‫بسم هللا الرحمن الرحيم‬

REHABILITATION OF ELBOW
FRACTURES
Distal Humeral Fractures
Olecranon Fractures
 Distal Humeral Fractures
Definition
Fractures of the distal humerus involve the metaphysis. They may or
may not extend into the intraarticular surface.
Lateral condyle fracture of the
distal humerus. This is an
intraarticular single-column
Y intracondylar fracture of the distal
Oblique supracondylar. This fracture
humerus. This is a two-column
is extraarticular and extracapsular.
fracture
Displaced transcondylar fracture. This is Lateral illustration of a transcondylar fracture bordering on a
an intracapsular extraarticular fracture. supracondylar fracture. This fracture is extraarticular
Mechanism of Injury
Intraarticular fractures result from compression forces across the
elbow in combination with a varus or valgus stress concentrate the
force to either the medial or lateral column of the distal humerus.
Supracondylar or transcondylar fractures (the most common
extraarticular injury) generally result from a fall on an outstretched
hand or a direct blow to the elbow.
 Treatment Methods
Cast or Posterior Splint
A long arm cast or posterior long arm splint is indicated for:
•Nondisplaced fractures of the distal humerus
•Displaced fractures able to closed reduction.
In nondisplaced injuries, the extremity is immobilized for 2 to 3 weeks,
followed by supervised active range of motion for another 4 to 6 weeks.
For displaced fractures following closed reduction, immobilization is
usually required for 4 to 6 weeks and rehabilitation of the elbow is
started only when radiographic evidence of healing and clinical stability is
present.
The use of a hinged cast or functional brace should be considered
when mobilization begins.
Open Reduction and Internal Fixation
Open reduction and internal fixation is the method of choice for open
fractures.
 Rehabilitation goals
A- Range of Motion
Restore and maintain the full range of motion of the elbow.
Protect the normal carrying angle of the elbow.
Reestablish the full range of shoulder and hand motion.
B- Muscle Strength
Improve the strength of the following muscles: Elbow extensor, Elbow flexor,
Forearm supinators and pronators, Wrist extensors, Wrist flexors, Deltoid.

Expected Time of Bone Healing

•8 to 12 weeks.

Expected Duration of Rehabilitation

•12 to 24 weeks.
 Associated problems
The most common complication of fractures around the elbow are :
1. Ischemic contracture (Volkmann contracture) due to
damage/occlusion to the brachial artery and resulting in volar
compartment syndrome.
2. Neuropraxia to the ulnar nerve (most common), median nerve, or
radial nerve.
3. Malunion resulting in cubitus varus (varus deformity of the elbow).
4. The development of myositis ossificans.
5. The production of excess callus.

Full extension of the elbow is the hardest to

achieve.
 TREATMENT
Treatment: Early to Immediate (Day of Injury to One Week)

BONE HEALING
Stability at fracture site: None.
Stage of bone healing: Inflammatory phase.
X-ray: No callus.
 Prescription
Precautions:
A. No internal or external rotation of the shoulder.
B. No passive range of motion to the elbow.
C. No pronation or supination.
• Range of Motion: Gentle active elbow flexion and extension allowed
for stable fractures treated with open reduction and internal fixation.
No range of motion to the elbow if treated by other methods.
• Muscle Strength: No strengthening exercises to the elbow.
• Functional Activities: The uninvolved extremity is used in self-care
and personal hygiene.
• Weight bearing : None.
 Treatment: Two Weeks
BONE HEALING

Stability at fracture site: None to minimal

Stage of bone healing: begin to reparative phase.
X-ray: No to early callus. (Visible fracture line)
 Prescription
Precautions: No internal or external rotation of the shoulder.
•No passive range of motion to the elbow
•No pronation or supination except for internal fixation

Range of Motion:
Gentle active elbow flexion and extension allowed for fractures only when
treated with open reduction and internal fixation.
Gentle assistive supervised active flexion and extension for non-displaced
stable fractures.

Muscle Strength: No strengthening exercises to the elbow.

Functional Activities: continue the previous weeks.
Weight bearing: None.
open reduction and internal fixation
 Treatment: 4 to 8 Weeks
BONE HEALING

Stability at fracture site: Become stable once callus is observed

Stage of bone healing: Reparative phase.
X-ray: Bridging callus is visible.
 Prescription
Precautions: Avoid rotational stresses across the elbow.
Range of Motion:
Active flexion and extension to the elbow.
Avoid passive range of motion to reduce the risk of myositis ossificans

Muscle Strength: begin isometric strengthening exercises to the elbow at 6

weeks.

Functional Activities: The patient uses the affected extremity for some self-
care and personal hygiene.

Weight bearing: None.

 Treatment: 8 to 12 Weeks
BONE HEALING
Stability at fracture site: Stable. Discontinue bracing, splinting, and
sling with radio graphic evidence of union as early as 8 weeks.

Stage of bone healing: Remodeling phase.

X-ray: Callus is present but less than in mid-shaft.

•The fracture line begins to disappear.
 Prescription

Precautions: Avoid heavy lifting or pushing.

Range of Motion: Active and passive range of motion to the elbow

Muscle Strength: Progressive resistive exercises to the elbow

musculature.

Functional Activities: The involved extremity is used in self-care and

functional activities.

Weight bearing: Full weight bearing by 12 weeks.

 Olecranon Fractures
An olecranon fracture involves the proximal end of the ulna.
It may be extraarticular or intraarticular, Displaced or nondisplaced,
transverse, oblique, comminuted, stable, or unstable.

Intraarticular fractures account for the majority of olecranon

fractures and are generally associated with joint effusions and
hematomas.
Extraarticular fractures include avulsion fractures and are most
commonly seen in the elderly.
Olecranon fractures may cause disruption of the extensor mechanism.
•To test this, the patient should be asked to attempt extension of the
elbow against gravity. If the patient is unable to do this, the extensor
mechanism is interrupted and will require operative repair.
• Olecranon fractures may be associated with coronoid fractures as
well as elbow fracture/dislocations.
 Mechanism of Injury
Direct blows are the most common injuries to the olecranon

Falls on an outstretched hand with the elbow in flexion, leading to

contraction of the triceps.

High energy trauma, such as a car accident, may also cause an

associated radial head fracture or elbow dislocation.
 Special Considerations of the Fracture
Age
•Elderly patients are more at risk for development of joint stiffness secondary
to the fracture

Articular Involvement
•With intraarticular fractures, posttraumatic degenerative changes can be
problematic, causing pain and limitation of motion, but they are not common.

Associated Injury
•Ulnar nerve neuropraxia or injury has been reported in approximately 2% to
10% of olecranon fractures.
 Treatment Methods

Closed Reduction and Splint or Cast

•Used for non-displaced, stable fractures.

Open Reduction and Internal Fixation

•Used for displaced and comminuted fractures.

Time of Bone Healing

• 10 to 12 weeks.

Expected Duration of Rehabilitation

• 10 to 12 weeks.
 TREATMENT
Treatment: Early to Immediate (Day of Injury to One Week)
BONE HEALING

Stability at fracture site: None.

Stage of bone healing: Inflammatory phase.
X-ray: No callus.
 Prescription
Precautions: Avoid premature elbow motion.
Range of Motion: No range of motion to the elbow or wrist in a cast or
splint.
•Gentle active elbow flexion and active range of motion to the wrist if
treated surgically.

Muscle Strength: No strengthening exercises to the elbow.

•3 to 4 days after fracture, isometric exercises to the wrist within the cast.

Functional Activities: The uninvolved extremity is used in self-care and

personal hygiene.
Weight bearing : None.
 Prescription
Precautions: Avoid premature elbow motion.
Range of Motion:
No range of motion to the elbow or wrist in a cast or splint.
Gentle active elbow flexion and active range of motion to the wrist if
treated surgically.

Muscle Strength: No strengthening exercises to the elbow.

•3 to 4 days after fracture, isometric exercises to the wrist within the cast.

Functional Activities: The uninvolved extremity is used in self-care and

personal hygiene.

Weight bearing : None.

 Treatment: Two Weeks
BONE HEALING

Stability at fracture site: None to minimal

Stage of bone healing: begin to reparative phase.

X-ray: No to early callus. (Visible fracture line)

 Prescription
Precautions: Cast or splint: no extension to the elbow less than 90
degrees.
Range of Motion: the same as previous weeks.
Muscle Strength:
•No strengthening exercises to the elbow in extension.
•Isometric exercises to the elbow in flexion in a cast.
•Isometric exercises to the wrist.

Functional Activities: The uninvolved extremity is used in self-care and

personal hygiene.

Weight bearing: None.

 Treatment: 4 to 6 Weeks
BONE HEALING
Stability at fracture site: Become stable once callus is observed
Discontinue bracing, .splinting, and sling with radiographic evidence of
union.

Stage of bone healing: Reparative phase.

X-ray: Bridging callus is visible

 Prescription
Precautions: Avoid passive range of motion at the elbow.

Range of Motion: Encourage active range of motion to the elbow in

flexion and extension.

Muscle Strength: Isometric exercises to the elbow and wrist in flexion

and extension.

Functional Activities: The patient uses the affected extremity for

stability and light self-care.

Weight bearing: None.

 Treatment: 6 to 8 Weeks
BONE HEALING

Stability at fracture site: With bridging callus, the fracture is usually

stable.

Stage of bone healing: reparative phase.

X-ray: Bridging callus is visible

 Prescription
Precautions: None.

Range of Motion: Active to active-assistive range of motion in all

planes to the elbow and wrist.

Muscle Strength:
•Resistive exercises to the elbow and wrist.

Functional Activities: The patient uses the involved extremity for

personal hygiene and self-care.

Weight Bearing: Gradual weight bearing is allowed.

 Treatment: 8 to 12 Weeks
BONE HEALING
Stability at fracture site: Stable.
Stage of bone healing: Remodeling phase.
X-ray: More Callus is seen
Prescription
Range of Motion: Full active range of motion in all planes to the elbow
and wrist.
Muscle Strength: Progressive resistive exercises to the elbow
musculature.
Weight bearing: Full weight bearing by 12 weeks.
 References
1. David J. Magee, Pathology and Intervention in Musculoskeletal
Rehabilitation , 2nd ed. 2016
2. Rehabilitation for the Postsurgical Orthopedic Patient, 3rd Edition.
2013
3. Treatment and Rehabilitation of Fractures. 2000
4. David J. Magee , Orthopedic Physical Assessments Atlas And Video:

5. Selected Special Testes and Movements , 5th ed. 2011

6. James Wyss, Therapeutic programs for musculoskeletal disorders
.2013