapist’s clinical examination of the intrinsic and extrinsic structures determines the primary sources of impairment. The treatment plan may then be customized to address the specific problems that may be encountered during the healing phases of each structure.
Elbow Fracture Considerations
Compared with other fractures, fractures of the elbow have a higher complication rate and poorer outcomes, often resulting in contracture and loss of function. Advances in open reduction and internal fixation provide stability that enables early motion and minimizes soft tissue complications.
Several classification systems are used for fractures and dislocations of the elbow, but no system is universally accepted. They generally are used to provide the surgeon with treatment guidelines and a prognosis. For the therapist, the classification systems are useful in communicating with the surgeon and help our understanding of the functional effect of the injury (see Chapter 78 ).
The ultimate goals of medical management are to reestablish articular congruity, obtain acceptable alignment, and provide rigid fixation to begin active motion as soon as possible. Stable anatomic reduction and early mobilization prevent or minimize loss of joint motion and post-traumatic arthritis. Prolonged immobilization results in fibrosis or ankylosis of the joint. The outcome depends on the degree of comminution, accuracy of reduction, and stability of internal fixation.
Common complications after fractures of the humerus and proximal radius and ulna include nonunion, malunion, stiffness, ectopic ossification, osteoarthritis, ulnar neuropathy, and prominent hardware. Injury to the wrist and distal radioulnar joint is not uncommon, with radial head fractures causing associated wrist pain and limited forearm rotation.
Elbow Dislocation Considerations
Despite the fact that the elbow is one of the most stable joints in the body, dislocation of the elbow in adults is relatively common, its incidence trailing behind that for shoulder and finger joint dislocations in the upper extremity. The focus of medical management is to achieve and maintain stable anatomic reduction that allows early active motion. Once reduced, recurring dislocation is rare, owing to the elbow’s intrinsic bony stability. Soft tissue damage with acute dislocation may be significant and commonly involves the medial and lateral collateral ligament complexes. Elbow dislocations may have associated fractures of the humerus, radial head, or ulna and may require surgery to obtain stability. Complex dislocation injuries generally have a poorer outcome than simple dislocations. Elbow dislocations can be posterior, anterior, or divergent, displacing the radius from the ulna. Simple posterior dislocations are most common. Anterior dislocations are less common, and divergent dislocations are rare.
Complications associated with acute elbow dislocations include compartment syndrome immediately after injury due to extensive soft tissue trauma and swelling, neurovascular injury, and distal radioulnar joint involvement. Late complications include elbow flexion contracture and ectopic bone formation. Although rare, there is some potential for recurrent dislocation, especially if adequate healing has not occurred prior to return to full function.
The focus of medical management of elbow dislocations is to achieve and maintain stable anatomic reduction that allows early active motion.
The therapist should obtain detailed information concerning the patient’s injury and surgery. The therapist and surgeon should have a mutual understanding regarding the patient’s prognosis and treatment plan, including any precautions, contraindications, and complications.
A thorough clinical examination of the elbow is key to developing an effective rehabilitation program that minimizes impairment and maximizes functional outcome. The examination should include the history; mechanism of injury; and, if possible, review of the referring physician’s notes, surgical report, and radiographs. It is important to know the type of fracture or dislocation, severity or comminution of the fracture, and any associated soft tissue injuries. If indicated, the details of the surgical procedure, including type and location of hardware as well as excision of bone that might weaken joint stability or soft tissue attachment, are important information for the therapist.
In order to establish a safe early motion program, it is important for the therapist to know the stability of the reduction, limits of the fracture or ligament repair, and what the surgeon considers to be the stable arc of elbow flexion and extension. For example, this is usually 60 degrees of flexion to full flexion because the elbow becomes unstable as it is moved into extension. The therapist also needs to know the stable position of forearm rotation. If only the lateral collateral ligament is damaged, the elbow is more stable in pronation, which tightens the medial ligaments and common extensor origin. If only the medial collateral ligament is damaged, the elbow is more stable in supination, which tightens the lateral ligaments and flexor–pronator origins. If both the medial and lateral ligaments are damaged, the forearm should be placed in neutral.
Wounds and scars can limit motion and interfere with other treatment procedures. The location, size, and color of the wound and surgical incision should be documented. The presence of sutures, exposed pins, and hardware should be noted. Signs of infection of the wound or pin tracts should be documented and reported to the surgeon immediately. Scars may contribute to limited motion and should be examined for hypertrophy, adherence, pliability, sensitivity, and blanching with stretch (which would indicate restriction of motion.)
The hand and forearm should be inspected for color, temperature, and signs of compromised circulation or compartment syndrome (if the patient is seen by the therapist within 12 to 24 hours after injury or surgery). Edema is typically present and measured circumferentially with a tape measure. Circumference measurements may be taken above and below the elbow flexion crease at specific distances that are recorded to allow repeated measurements over time. Avoid measuring circumference at the elbow flexion crease when the elbow is flexed because this will skew the measurement.
Since nerve injury may have occurred at the time of the initial injury or surgery, sensory and motor nerve function should be assessed at the initial visit and monitored throughout the course of rehabilitation. Note the pattern of numbness and paresthesias, muscle weakness, and posturing of the digits and wrist to determine possible involvement of the ulnar, median, or radial nerves.
Active and passive range of motion (AROM and PROM, respectively) should be recorded. Initially, motion should occur only within the stable arc of motion for flexion–extension and supination–pronation. Passive joint measurements should be deferred until healing permits passive stress. The shoulder, wrist, and digits should be examined initially, to rule out any associated injury or loss of motion. Uninvolved joints should be monitored throughout the course of therapy to ensure that full ROM is being maintained.
Treatment Goals and Techniques Following Elbow Fracture or Dislocation
Optimal rehabilitation of the elbow after injury or surgery requires careful timing and progression of therapy during the physiologic phases of tissue healing, balancing appropriate tissue stress to increase motion and function without provoking inflammation and compromising the healing structures. This requires the therapist to have a sound knowledge of the physiology of tissue healing and its response to stress.
Phase I: Inflammatory Phase (0 to 2 Weeks)
During the inflammatory phase, treatment goals are to control pain, minimize or prevent edema, promote healing, protect healing structures, maintain stability, maintain ROM, and monitor for complications. Because of the risk of instability and the potential for recurrent dislocation in extension, it is important for the therapist to know the surgeon’s intraoperative assessment of elbow stability in extension, which will determine the stable arc of motion in the sagittal plane (flexion–extension).
An informed patient is less likely to become anxious and is more cooperative and involved in rehabilitation. The therapist should give the patient an overview of the course of treatment and explain the importance of his or her efforts in reaching maximum potential. The therapy program should include a written and structured home program in addition to therapy provided in the clinic. The home-program instructions should be part of the initial treatment session, frequently reviewed, and updated depending on the patient’s progress.
Pain can be a major obstacle because it limits the patient’s efforts and affects emotional well-being. The therapist should carefully assess the source of pain. The therapist should consider whether the pain is the result of a nerve injury (irritability or compression), or if it is caused by the normal inflammatory response to the injury or surgery. The patient should be reassured that pain in the early phase of healing is expected and common with the inflammatory response. Patients should be encouraged to distinguish between acceptable, tolerable discomfort and the type of pain that warns of impending damage. The patient should also understand that much of the pain comes from edema and stiffness; as they resolve, so will the pain. The patient and therapist should distinguish between expected discomfort and pain that causes the patient to co-contract or prevents cooperation in the therapy program. Severe pain combined with excessive swelling might be a warning sign of impending compartment syndrome. Various physical agents, therapeutic exercise, and manual therapy techniques may be indicated to modulate (reduce) pain so that the patient is able to perform the much needed motion program.
Initially, elevation may be the only edema control measure that can be used if a cast or external fixation is in place. The patient should keep the elbow above heart level whenever possible. When the patient is sleeping, the entire upper extremity should be supported on pillows, so that the elbow remains above heart level. Physical agents, especially ice or cold packs, light compression wraps, and manual edema mobilization or retrograde massage may be used to help control edema. The added benefit of cryotherapy techniques is simulataneous analgesic response. Ice or cold packs may be applied several times per day; before or after ROM exercises. Cold may initially create the perception of stiffness, so additional repetitions of ROM exercises may be needed.
Compression sleeves and wraps work best if there are no exposed pins or external hardware. They may be worn for hours at a time as long as it does not cause discomfort, constrict circulation, or restrict motion ( Fig. 79-1 ). Decongestive or retrograde massage of the hand, wrist, forearm, and upper arm is effective for reducing edema. The massage can be combined with elevation, with the patient supine and the arm either supported in elevation or with the shoulder flexed so that the humerus is vertical and the hand is raised to the ceiling ( Fig. 79-2 ).The patient may be more relaxed and less anxious lying down. The elbow should be kept within the stable arc of motion throughout the massage. External hardware and wounds should be avoided during the massage.
Range of Motion
Active, Active-Assisted, or Controlled Passive Elbow Motion
Early protected motion of the elbow minimizes joint stiffness and facilitates healing. As previously stated, joint stiffness is common with elbow fractures, and immobilization longer than 3 weeks may result in significant loss of motion. Most rehabilitation guidelines begin ROM within 2 to 3 days postoperatively. During the inflammatory phase, ROM should be initiated only within the stable arc allowed by the injury and surgery, avoiding pain and excessive stress on healing structures. In most cases, active, active-assisted, or gentle PROM should begin within 1 week of establishing fracture reduction or joint stability. With unstable fractures and dislocations that have to be immobilized, motion should begin no later than 3 weeks.
The muscles crossing the elbow serve as dynamic stabilizers of the elbow, minimizing posterolateral instability and increasing joint compressive forces and joint stability. The dynamic stabilizers include the biceps brachii, brachialis, brachioradialis, triceps brachii, and the muscles of the anterior and posterior compartments of the forearm. Lateral collateral ligament repairs are more stable with active muscle contraction with the forearm in pronation and the shoulder adducted so that the humerus is vertical. , Active muscle contraction of the flexor–pronator muscles contribute to valgus stability on the medial side of the elbow.
Joint mobilization techniques using grades I and II oscillations may decrease pain and promote relaxation prior to active ROM exercises. Effective active exercise requires that the patient be relaxed and able to isolate the agonist muscle and avoid co-contracting. I prefer to initially position the patient supine with the upper arm and elbow supported on pillows. The patient may perform these exercises in a sitting position once the patient is able to maintain the position in the stable arc of motion and avoid co-contraction. In the clinic, the therapist gently guides the patient’s active efforts through the full stable arc of motion for extension–flexion and supination–pronation.
Forearm rotation exercises emphasizing supination are essential to any early motion program following elbow fracture or dislocation, especially with radial head fractures. To minimize the supination loss, these ROM exercises are initiated as tolerated by the patient and within the limits of a stable arc of motion. Supination and pronation ROM exercises are typically performed with the patient sitting or standing, with the elbow at 90 degrees of flexion held against the side of the body to ensure pure radioulnar motion without shoulder motion substitution. With the elbow flexed at 90 degrees, forearm rotation can be performed without excessive stress on the medial and lateral collateral ligaments. However, if there is known ligamentous injury, protected motion is indicated within a limited arc of rotation, typically communicated by the referring surgeon. For example, with the elbow in extension, forearm rotation beyond neutral may be avoided for 4 to 6 weeks with ligamentous repairs. ,
To emphasize elbow flexion and extension ROM exercises, I typically have the patient lie supine on the treatment table. This position stabilizes the trunk and scapula, and in my experience, patients have less discomfort in the supine position. The arm is positioned so the scapula is stable, the shoulder is adducted and flexed to 90 degrees with the humerus vertical to the table, and the elbow is pointing to the ceiling. Elbow extension is assisted by the therapist or the patient’s opposite arm, within the full stable arc of motion in the sagittal plane. Initially, the patient may only be able to engage the triceps against gravity with a place-and-hold technique ( Fig. 79-3 ). Gravity assists flexion when the patient relaxes the triceps. The greatest advantage of the supine position is isolation of the triceps during active elbow extension. As previously stated, ligamentous instability may be present after dislocation. The forearm should be pronated to protect the lateral collateral ligament complex during elbow flexion and extension ROM ( Fig. 79-4 ), and the forearm should be supinated to protect the medial collateral ligament in sagittal plane elbow motion. It cannot be overemphasized that any exercise to increase motion at the elbow should not inappropriately stress healing tissues and that exercises in any plane or direction must not exceed the safe arc.
Active motion may be limited by muscle guarding or co-contraction of the biceps and triceps. The biceps tends to be hyperactive or in spasm with reciprocal inhibition of the triceps after elbow injury or surgery. In a sitting or standing position, the elbow extends with an eccentric or lengthening contraction of the biceps and the assistance of gravity rather than with concentric contraction of the triceps. The arm is carried in a protected adducted position with elbow flexion, and the biceps tends to be hyperactive and in spasm. In the supine position with the shoulder at 90 degrees and the humerus vertical, the triceps is recruited and the biceps is typically quiet. The triceps is isolated during elbow extension and gravity assists elbow flexion with less pain and muscle guarding of the biceps.
The gravity-eliminated position is another option for isolating the triceps and biceps muscles. The patient can be supine on a mat with the shoulder abducted to 90 degrees and the elbow positioned with gravity eliminated. The forearm and hand are placed on a skateboard to avoid resistance from friction as the forearm slides across the surface with active elbow extension and flexion.
During the inflammatory phase, emphasis may be on either mobility or stability of the elbow, depending on the specific injury. To date, there is no specific evidence on the appropriate exercise prescription to be used. I have found that if the emphasis is on elbow mobility, 5 to 10 repetitions should be performed every 2 to 3 hours, holding each contraction for 5 seconds to maximize muscle fiber recruitment. To maximize stability but still maintain mobility, my experience suggests that 10 to 15 repetitions should be performed two or three times per day. The patient maintains comfortable end-range joint position for several minutes. Each patient’s physiology and propensity for stiffness is different; therefore, each exercise regimen must be individualized.
Active Range of Motion of Uninvolved Joints
AROM and PROM of the shoulder, wrist, and digits should be included to prevent loss of motion and weakness caused by disuse and protective posturing. If necessary, shoulder and hand exercises may be performed with the elbow in the appropriate protective orthosis. ROM of the uninvolved joints also assists edema reduction and prevents the development of a frozen shoulder ( Fig. 79-5 ).
Composite stretching exercise for the forearm flexor and extensor compartments should also be included to prevent loss of muscle–tendon length. Initially, the composite stretching of the fingers and wrist should be performed with the elbow in protected flexion in an orthosis to prevent overstressing the elbow at the muscle–tendon origin. As comfort permits and flexibility improves, composite stretch can be applied with the elbow in progressive extension as long as the lateral collateral ligament complex is not injured or repaired. To protect the injured or repaired lateral collateral ligament, extension should be performed with the pronated forearm (safe position) for the first 6 to 8 weeks, and full extension with supination may be delayed up to 12 weeks (see Fig. 79-4 ). The therapist and surgeon need to communicate about the progression of ROM with respect to injury or repair of the lateral collateral ligament. For more information on the management of elbow collateral ligament injuries, please refer to Chapters 86 and 87 .
Muscle strength can be maintained using isometric strengthening exercises while the healing structures are immobilized. Isometrics should only be considered if active muscle contraction and compressive forces are not contraindicated. Isometric strengthening exercises may be performed for the biceps, triceps, shoulder girdle, and forearm muscles. Gentle hand-strengthening exercises with light putty or a soft sponge may be performed with the elbow in an orthosis. These hand exercises also facilitate venous return.
Continuous Passive Motion
Primary indications for the use of continuous passive motion (CPM) for the elbow are limited to stable fractures, rigid fixation, or postsurgical contracture release. The reported benefits of CPM are to prevent stiffness, minimize edema and pain, enhance tissue healing (including articular cartilage and periarticular connective tissues), minimize adhesion formation, maximize ROM, and prevent ectopic ossification. CPM is not recommended with ligament injuries and potentially unstable joints because it is not possible to maintain alignment with the changing joint axis of motion at the extremes of extension and flexion.
During the inflammatory phase of elbow healing, CPM is used to minimize edema and pain and to maximize mobility within the safe limits of the involved tissues. It may be applied immediately after surgery, with controls set for a short cycle time within the safe arc of motion. Initially, the elbow is in the CPM machine full time, day and night. As swelling subsides, time out of the machine may be increased. ,
No definitive studies support optimal dose-response of CPM or optimal parameter settings. Hotchkiss reports that elbow CPM is helpful for “intermittent passive positioning” for 20 to 30 minutes, alternating flexion and extension at the maximum tolerable end-range. O’Driscoll’s protocol is to begin the CPM with a small, tolerable ROM and increase it gradually with each day. The goal with CPM in the early phases of healing is to obtain 90% stable PROM within the first 2 to 3 postoperative weeks. See archived chapters on the companion Website to review more information on the use of CPM for hand and upper extremity CPM.
During the inflammatory phase, the goals of orthotic intervention are to protect and support healing structures, to prevent injury, and to maintain stability. The optimal protective position of the elbow is dictated by the extent of the injury, the surgical procedure, the elbow’s stability, and the surgeon’s preference. Several orthosis options may be considered. Typically, the protective orthosis is worn full time and is removed only for exercise and wound care. It may be static or hinged, with or without motion blocked. Elbow dislocations that are stable after reduction are typically treated with protected mobilization, positioned in 90 degrees of flexion between exercise sessions for 1 to 2 weeks. A hinged orthosis with an adjustable block that limits elbow extension provides stability while allowing motion. It may be indicated for humeral fractures, elbow dislocation, fractures of the radial head and neck, and injury of the brachialis. The hinged orthosis should block extension at the appropriate angle, as determined by the surgeon, to protect the reduction for 2 weeks ( Fig. 79-6 ). Later, more extension is allowed. Elbow flexion and forearm pronation and supination may or may not be restricted, depending on the injury.
The specific elbow fracture dictates the type of orthoses required. For example, type I radial fractures may only need to be immobilized in a sling for comfort. A progressive static orthosis may be initiated in the inflammatory phase, again depending on the extent of the injury and joint or fracture stability to prevent the loss of motion. Table 79-1 presents information regarding the types of orthoses and the positions recommended for specific fractures and dislocations.
|Injury||Nonoperative Treatment||Nonoperative Orthosis||Operative Treatment||Postoperative Orthosis||Considerations/Complications|
|Distal Humeral Fractures|
|Immobilization for minimal to absent displacement||LAS for 7–10 days with elbow in 90 degrees flexion, forearm pronated, and wrist flexion to 30 degrees||ORIF (may repair collateral ligament)||LAS as in nonoperative management, may wear for up to 4 weeks||If fragment is large, can be associated with elbow dislocation: if MCL is repaired, more difficult to regain motion; ulnar nerve neuropathy|
|Closed reduction||LAC/LAS: Same as immobilization but may wear for up to 5 weeks|
|Lateral epicondyle||Immobilization for minimal to absent displacement||LAS for 7–10 days with elbow in 90 degrees flexion, forearm supinated, and wrist extension to 30 degrees||ORIF (may repair collateral ligament)||Las as in nonoperative management, may wear for up to 4 weeks||Cubitus valgus deformity; ulnar nerve neuropathy; rare in adults|
|Closed reduction||LAC/LAS: Same as immobilization, but may wear up to 4 weeks|
|Immobilization for nondisplaced to minimally displaced fracture||LAC for 1–2 weeks with elbow in 90 degrees flexion, forearm neutral/pronated, and wrist in extension||Perculaneous pinning||LAC/LAS for 2–6 weeks with elbow in 90 degrees flexion, forearm neutral/pronated, and wrist in extension||Brachial artery and all three major UE nerves subject to trauma; significant edema often noted|
|Closed reduction||LAC for 2–4 weeks with elbow flexed 10 degrees less than loss of radial pulse (at least 95–100 degrees), forearm neutral/pronation, and wrist in extension||ORIF||LAC/LAS for 1–2 weeks with elbow in 90 degrees flexion, forearm neutral, and wrist in extension|
|Flexion high/low||Immobilization||LAC for 1–6 weeks with elbow flexed to 90 degrees, forearm in supination, and wrist neutral||Percutaneous pinning||LAC for 1–4 weeks with elbow in 90 degrees flexion, forearm supinated, and wrist in extension|
|Closed reduction||LAC for 2–4 weeks with elbow fiexed 75–100 degrees, forearm neutral/supinated, and wrist in extension||ORIF||Same as above|
|Abduction and adduction (transcondylar)||Closed reduction||LAC for 2–6 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Percutaneous pinning||LAC for up to 3 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Common in elderly|
|ORIF||Same as above|
|Closed reduction||LAC for 2–4 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Percutaneous pinning||LAC for 3–4 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Potential for neurovascular injury; compartment syndrome; injury to brachial artery; injury to median, radial, or ulnar nerves; significant edema often present|
|Olecranon traction||2 weeks traction f/b 2–3 weeks; LAS with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||ORIF||LAC/LAS for up to 3 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral|
|Bag of bones||Collar and cuff technique up to 6 weeks||Total elbow replacement|
|Immobilization||LAC/LAS for 4–5 weeks, with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Percutaneous pinning||LAC/LAS for 1–4 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||Uncommon fracture: fracture fragment often has soft tissue attachment; ulnar nerve neuropathy|
|Closed reduction||LAC/LAS for 4–5 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral||ORIF||LAC/LAS for 4–5 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist neutral|
|Capitellum fracture (rare)||Closed reduction, type I||LAC for 3–4 weeks with elbow in 90 degrees flexion, forearm neutral, and wrist neutral; avoid full extension and pronation with AROM||ORIF types II and III||LAC for up to 3 weeks with elbow in 90 degrees flexion, forearm neutral, and wrist neutral||Avascular necrosis; ruptured UCL; capsular and ligamentous injury restriction motion; associated injuries of radial head, wrist, and ligaments|
|Trochlear fractures (rare in isolation—often associated with coronal fracture of capitellum)||Closed reduction—difficult to achieve and maintain||LAC for up to 5 week with elbow in 90 degrees flexion, forearm neutral, and wrist neutral||Excision of small fragments||LAS for 3–5 day with elbow in 90 degrees flexion, forearm neutral, and wrist neutral; if motion does not begin early, dense adhesions form|
|ORIF (with or without distraction device)||LAC/LAS for up to 3 weeks with elbow in 90 degrees flexion forearm neutral, and wrist neutral|
|Radial Head Fractures|
|Type I||Nonoperative||Sling/LAS for pain reduction, but motion begins as soon as tolerated (days 1–4)||Concornitant Essex–Lopresti lesion; decreased strength; proximal radioulnar synostosis; late development of radial tunnel syndrome; MCL tear causes joint instability; forearm rotation can be painful|
|Type II and III||Nonoperative (type II only)||LAS for 2–3 weeks with elbow in 90 degrees flexion, forearm neutral, and wrist neutral||Fragment excision (rarely, recommended)||LAC/LAS for up to 3 weeks elbow in 90 degrees flexion, forearm midpronation, and wrist neutral|
|Excision radial head||As above|
|Type I||Nonoperative||LAC/LAS for 2–3 weeks with elbow in 45 to 70 degrees flexion, forearm neutral, and wrist neutral||Extension loss; ulnar nerve neuropathy; nonunion possible; protection may be needed. If triceps repaired directly; fracture/dislocation cases cause severe bone and soft tissue damage; post-traumatic arthritis|
|Type II||ORIF||LAC/LAS for 2–3 weeks with elbow flexed to 45–70 degrees, neutral forearm and wrist.|
|Excision and reconstruction of triceps||Limit extremes of elbow flexion for 4 weeks|
|Type III||ORIF||As per ORIF for type II|
|Type I||Nonoperative||Hinged elbow splint with blocks as needed to prevent recurrent dislocation||Associated with elbow dislocations|
|Type II||ORIF||LAC/LAS for 2–3 weeks with elbow in 90 degrees flexion, forearm neutral, and wrist neutral|
|Type III||ORIF||As above|
|Hinged external flxator|
|Posterior dislocation||Closed reduction||LAS for 3–6 weeks with elbow flexed to 90 degrees and full pronation or hinged orthosis with extension block at desired position||Acute ligament repair||LAS for 2–4 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist free||Associated fractures are common; extensive edema; potential for neurovascular injury; MCL may rupture; triceps insertion may be stripped for anterior dislocation|
|Anterior dislocation (very rare)||Closed reduction||LAS for 3–6 weeks with elbow flexed to 90 degrees and full pronation or hinged orthosis with extension block at desired position||Acute ligament repair||LAS for 2–4 weeks with elbow flexed to 90 degrees, forearm neutral, and wrist free|