Elbow Fracture Physiotherapy &Treatment

Elbow Fracture

What is Elbow Fracture ?

An elbow fracture, also known as a broken elbow, is a break in one or more of the three bones that form the elbow joint: the humerus (upper arm bone), the radius (forearm bone on the thumb side), and the ulna (forearm bone on the pinky finger side, which includes the olecranon, or “funny bone”).

Causes of Elbow Fracture

Elbow fractures are common, especially in children and the elderly, but can affect anyone. They can range from simple cracks to complex breaks with multiple fragments

Falling directly on the elbow: This is a common cause of olecranon fractures (fractures of the bony tip of the elbow).
Falling on an outstretched arm (FOOSH): This mechanism often results in radial head fractures or distal humerus fractures, as the force is transmitted up the arm to the elbow joint.

Direct Blows: A direct impact to the elbow, such as from a sports injury, car accident, or other trauma.
Twisting Injuries: Forceful twisting of the arm beyond its normal range of motion.

Sports Injuries: Common in contact sports or activities with a high risk of falls (e.g., cycling, skating, football).
Osteoporosis: In older adults, weakened bones due to osteoporosis can make them more susceptible to fractures from less significant trauma.

Types of Elbow Fractures

Elbow fractures are classified based on which bone is broken and the nature of the break:

Olecranon Fractures:
Location: The bony tip of the ulna, which forms the prominent part of the elbow.
Vulnerability: This area is relatively unprotected by muscle, making it susceptible to direct impact.
Mechanism: Often a direct fall on the elbow or forceful contraction of the triceps muscle during a fall.

Radial Head Fractures:
Location: The top part of the radius bone, near the elbow joint.
Mechanism: Usually caused by falling on an outstretched hand, where the radial head is driven into the humerus
Distal Humerus Fractures:
Location: The lower (distal) end of the humerus, just above the elbow joint.
Commonality: Less common in adults but more frequent in children (supracondylar fractures are common in children) and the elderly with osteoporosis.
Mechanism: Can result from a direct blow, a fall on an outstretched arm, or falling on a bent elbow. These can be complex due to the proximity of nerves and blood vessels.

Fractures can also be classified as:

Non-displaced: The bone is broken, but the pieces are still in proper alignment.
Displaced: The bone fragments have moved out of their normal position.
Open (Compound): The broken bone has pierced through the skin, increasing the risk of infection.
Closed: The skin remains intact over the fracture

Symptoms of Elbow Fractures

Symptoms can vary based on the type and severity of the fracture but commonly include:

Immediate and Intense Pain: Localized to the elbow.
Swelling: Rapid and often significant swelling around the elbow joint.
Bruising: May appear around the elbow and can spread up or down the arm.
Tenderness to Touch: Over the fractured area.
Limited or Painful Movement: Difficulty or inability to bend, straighten, or rotate the forearm.
Deformity: Visible distortion or abnormal angle of the elbow or surrounding area in displaced fractures.
Popping or Cracking Sound: May be heard or felt at the time of injury.
Numbness, Tingling, or Weakness: In the hand or fingers if nerves (e.g., ulnar nerve) are affected.
Cold Sensation or Pallor: In the hand or fingers if blood vessels are compromised.

Diagnosis Typically Involves

Physical Examination: The doctor will examine the arm for swelling, bruising, deformity, and tenderness. They will also assess nerve function (sensation and movement of fingers/wrist) and blood flow (checking pulse).
X-rays: Standard X-rays from multiple angles are usually sufficient to diagnose most elbow fractures and determine the type and displacement.
CT Scan (Computed Tomography): May be used for more complex fractures or if the fracture extends into the joint (intra-articular) to get detailed 3D images and plan surgery.
MRI (Magnetic Resonance Imaging): Less commonly used for acute fractures but may be ordered to assess soft tissue injuries (ligaments, tendons) or nerve damage if suspected.

Treatment

Treatment depends on the type, location, severity, and displacement of the fracture, as well as the patient’s age.

Non-Surgical Treatment (for non-displaced or minimally displaced fractures)

Rest and Immobilization: The elbow is typically immobilized in a cast, splint, or sling for several weeks (e.g., 4-6 weeks) to allow the bones to heal.
Pain Management: Over-the-counter pain relievers or prescription medications.
Ice and Elevation: To reduce swelling and pain.
Early Motion (for some stable fractures): In some cases, particularly with radial head fractures, early, gentle range of motion exercises may be started within a few days to a week to prevent stiffness, under strict guidance from a surgeon or therapist.

Surgical Treatment (for displaced, unstable, or open fractures)

Open Reduction and Internal Fixation (ORIF): The most common surgical approach. An incision is made, the bone fragments are manually realigned (reduced), and then held in place with internal hardware like screws, plates, wires, or pins.

Excision of Fragments: For severely comminuted (shattered) radial head fractures that cannot be repaired, the radial head may be removed.
Joint Replacement: In very severe cases, particularly in older adults with complex fractures

involving significant joint damage (e.g., radial head replacement or total elbow replacement) may be considered.

Nerve Transposition: If a nerve (like the ulnar nerve) is entrapped or irritated by the fracture, it may need to be surgically moved.

Advanced Physiotherapy for Elbow Fractures

The rehabilitation process is progressive and tailored to the individual, the type of fracture, and the treatment method.

Early Phase (Immobilization & Initial Healing)

Pain and Swelling Management: Modalities like ice, gentle compression, and elevation.
Maintain Proximal & Distal Mobility: While the elbow is immobilized, exercises for the hand, wrist, and shoulder are crucial to prevent stiffness in these adjacent joints and maintain overall upper limb function.
Shoulder: Pendulum exercises, shoulder flexion/abduction.
Wrist/Hand: Wrist flexion/extension, pronation/supination (if not restricted by cast), finger range of motion, grip strength (with foam ball).
Isometric Exercises: Gentle isometric contractions (tensing muscles without moving the joint) of the forearm muscles.

Mid-Phase (Controlled Motion & Early Strengthening

– Post-Immobilization/Early Post-Op)

Gradual Restoration of Range of Motion (ROM): This is the most crucial aspect of elbow fracture rehabilitation, as the elbow is highly prone to stiffness.
Passive Range of Motion (PROM): Gentle, pain-free movements performed by the therapist or with assistance (e.g., pulley system).
Active-Assisted Range of Motion (AAROM): Patient assists the movement with the other hand.
Active Range of Motion (AROM): Patient performs movements independently.
Focus on Flexion, Extension, Pronation, and Supination: These are the primary movements of the elbow and forearm.

Manual Therapy

Joint Mobilization: Gentle, specific glides and oscillations of the elbow joint (humeroulnar, humeroradial, proximal radioulnar joints) to restore joint play and improve ROM. This is often started early by a skilled therapist if the fracture is stable.
Soft Tissue Mobilization: Gentle massage, kneading, or stroking of the muscles and soft tissues around the elbow and forearm to reduce stiffness, improve circulation, and address muscle guarding.
Myofascial Release (MFR): To address fascial restrictions in the forearm, upper arm, and around the elbow that may limit motion or cause pain.
Instrument-Assisted Soft Tissue Mobilization (IASTM): Can be used to address scar tissue (post-surgical) and fascial restrictions, improving tissue extensibility and reducing stiffness.
Early Strengthening (Isometric): Isometric exercises for biceps, triceps, pronators, and supinators.

Advanced Manual Therapy

Muscle Energy Technique (MET): Can be used to improve end-range elbow extension or flexion, or to address persistent muscle tightness, by using the patient’s own muscle contractions against resistance.
Active Release Technique (ART): To address specific adhesions or restrictions in muscles or tendons that may limit full range of motion or contribute to pain, particularly in the forearm and around the elbow.
Dry Needling: Can be used to address persistent myofascial trigger points in the surrounding muscles (e.g., triceps,biceps, forearm flexors/extensors) that contribute to pain, muscle spasm, or limit range of motion.
Proprioceptive Training: Exercises to improve the sense of joint position and movement, essential for coordination and stability. Examples include closed kinetic chain exercises (e.g., leaning on a wall, gentle weight-bearing) and balance activities.

Scar Management (Post-Surgical):

Scar Massage: To soften the scar, prevent adhesions, and improve pliability.
Silicone Sheeting/Gels: To aid in scar maturation and reduce hypertrophy.
IASTM: As mentioned, highly effective for scar tissue remodeling.
Functional Training: Gradually incorporating activities that mimic daily tasks, work-related movements, or sport-specific movements. This might include lifting, carrying, reaching, and fine motor tasks.
Kinesiology Taping: Can be used to provide gentle support, reduce residual swelling, or provide proprioceptive feedback to encourage specific movement patterns during activities.

Complications

Elbow Stiffness: This is the most common complication and the primary reason for intensive physiotherapy. It can be particularly challenging with intra-articular fractures.
Heterotopic Ossification (HO): Abnormal bone growth in soft tissues around the joint, which can severely limit motion. Early, gentle ROM and sometimes medication or radiation can help prevent this.
Nerve Damage: Particularly the ulnar nerve.
Nonunion/Malunion: The fracture not healing properly or healing in a deformed position.
Post-traumatic Arthritis: Long-term degeneration of the joint surfaces.

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