Treatment Guidelines for Elbow Fractures

American Society of Hand Therapists

DEFINITION
An elbow fracture is defined as a break in the continuity or structural integrity of the distal humerus, proximal ulna or the proximal radius. These fractures can take many configurations surrounding and possibly involving the elbow joint. Injuries of adjacent soft tissue components, including neurovascular structures, joint capsule and ligamentous structures, may occur concurrent with the fracture, and present the need for clinical attention.

Treatment Guidelines for Elbow Fractures

ETIOLOGY/INCIDENCE
Elbow fractures are an acquired condition involving a break in the integrity of the distal humerus, proximal ulna or the radial head and/or neck. Approximately 7 percent of all fractures treated are classified as elbow fractures. Among these, approximately 33 percent involve the distal humerus.11 Twenty percent of all elbow fractures in adults involve the proximal ulna and olecranon and 50 percent involve the proximal radius.10

Elbow Fractures Guidelines Authors Peggy Boineau, OTR, CHT (sub-chair) Romina Astifidis MS, PT, CHT (chair) Sylvia Boddener, B.Sc., B.H.Sc. (OT), OTReg, (Ont), CHT Gregory Alan Hritcko, MS, OTR/L, CHT Sarah Teague Johnson, OTR/L, CHT Mary Loughlin, OTR/L, CHT Stephanie Williams, OTR/L Special thanks to the following reviewers: Sylvia A. Davila, PT, CHT Aviva L. Wolff, OTR/L, CHT Thomas J. Graham M.D. Amy L. Barenholtz, OTR, CHT
Copyright, 2004 American Society of Hand Therapists. These guidelines are property of the American Society of Hand Therapists and cannot be reproduced without written consent from the ASHT. Date of publication, February 2004. These clinical policies represent the professional judgment of the authors as of the date of publication. These should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The final judgment regarding any specific procedure or treatment must be made by the hand therapist in light of all circumstances presented by the patient and the resources available.

ICD-9 CODES8
812.40-812.49 closed distal humeral fractures 812.41 supracondylar fx humerus, closed 812.42 fx humerus, lateral condyle, closed 812.43 fx humerus, medial condyle, closed 812.50-815.59 open distal humeral fractures 812.51 supracondylar fx humerus, open 812.52 fx humerus, lateral condyle, open 812.53 fx humerus, medial condyle, open 813.00-813.08 closed proximal radius/ulna fractures 813.01 fx olecranon process ulna, closed 813.02 fx coranoid process ulna, closed 813.03 Monteggias fx, closed 813.05 fx radius head, closed 813.06 fx radius neck, closed 813.10-813.18 open proximal radius/ulna fracture 813.11 fx olecranon process ulna, open 813.12 fx coronoid process ulna, closed 813.13 Monteggias fx, open 813.15 fx radius head, open 813.16 fx radius neck, open

American Society of Hand Therapists February, 2004

SETTING
Generally, patients treated with closed reduction or open surgical reductions are seen in an outpatient therapy clinic. Those treated with open surgical reduction or external fixation with indications for early mobilization may be seen in an inpatient therapy clinic.

MODIFIERS TO OUTCOME
The following variables may affect the functional outcome of the upper extremity: age, co-existing medical conditions, delayed fracture reduction or surgical intervention, length of post-operative immobilization, patient compliance, mental status, quality of rehabilitation, associated injuries (e.g. elbow instability, other fractures, neurovascular involvement, complexity of the fracture, ligament involvement), and patients daily function demands (low or high demand elbow).

INTENSITY, FREQUENCY, AND DURATION OF TREATMENT

Treatment is dependent upon severity of etiology, method of reduction, severity of symptoms, and other modifiers. Due to the tendency of the elbow to become stiff, early and intense rehabilitation is often critical to restore motion. Treatment often begins within the first several days post injury but occasionally may be delayed as late as 3 weeks depending on the stability of the elbow. Frequency of visits can range from 1 to 5 visits per week and is determined by the parameters mentioned above and timing in the healing process. Typical treatments range 45-90 minutes per session. Overall duration of treatment is 3-6 months from the date of injury.

GENERAL COMPLICATIONS11,2
1) Motion loss or stiff elbow, often due to capsular contraction 2) Failed fixation or hardware prominence 3) Delayed union, malunion or non-union 4) Heterotopic ossification (HO) 5) Post-traumatic arthritis 6) Medial collateral ligament disruption or joint instability 7) Ulnar nerve neuropathy/ Radial nerve dysfunction 8) Infection or wound breakdown 9) Avascular necrosis 10) Recurrent dislocations 11) Elbow ankylosis 12) Myositis ossificans 13) Injury to the wrist and distal radioulnar joint with resultant wrist pain and limited forearm rotation

DIAGNOSTIC EVALUATION PERFORMED BY PHYSICIAN

Radiographic evaluation (x-rays, CT, MRI as needed) Assess wound status Neurovascular examination including angiographic evaluation as needed Assess esdema, point tenderness, crepitus, ROM and mechanical blocks to ROM Evaluation of soft tissue integrity and elbow stability Assess for risk of compartment syndrome Assess for associated injuries of the elbow and forearm Assess patient history and existing medical conditions that might affect treatment/care Assess patients daily function demands (i.e. high or low demand elbow)

REDUCTION TECHNIQUES
CASTING/SPLINTING

Nondisplaced or minimally displaced nonarticular injuries that are stable can be reduced and placed in protective splint or dorsal elbow cast. Immobilization for longer than 2 weeks is generally not recommended2 due to the tendency of the elbow to stiffen when immobilized even for a short time. Nondisplaced or minimally displaced fractures of the radial head can be treated with immobilization in a sling for a week followed by a range of motion program.2

OPEN REDUCTION INTERNAL FIXATION (ORIF)

ORIF is used for displaced open or closed fractures of the distal humerus, capitellum, trochlea and olecranon process, Type II displaced radial head fractures with mechanical motion block that is not reducible, and coronoid Type 3 fractures involving the base. ORIF is recommended for all condylar fractures and displaced Type I and Type II fractures. ORIF provides stable internal fixation to allow for an early postoperative range of motion program thereby minimizing elbow contracture.2
EXTERNAL FIXATION

of motion depending on stable arcs of motion. For example, end range extension may be blocked if the elbow becomes more unstable as it is moved into extension. Also, depending on ligament stability, rotation may need to be limited. If only the lateral collateral ligament is damaged, the elbow is more stable in pronation; if only the medial collateral ligament is damaged, the elbow is more stable in supination. If both are damaged, the forearm should be maintained in neutral.7 8. Defer strength evaluations and avoid lifting or resistive activities. 9. Protect repaired soft tissue structures. Secondary Stage: (2-8weeks) 1. Protect structures including ligaments using appropriate splinting (e.g. hinge splint). 2. Avoid overly zealous stretching and forceful passive manipulation, which may result in damage to soft tissue or heterotopic ossification.7 3. Defer strength evaluation further depending on fracture stability and ligamentous integrity. 4. Continue to avoid full motion if it is still contraindicated. Tertiary Stage: (8 weeks to 6 months) 1. Restrict medium to heavy lifts (over 50 lbs on occasional basis) depending on fracture healing. 2. Monitor radial head fractures for distal radioulnar joint disruption. 3. Monitor return to work/ADL/avocational activity to avoid undue stress to healing fracture site.

External fixation about the elbow is often used for force neutralization and distraction of a complex fracture- dislocation that is reconstructed. It is used for Type 3 coronoid fractures.3 May also be used in massive HO excisions where extensive soft tissue dissection, including resection of ossified ligamentous structures has taken place. Can also be used for resection arthroplasties after infections or massive bone losses.

GENERAL PRECAUTIONS
Relates to all reduction techniques. Stages often overlap. Primary Stage: (0-2weeks) 1. Ensure clear physician communication regarding injury, length of immobilization, treatment to date, and ROM parameters. 2. Monitor nerve function (sensory and motor) and avoid undue tension on nerve or nerve irritation. 3. Avoid irritation caused by cast/splint immobilization. 4. Avoid vascular compromise. 5. Monitor autonomic/sympathetic response to treatment. 6. Protect and monitor pin sites for infection and monitor wound closure. 7. Begin aggressive elbow flexion/extension and forearm rotation motion recovery program if appropriate, but limit elbow and forearm range

EVALUATION
Basic Principles: Obtain detailed medical history including mechanism of injury, medical management and precautions, contraindications, and complications. An operative note is helpful in determining type, severity, comminution of fracture and/or dislocation as well as associated

injuries including soft tissues. Also note surgical procedure, type and location of hardware and any mal-alignment issues and/or bony excision. Determine from physician or orders the stability of elbow and limits of fracture and/or soft tissue repair. More detailed evaluation techniques are noted below. Specifics of the evaluation vary dependent on type of reduction and stage of healing.

7) Function/Disability: Note limitations and/or substitutions in ADL, vocational and avocational interests; incorporate standard outcome measure such as DASH or SF-36 for patients perception of disability and function. Secondary Stage (2-8 weeks): As above and add: 1) Wound/Scar: note location, size, pigmentation, vascularity, pliability, and height. Also note if scar is hypersensitive, insensate, adhered/contracted, hypertrophic, or keloid. 2) Musculoskeletal: Measure active or activeassisted range of motion measurements within stable arcs of motion for elbow, forearm and wrist. Measure passive range of motion as appropriate and recommended by physician to assess for end feel and splinting requirements. Monitor/measure composite length of forearm musculature, triceps and biceps for shortening.7 Can test upper extremity strength using standard manual muscle testing when appropriate. Test grip and pinch when appropriate. Tertiary State (8 weeks to 6 months): As above and add: 1) Sensory: assess for permanent impairments and for adaptive splints/devices if necessary. 2) Function/Disability: Assess need for Functional Capacity Evaluation (FCE) and job site analysis as needed for return to work (RTW).

EVALUATION
Primary Stage (0-2 weeks): 1) Edema: Describe edema and note type. Take circumferential measurements around the elbow where appropriate. 2) Wound: Inspect skin especially as related to irritation due to splint/cast fit. Note type of fixation, type of wound closure and wound/graft size, color, drainage, odor, and temperature. Note fixation condition including signs of looseness or migration. 3) Musculoskeletal - Measure active (AROM) and passive (PROM) range of motion measurements of uninvolved joints e.g. shoulder, wrist and digits, to rule out associated limitations. Assess for adequate/prescribed post-operative immobilization. If appropriate, measure AROM and active-assisted range of motion (AAROM) of the involved joint within stable arc. 4) Vascular - Inspect hand and forearm for color, temperature and signs of compromised circulation or compartment syndrome. Assess and note pulses, capillary refill, and color. 5) Sensory/Motor - Assess sensation using appropriate tests including Semmes-Weinstein or two-point discrimination. Also, assess motor function to rule out ulnar or radial nerve disruption. Notify physician if abnormality is significant. 6) Pain - Assess and document the patients pain using standard assessments including McGill Pain Questionnaire, Modified Somatic Perception, Present Pain Index, Verbal Pain Score, Visual analog Pain Score and Scoreable Body Sketch.

TREATMENT GOALS
Primary Stage (0-2 weeks): 1. Protect healing structures and promote wound closure. 2. Decrease/prevent edema. 3. Decrease/control pain. 4. Maintain/restore ROM of uninvolved joints. 5. Educate patient in course of treatment and promote independence with precautions and home exercise program.

6. Promote independence with adapted ADLs. 7. Maintain strength of involved UE with isometrics, light gripping (when muscle contraction/ compression not contraindicated.) 8. Monitor sensory and motor nerve involvement associated with injury i.e. wrist drop or clawing. 9. Minimize formation of scar tissue using appropriate scar management techniques. 10. Initiate ROM of involved joint within limits of stability. Secondary Stage ( 2-8 weeks): 1. Increase active/passive range of motion of the elbow, forearm and wrist. 2. Increase function of involved UE with light activity. 3. Increase strength and endurance of involved UE with isotonic exercise. 4. Promote independence with splint wear, care and precautions if splinting is indicated. 5. Promote independence with ADLs and work using involved UE as an assist based on status of healing fracture. 6. Return to modified or regular duty as indicated for light and sedentary work. Tertiary Phase ( 2-6 months): 1. Maximize ROM of involved UE. 2. Maximize strength and endurance of involved UE. 3. Maximize function of involved UE - return to moderate, then heavy activity. 4. Return to modified or regular duty as indicated for heavy manual labor.

TREATMENT
Stages of healing can overlap and the duration of each stage can vary according to the type and severity of fracture. Primary Stage (0-2 weeks): 1) Splinting: Provide splint as appropriate. Generally, a long arm resting elbow splint that can be removed for exercise, wound care and hygiene is recommended. 2) Edema: Consider elevation, retrograde massage, compressive sleeves/wraps, intermittent compression, High Volt Galvanic Stimulation (HVGS), cold therapy. 3) Wound: Provide light dressings and appropriate ointments. Dressings should protect incision/fixation but allow motion. Signs of infection in the wound or pin sites should be reported to physician immediately. 4) Musculoskeletal: ROM: Begin A/AAROM/ controlled PROM exercises in flexion/extension and pronation/supination as recommended by physician. Flexion and extension exercises can be performed with patient in supine and shoulder flexed. This position allows for gravity assisted flexion and isolation of triceps. Emphasize elbow extension except if restricted by physician when triceps has been repaired. Limit rotation of forearm if there is collateral ligament damage. Instruct patient in ROM to all uninvolved joints (hand, wrist, shoulder) to prevent stiffness.

Strength - Non-resistive exercises may be used to increase endurance. Begin with gentle isometrics to the biceps, triceps, shoulder, and wrist if not contraindicated. Light gripping exercises can also be performed.
5) Pain: Decrease pain using appropriate modalities to include hot/cold treatments, Transcutaneous Electrical Nerve Stimulation (TENS) and modification of activity.

Secondary Stage (2-8 weeks) 1) Splinting: Provide hinged or resting splint if appropriate or indicated by the physician. Forearm motion restrictions or positioning may be included in the hinged splint depending on ligamentous damage. Later in this stage, may need to consider serial static, static progressive, or dynamic elbow splints to increase motion if appropriate and necessary. 2) Scar: Initiate scar massage when incision is dry and closed. Compression, silicone gel sheet or elastomer scar pad can be used to promote improved scar healing. 3) Musculoskeletal: monitor response to treatment to minimize inflammatory response

Tertiary (2-6 months) 1) Splinting: Continue resting splint or hinge splint as appropriate. Serial static/static progressive/dynamic splinting can be used as needed to improve motion. Static splinting at night can help maintain ROM without limiting function. 2) Musculoskeletal: ROM: Maintain or achieve maximal ROM of elbow and forearm including composite motion. Combining heat with low-load prolonged stretch followed by AROM can be effective to improve motion. Neuromuscular electrical stimulation (NMES) can be used to isolate muscle contraction. Proprioceptive neuromuscular facilitation (PNF) techniques such as contractrelax and muscle energy techniques can be used to facilitate motion. Joint mobilization and myofascial soft tissue mobilizations can be used to increase motion only after proper union has been achieved with permission from physician.

ROM- Apply heat packs/ Fluidotherapy prior to treatment as needed to promote increased flexibility. Perform AROM and AAROM exercises with high repetitions and minimal force of contraction. Emphasize elbow extension, except if restricted by MD or contraindicated by diagnoses. Composite stretching exercises for the forearm flexor and extensor compartments should be added, but performed in protected elbow flexion. PROM can be added per physician but must be applied slowly, gently, within tissue tolerance, and on a relaxed patient. Gentle prolonged end-range stretch is most effective in permanent changes in tissue. Stretching should only cause mild discomfort as pain will inhibit relaxation and cause co-contraction. Light functional activities can be performed to increase desired motion. Strength: Initiate isotonic strengthening, muscle conditioning, and endurance exercise with low resistance, high reps to biceps, triceps, pronators/supinators, wrist flexors/extensors when appropriate.
4) Pain: Re-evaluate pain as severe unremitting pain may indicate a structural problem or nerve compression. 5) Function: Resume light ADL activity with lifting restrictions per physician.

Strength: Strength and endurance can be increased using isotonic exercises to include weights, pulleys and Theraband/Theratubing
3) Initiate work simulation/conditioning or leisure simulation for full return of function.

REFERENCES
REFERENCES
1) Barenholtz, A., Wolff, A. Elbow Fractures and Rehabilitation. Orthopedic Physical Therapy Clinics of North America, Dec.2001. 2) Beredjiklian, Pedro K.: Management of fractures and dislocations of the elbow. In Mackin, Callahan, Skirven, Schneider, Osterman editors: Rehabilitation of the Hand and Upper Extremity, ed 5, volume 2, St. Louis, 2002, Mosby. 3) Bonzani, P.J.: Rehabilitation of the Elbow. ASHT 25th Annual Meeting. 4) Bucholz, R.W., MD. & Heckman, J.D., MD. Rockwood and Greens Fractures in Adults. Philadelphia: Lippincott Williams and Wilkins, 2001. 5) Eiff, M.P., MD, Hatch, R.L., MD, & Calmbach, W.L., MD. Fracture Management for Primary Care. Philadelphia: W.B. Saunders Company, 1998. 6) Canale, S.T., MD. Campbells Operative Orthopaedics. Philadelphia: Mosby, 1998. 7) Davila, Sylvia A: Therapists Management of Fractures and Dislocations of the Elbow. In Mackin, Callahan, Skirven, Schneider, Osterman editors: Rehabilitation of the Hand and Upper Extremity. ed 5, volume 2, St. Louis, 2002, Mosby. 8) Hart, AC, Hopkins, CA (eds): Ingenix/St. Anthony Publishing/Medicode: ICD.9.CM, Experts for Physicians, Vol 1and 2, 6th ed, Salt Lake City, 2002. 9) Hastings, H. and Engles, D.: Fixation of Complex Elbow Fractures, Part I., Hand Clinics. ed 4, volume 13, Indianapolis, 1997. 10) Morgan. WJ, Breen, TF: Complex Fractures of the Forearm. In Weiss, APC (ed): Hand Clinics: Difficult Disorders of the Elbow and Forearm, 10:3, Philadelphia, Aug., 1994. 11) Morrey, BF: The Elbow and Its Disorders, 3rd ed. NY,Saunders,2000. 12) Schmidt, JI: Elbow Fractures and Dislocations. In Clark, G., Wilgis, E., Aiello, B., Eckhaus, D. and Eddington, L (eds): Hand Rehabilitation: A Practical Guide, 2nd ed. New York, Churchill Livingston, 1997. 13) Skinner, H.S., MD. Current diagnosis and Treatment in Orthopedics. New York: McGraw-Hill Companies, Inc., 2000. The ICD-9 codes were obtained from web site www.eatonhand.com/ coding/icd919c.htm, which quoted its source as The International Classification of Diseases, 9th Revision.

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