Treatment of Elbow Fractures: Immobilization and Pain Management
For elbow fractures, rigid immobilization is recommended over removable splints when treating displaced fractures, while removable splints can be considered for minimally displaced fractures. 1
Immobilization Options
Displaced Fractures
- Rigid immobilization (cast) is preferred for displaced elbow fractures 1
- Provides better stability and maintenance of reduction
- Prevents loss of alignment during healing process
- Should be maintained until radiographic evidence of healing (typically 3-4 weeks)
Minimally Displaced Fractures
- Removable splints are a viable option 1
- Allow for easier hygiene
- Enable periodic assessment of the fracture site
- May improve patient comfort while maintaining adequate support
Elbow Position Considerations
- There is insufficient evidence to recommend for or against immobilization of the elbow to prevent forearm rotation in patients with distal radius fractures 1
- One randomized controlled trial comparing above-elbow to below-elbow splinting for maintenance of reduction found no significant differences in outcomes 1
Pediatric Considerations
For pediatric supracondylar humerus fractures:
Type I (nondisplaced) fractures:
- Can be treated with either posterior splint/back-slab or collar and cuff immobilization
- Studies show better pain relief within the first 2 weeks with posterior splint/back-slab method 1
Type II and III (displaced) fractures:
- Closed reduction and percutaneous pinning is preferred over casting alone 1
- Surgical fixation provides more favorable outcomes regarding cubitus varus and Flynn's elbow criteria
Rehabilitation Approach
Early rehabilitation is crucial for optimal recovery:
After casting or surgery for distal radius fracture:
- Early finger motion is essential to prevent edema and stiffness
- When immobilization is discontinued, aggressive finger and hand motion is necessary 1
Following surgical treatment of shoulder fractures:
- Range-of-motion exercises including shoulder, elbow, wrist, and hand motion should begin within the first postoperative days
- A sling is usually worn for comfort only and may be discarded as early as pain allows 1
- Above chest level activities should be restricted until fracture healing is evident
Pain Management
Pain management should be multimodal:
- NSAIDs for mild to moderate pain
- Short-term opioid analgesics for severe pain
- Consider acetaminophen as an adjunct or alternative
- Ice application to reduce swelling and pain
Innovative Approaches
For specific cases, consider:
- Functional cast bracing with metal hinge joints at the elbow can be effective in preventing contractures and ankylosis while allowing elbow joint movement during immobilization 2
- Removable long-arm soft casts have shown comparable outcomes to traditional hard casts for nondisplaced pediatric elbow fractures, with similar rates of range of motion recovery, pain control, and patient satisfaction 3
Monitoring and Follow-up
- Regular radiographic evaluation for 3 weeks and at cessation of immobilization 1
- Monitor for:
- Loss of reduction
- Neurovascular compromise
- Compartment syndrome
- Joint stiffness
Pitfalls and Caveats
- Overly aggressive physical therapy may increase the risk of fixation failure in the postoperative period 1
- Prolonged immobilization can lead to joint stiffness and muscle atrophy
- Inadequate immobilization of displaced fractures may result in malunion
- Elbow fractures are challenging to treat because articular surfaces must be restored perfectly and associated soft tissue injuries must be recognized 4
By following these evidence-based recommendations, clinicians can optimize outcomes for patients with elbow fractures while minimizing complications and maximizing functional recovery.