Elbow Fracture Post-Op Rehabilitation Protocol

Pathophysiology

Elbow fractures are common injuries, often resulting from falls onto an outstretched hand (FOOSH), direct trauma, or high-energy impacts. These fractures can involve the distal humerus, proximal ulna (olecranon), or proximal radius (radial head). Fracture patterns vary, ranging from simple undisplaced fractures to complex multi-fragmented injuries requiring surgical intervention. Surgical management typically involves open reduction and internal fixation (ORIF) using plates, screws, or pins to stabilize the fracture fragments. The primary goals of surgery are to restore anatomical alignment, provide stable fixation for early mobilization, and minimize long-term complications such as stiffness, pain, and functional limitations. Post-operative rehabilitation is crucial for optimizing functional outcomes, preventing stiffness, and restoring strength and range of motion (ROM).

Rehabilitation Phases

This rehabilitation protocol is divided into three phases, progressing from protection to loading and finally to return to function. Progression criteria between phases are based on clinical findings and individual patient tolerance. Communication between the physical therapist and the surgeon is essential throughout the rehabilitation process.

Phase I: Protection (Weeks 0-4)

• Goals:
• Protect the surgical site and healing bone.
• Control pain and edema.
• Initiate early ROM exercises to prevent stiffness.
• Maintain strength in uninvolved joints.
• Precautions:
• Avoid active elbow flexion and extension, especially against resistance.
• Adhere to surgeon's weight-bearing restrictions.
• Monitor for signs of infection (redness, swelling, drainage, increased pain).
• Interventions:
• Immobilization: Typically, a long-arm cast or splint is used. Follow surgeon's specific instructions.
• Edema Control: Elevation of the arm, gentle active range of motion (AROM) of the wrist and hand, and retrograde massage. Consider ice packs.
• Pain Management: Pain medication as prescribed by the physician. TENS unit may be used.
• AROM of Uninvolved Joints: Shoulder, wrist, and hand AROM exercises to maintain mobility and prevent stiffness.
• Gentle PROM/AAROM (Protected Range of Motion) Exercises: Initiate gentle PROM or AAROM exercises of the elbow within pain-free limits as per surgeon's protocol. Emphasis on avoiding stressing the surgical site. Often uses a CPM (continuous passive motion) machine. Pronation and supination should be initiated cautiously.
• Scapular Exercises: Scapular retractions, protractions, elevation, and depression to promote shoulder girdle stability and prevent compensatory movement patterns.
• Patient Education: Proper positioning, pain management techniques, and activity modifications. Reinforce precautions and importance of adherence to the rehabilitation program.

Phase II: Loading (Weeks 4-8)

• Goals:
• Gradually increase elbow ROM.
• Begin light strengthening exercises.
• Improve neuromuscular control and stability.
• Minimize pain and edema.
• Precautions:
• Avoid aggressive stretching or strengthening that could compromise fracture healing.
• Monitor for signs of instability or hardware failure.
• Progress exercises gradually based on patient tolerance.
• Criteria to Progress:
• Radiographic evidence of bone healing.
• Minimal pain and edema.
• Sufficient ROM to perform basic activities of daily living (ADLs).
• Interventions:
• AROM and Stretching Exercises: Progress from PROM/AAROM to AROM exercises, gradually increasing the range of motion. Gentle stretching exercises to improve elbow flexion, extension, pronation, and supination. Consider heat application prior to stretching.
• Light Strengthening Exercises: Initiate isometric exercises for elbow flexors, extensors, pronators, and supinators. Progress to light isotonic exercises using resistance bands or light weights.
• Wrist and Hand Strengthening: Continue strengthening exercises for wrist flexors, extensors, radial/ulnar deviators, and grip strength.
• Proprioceptive Exercises: Incorporate balance and proprioception exercises to improve joint awareness and stability. Examples include weight shifting and closed-chain exercises.
• Scar Mobilization: Initiate scar mobilization techniques to prevent adhesions and improve tissue extensibility.
• Activity Modification Training: Practice functional activities with modified techniques to minimize stress on the elbow joint.

Phase III: Return to Function (Weeks 8+)

• Goals:
• Restore full elbow ROM and strength.
• Improve functional capacity for ADLs and recreational activities.
• Return to pre-injury activity level.
• Precautions:
• Avoid activities that cause pain or swelling.
• Progress exercises gradually to prevent re-injury.
• Ensure adequate warm-up and cool-down periods.
• Criteria to Progress:
• Full or near-full elbow ROM.
• Sufficient strength to perform functional activities.
• Minimal or no pain.
• Interventions:
• Progressive Strengthening Exercises: Increase the intensity and volume of strengthening exercises using weights, resistance bands, or functional activities. Focus on endurance and power.
• Plyometric Exercises: Introduce plyometric exercises to improve power and explosiveness. Examples include medicine ball throws and jump training (if appropriate for the individual's activity goals).
• Sport-Specific Training: Implement sport-specific exercises to prepare the individual for return to their desired activity.
• Work Conditioning: If applicable, participate in work conditioning to simulate job-related tasks and improve work tolerance.
• Functional Exercises: Continue practicing functional activities to improve coordination, balance, and agility.
• Patient Education: Provide education on proper body mechanics, injury prevention strategies, and self-management techniques.

Common Special Tests

• Lateral Epicondylitis Tests:
  • Cozen's Test: Patient makes a fist, pronates forearm, and radially deviates and extends the wrist against resistance.
  • Mill's Test: Examiner passively pronates the forearm, flexes the wrist, and extends the elbow.
• Medial Epicondylitis Test:
  • Golfer's Elbow Test: Examiner passively supinates the forearm, extends the wrist, and extends the elbow.
• Ligamentous Instability Tests:
  • Valgus Stress Test: Assesses medial collateral ligament (MCL) integrity.
  • Varus Stress Test: Assesses lateral collateral ligament (LCL) integrity.
• Posterolateral Rotatory Instability Test: Apprehension test to assess for instability of the radiocapitellar joint.
• Moving Valgus Stress Test: Reproduction of pain with valgus stress through a range of motion suggests MCL pathology.

Disclaimer: This rehabilitation protocol is a general guideline and should be adapted to each individual patient based on their specific needs and surgeon's recommendations. Regular communication between the physical therapist and surgeon is crucial to ensure optimal patient outcomes.