What is the treatment for a hyperextension elbow injury?

Treatment for Hyperextension Elbow Injury

The treatment for hyperextension elbow injury should follow a phased approach, beginning with conservative management including rest, ice, compression, and elevation (RICE), followed by progressive rehabilitation exercises, with surgical intervention reserved only for cases with significant instability or failure of conservative treatment. 1

Initial Assessment and Classification

• Imaging: Radiographs should be the first-line imaging to rule out fractures or dislocations
• Stability testing: Evaluate joint stability under stress to determine severity:
  • Slight instability: <10° of widening
  • Moderate instability: >10° of widening
  • Gross instability: Frank redislocation during stress testing 1

Treatment Algorithm Based on Severity

Mild to Moderate Instability (Most Common)

1. Acute Phase (0-2 weeks)

   • RICE protocol
   • Pain management with NSAIDs (ibuprofen 1.2-2.4g daily) 2
   • Immobilization with splint or brace in functional position (avoid hyperflexion)
   • Protected range of motion exercises

2. Intermediate Phase (2-6 weeks)

   • Progressive range of motion exercises
   • Begin gentle strengthening exercises
   • Proprioception training
   • Continue pain management as needed

3. Advanced Phase (6-12 weeks)

   • Sport-specific or occupation-specific training
   • Progressive resistance exercises
   • Eccentric strengthening exercises 2, 3

Severe Instability or Dislocation

• Closed reduction followed by stability assessment
• If grossly unstable: Surgical fixation is indicated 1
• If stable after reduction: Conservative management as outlined above

Special Considerations

Athletes (particularly throwers, boxers, water polo goalkeepers)

• More aggressive rehabilitation program focusing on:
  • Specific strength training of elbow flexors and extensors
  • Eccentric exercises at 80% of one repetition maximum
  • 8-10 repetitions, 3 times daily, 3 days per week 3
• Return to play criteria:
  • Complete resolution of pain during and after activity
  • Full range of motion compared to uninjured side
  • Strength symmetry >90% compared to uninjured side
  • Successful completion of sport-specific functional tests 2

Children with Supracondylar Fractures

• Different management protocol:
  • Displaced fractures (Gartland types II and III): Closed reduction with pin fixation is recommended
  • Pin configuration: Two or three laterally introduced pins are suggested (avoid medial pins due to ulnar nerve risk) 1

Complications to Monitor

• Ulnar nerve injury (particularly with medial approaches)
• Development of osteochondritis dissecans (especially in athletes with inadequately treated injuries) 4
• Chronic instability
• Post-traumatic arthritis
• Recurrent hyperextension injuries

Follow-up Recommendations

• Regular follow-up at 2,6, and 12 weeks to assess healing and function
• Consider MRI for persistent symptoms to evaluate for soft tissue injuries
• Surgical consultation if pain persists despite 3-6 months of well-managed conservative treatment 2

This treatment approach prioritizes joint stability and function while minimizing the risk of long-term complications. The evidence strongly supports conservative management for most hyperextension injuries, with surgical intervention reserved for cases with significant instability or failure of conservative treatment.