Elbow Fractures

Post-op (ORIF) and Conservative Care

Liz Hoffman, Alli Horning, Ana Livecchi, Madelyn Wilkinson

Surgical Procedure
General Points (Giangarra et al. 2018)

● Rarely treated nonoperatively

● Usually fixed via open reduction internal fixation (ORIF) with plates and screws
● Can also use intramedullary (IM) devices
● Patients leave surgery with possible immobilization of arm until sutures are removed

Procedure (The Johns Hopkins University 2021)

● Details of surgery depend on location and severity of the injury

● Pt. will receive general anesthesia
● Surgeon will clean the affected area and will make an incision through the skin and muscle of the elbow (site is specific to the injury)
● Surgeon will bring the bone pieces back into alignment (reduction)
● Surgeon will secure the pieces to each other (fixation) using screws, metal plates, wires, or pins
● Surgeon will make any other necessary repairs
● Surgeon will surgically close the layers of skin and muscle once the bone is secured
Post-Operative Precautions
Varies between surgeons/hospitals - PT should follow the directions of the referring
surgeon

General Guidelines (Giangarra et al. 2018)

● Forearm immobilization
● Non weight bearing or 5 lb weight restriction
● No repetitive forearm twisting
● ROM of fingers only (until week 2-6)
 Radial Head Therapy Guidelines
Fracture for Rehabilitation
(without assoc. ligamentous injury or repair)
Phase 1: Weeks 0-2
● Expected Impairments/Limitations: ● Goals:
○ Radial head ORIF immobilized in splint for 1-2 weeks ○ Decrease pain
■ Sling if necessary for comfort ○ Decrease edema
○ Pain ○ Achieve beginning ranges of elbow range of
○ Limited ROM at the affected elbow
motion
○ Maintain range of motion for adjacent joints

● Therapeutic Procedures:
○ Start ROM first postoperative day if tolerable
○ Elbow active and active-assisted flexion and
● Rationale:
extension ROM ○ Begin achieving normal range of motion within
○ Varus/Valgus stress avoided by performing ROM close elbow joint
to body ○ Enable patient to return to sport and/or
○ Avoid flexion when pronated previous activities
○ Maintain motion of adjacent joints
Sample Exercise Plan - Phase I
● Walking Program
○ Increase and/or maintain cardiovascular fitness
○ 25 minutes, 5x per week
● Range of motion:
○ Shoulder:
■ Pendulums
● ~5 minutes, 1-2x per day
○ Elbow:
■ Self-assisted AAROM
● 2x10 repetitions, 1x per day
○ Wrist:
■ Wrist alphabets:
● 2x15 repetitions, 1-2x per day
○ Hand:
■ Towel scrunches:
● 2x15 repetitions, 1-2x per day
Phase II: Weeks 2-6
● Expected Impairments/Limitations:
○ Sutures or staples removed at ~2 weeks
○ Pain
○ Continued limited ROM at the affected elbow
○ Weight lifting/bearing restrictions
● Therapeutic Procedures:
○ Phase I exercises continued and progressed
when appropriate
■ Maintain ROM at adjacent joints
○ Begin light strengthening exercises in elbow
and adjacent joints if cleared by surgeon
● Goals:
○ Decrease pain
○ By week 6, achieve full elbow flexion and extension
range of motion
○ Decreased weight lifting/bearing restrictions by surgeon
○ Maintain range of motion and strength in adjacent joints
● Rationale:
○ Achieve and maintain normal range of motion within
elbow joint
○ Bony healing typically complete by 6 weeks
○ Enable patient to return to sport and/or previous
activities
Sample Exercise Plan - Phase II
● Continued/progressed walking program
● Strengthening:
○ Increase and/or maintain cardiovascular fitness
○ 30 minutes, 5x per week ○ Elbow isometrics:
● ROM: ■ 4x15 holds in each position, 1-2x per day
○ Shoulder: ○ Wrist isometrics:
■ Pendulums - out of sling ■ 4x15 holds in each position, 1-2x per day
● ~5 minutes, 1-2x per day
○ Hand/grip:
■ Table or wall slides
● 2x15 repetitions, 1-2x per day ■ ~5 minutes of stress ball or theraputty
○ Elbow: squeezes, 1-2x per day

○ Wrist:
■ Wrist alphabet
● 3x15, 1-2x per day
■ Hand flips:
● 2x10 repetitions, 1-2x per day
○ Hand:
■ Continue towel scrunches
● 2x10, 1-2x per day
Phase III: Weeks 6 and Beyond
● Expected Impairments/Limitations:
○ Minimal
■ May still have some limitations in
range of motion or pain
● Therapeutic Procedures:
○ Previous exercises continued and/or
progressed appropriately
○ Additional strengthening exercises
○ Exercises that prepare individual to return
to prior activities
● Goals:
○ Minimal pain
○ By week 8, full elbow flexion,extension, pronation
and supination range of motion achieved
○ No weight lifting/bearing restrictions
○ Complete bony union
● Rationale:
○ Achieve and maintain normal range of motion
within elbow joint
○ Bony healing typically complete by 6 weeks
○ Enable patient to return to sport and/or previous
activities
Sample Exercise Plan - Phase III
● Continued/progressed walking program
○ Increase and/or maintain cardiovascular fitness
○ 30 minutes, 5x per week
● Strengthening:
○ Shoulder:
■ Planks on forearms:
● 4x30sec holds
■ Resistance Band extension:
● 3x10 repetitions, 1-2x per day
■ Resistance Band rows:
● 3x10 repetitions, 1-2x per day
○ Elbow:
■ Bicep curls with dumbbell weight:
● 2x15 repeititons
■ Resisted pronation and supination:
● 2x10 repetitions
○ Wrist:
■ Wrist alphabet with dumbbell
weight:
● 2x15, 1-2x per day
■ Wrist eccentrics with dumbbell:
● 2x10 repetitions, 1-2x per day
○ Hand:
■ Resisted Finger Extension/Flexion
with rubber band:
● 2x15 repetitions, 1-2x per day
■ Grip squeezes with stress ball or
theraputty:
● ~5 minutes, 1-2x per day
 Therapy
Olecranon
Guidelines for
Fractures
Rehabilitation
Phase I - 0-2 Weeks
● Posterior splint placed for 1-2 weeks
○ Splint is used to immobilize at roughly 45 - 90 degrees of elbow flexion
● Gentle passive and active-assisted ROM started when splint is removed
● Utilize ice to manage edema
Sample Exercise Plan - Phase 1
- Active wrist range of motion
- Throughout the day or focused sets of 30 seconds / 2-3x a day
- Active shoulder range of motion
- Throughout the day or focused sets of 30 seconds / 2-3x a day
- Shoulder isometrics in neutral
- Except external rotation
- 2 sets of 20 second holds for all directions / 1-2x a day
- Theraputty gripping
- 3 sets of 30 seconds / 1-2x a day
- Passive elbow range of motion
- 30-100 degrees, greater extension is acceptable
- 3 sets of 30 seconds / 1-2x a day
Phase II - 2-6 weeks
● Sutures or staple removed at ~2 weeks
● Continue gentle movement of elbow
● No resistance exercises
● Maintain ROM of shoulder, wrist and fingers
● Throughout the weeks the brace will be open to full range of motion with no
restrictions
Sample Exercise Plan - Phase 2
- Elbow range of motion active and passive
- 3 sets of 30 second holds / 3-4x a day
- Elbow range - 15-105 degrees at week 3 / 0-125 degrees at week 4 / full at week 5
- Shoulder range of motion
- Tubing ER/IR
- Lateral raises
- 3 sets of 30 second holds / 2-3x a day
- Scapular strengthening with addition of rotator cuff movements as
tolerated
- Unweighted I / Y / T
- 2 sets of 15 / 1-2x a day
- Light resistance exercises
- Wrist curls / extension / pronation / supination
- Elbow extension
- Start with 1lb and progress as tolerated
- 2 sets of 12 / 1x a day
- Throwers 10 program can be utilized if appropriate
Phase III - 6 weeks and beyond
● Once confirmed bony union has been achieved, gentle and progressive resistance
exercises initiated
● Weight bearing restrictions decreased with bony union achievement
● Work on regaining preoperative ROM
Sample Exercise Plan - Phase 3
- Introduce plyometric exercise
- Chest pass or side toss
- 2 sets of 10 on both sides
- Strengthening
- Wrist / hand
- Weighted supination / pronation / flexion / extension
- 2 sets of 10 for all directions
- Gripping exercises
- 3 sets of 30 seconds
- Elbow
- Eccentric and concentric motions
- 3 sets of 12 with weight as tolerated
- Shoulder
- Throwers 10 (if appropriate)
- Resisted rows / lateral raises / IR / ER
- Closed chain
- BOSU ball planks with extended forearm
- Push ups
- Range of motion
- Progress range of motion activity and passively until full elbow range
 Therapy
Supracondylar
Guidelines for
Fractures
Rehabilitation
Phase I - 0-6 Weeks
Weeks 0-1: no formal PT for wound healing

Weeks 1-6: Begin formal PT

● Range of motion: PROM → AAROM → AROM

elbow and forearm
● Strengthening: shoulder, scapular, forearm
isometrics

(Rao, 2021)
Sample Exercise Plan - Phase I
- Active wrist range of motion
- Flexion, extension
- Perform frequently throughout the day, at least 3x/day
- 2x 10 reps
- Active-assisted elbow range of motion
- Flexion and extension, assist with unaffected arm
- 1-2x/day, 2x 10 reps
- Shoulder isometrics in neutral
- Flexion, extension, abduction
- 1-2x/day, 2x 10 reps
- Scapular isometrics in neutral
- Retraction
- 1-2x/day, 2x 10 reps
- Wrist isometrics
- Flexion, extension
- 1-2x/day, 2x 10 reps
(Supracondylar Elbow Fracture, 2021)
Phase II - 6-12 Weeks
Range of motion

● Aggressive passive stretching at end ranges

○ Elbow and forearm
● Active range of motion
● Pain-free

Strengthening

● Isometrics with band/weights with elbow in brace

○ Shoulder, scapula, forearm

(Rao, 2021)
Sample Exercise Plan - Phase II
- Elbow range of motion active and passive - Scapula isometrics with theraband (elbow in
- Flexion, extension brace)
- Passive: 3x/day, 2 sets 30 second holds; followed by… - Retraction
- Active: 3x/day, 2x 10 reps - 3x/week, 3 sets 10 reps
- Forearm range of motion active and passive - Forearm isometrics with 1 lb weight (elbow in
- Flexion, extension, pronation, supination
-
brace)
Passive: 3x/day, 2 sets 30 second holds; followed by…
- Wrist flexion, extension
- Active: 3x/day, 2x 10 reps
- 3x/week, 3 sets 10 reps
- Shoulder isometrics with 2 lb weight (elbow in
- Global program of patient’s choice
brace) - Work up to 5x/week, 30 min of moderate intensity
- Flexion, extension, abduction, internal rotation, exercise
external rotation
- 3x/week, 3 sets 10 reps

(Rao, 2021)
Phase III - 3-12 Months
Range of motion
● Unrestricted passive and active stretching at end ranges as tolerated

Strengthening
● Continue exercises with bands/weights
● Introduce eccentrically resisted motions and closed chain upper extremity/forearm
strengthening

4 months: progress to sport-/job-specific exercises

● Resume lifting once full strength and adequate healing is achieved (approx. 6-9 months)

(Rao, 2021)
Sample Exercise Plan - Phase III
- Range of motion
- Continue to progress passive and active motion to full pain-free
range
- Strengthening
- Planks: 3x/week, 4x 15 second holds
- Prone T’s with 1 lb weight: 3x/week, 3x 10 reps
- Eccentrically resisted, with 2 lb weight, elbow extension:
3x/week, 3x 10 reps
- Resisted, with 1 lb weight, pronation/supination: 3x/week, 2x 10
reps
- Eccentrically resisted, with 1 lb weight, wrist flexion/extension:
3x/week, 3x 10 reps
- Global program
- Continue with patient’s selected global exercise
Prognosis and Return to Sport/Activity Decision
- Most patients return to their normal activities within 4 months (Elbow [Olecranon]
Fractures, 2021)
- Full healing can take > 1 year
- Some patients report limitations with movement, even after their elbow has
healed (Elbow [Olecranon] Fractures, 2021)
- Patients typically show continued improvement over time
- Criteria to return to lifting:
- Full strength of involved arm is achieved (Rao, 2021)
Questions
1. True/False: elbow fractures are typically treated nonoperatively.
2. What are the post op precautions for elbow ORIF?
3. How long does it take to fully heal from an elbow fracture?
References
Elbow (Olecranon) Fractures . OrthoInfo. (2021). Retrieved November 14, 2021, from
https://orthoinfo.aaos.org/en/diseases--conditions/elbow-olecranon-fractures/.
Giangarra, C. E., Manske, R. C., Brotzman, S. B. (2018). Clinical Orthopaedic Rehabilitation A Team Approach. Elsevier
Keyword Analysis & Research: OLECRANON ORIF. free invisible hit counter. (n.d.). Retrieved November 13, 2021, from
https://www.bethanne.net/search/olecranon-orif.
Rao, A. (n.d.). Distal Humerus Open Reduction Internal Fixation (ORIF). (2021). The Christ Hospital. Retrieved November
14, 2021, from https://www.link-de.com/search/distal-humerus-fracture-protocol.
Supracondylar Humeral Fracture. Physiopedia. (2021). Retrieved November 14, 2021, from https://www.physio-
pedia.com/Supracondylar_Humeral_Fracture.
The Johns Hopkins University. (2021). Elbow Fracture Open Reduction and Internal Fixation. Johns Hopkins Medicine.
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/elbow-fracture-open-reduction-and-inter
nal-fixation