Injury, Int. J.

Care Injured 45 (2014) 540545

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Injury
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c a t e / i n j u r y

Critical time period for recovery of functional range of motion after

surgical treatment of complex elbow instability: Prospective study on
76 patients
Giuseppe Giannicola *, David Polimanti, Gianluca Bullitta, Federico M. Sacchetti,
Gianluca Cinotti
Department of Orthopedic Surgery, Sapienza University of Rome, Rome, Italy

A R T I C L E

I N F O

Article history:
Accepted 29 November 2013
Keywords:
Complex elbow instability
Elbow fracturedislocation
Elbow range of motion
Functional elbow range of motion
Elbow rehabilitation
Elbow postoperative management
Recovery of range of motion
Elbow outcomes

A B S T R A C T

Introduction and aim: Complex elbow instability (CEI) is one of the most troublesome pathologies that
orthopaedic surgeons have to face. One of the key requirements regarding the CEI surgical treatment is
an early rehabilitation programme to avoid the elbow stiffness caused by a long period of
immobilisation. Although this is well known, no study has ever examined how, and to what extent,
the functional range of motion (ROM) is recovered during the various stages of a prompt rehabilitation.
Our aims were: (1) to prospectively analyse the pattern of ROM recovery in a series of patients with CEI
who underwent early rehabilitation and (2) to identify the period of time during rehabilitation in
which the greatest degree of motion recovery is obtained.
Materials and methods: A total of 76 patients (78 elbows) with CEI were followed up for 2 years. All the
patients underwent anatomical and stable ostheosynthesis of all the fractures, radial head
replacement in Mason III fractures, ligament injuries reconstruction and early rehabilitation that
started 2 days after surgery. Two surgeons evaluated the ROM with a hand-held goniometer every 3
weeks for the rst 3 months, then at 6, 12 and 24 months after surgery.
Results: At the 3-week follow-up, the mean exion (F), extension (E), pronation (P) and supination (S)
were 1138, 298, 608 and 628, respectively. At the 6-week and 9-week follow-up, F, E, P and S were 1198,
238, 708 and 698 and 1238, 248, 728 and 718, respectively. At the 3-month follow-up, these values were
1318, 188, 768 and 728, while at the 6-month follow-up they were 1368, 158, 798 and 778, respectively.
Thereafter, the ROM improvement was not signicant.
Discussion: This study shows that the rst 6 months represent the critical rehabilitation period to
obtain a functional elbow; indeed, 70% of the patients recovered functional ROM between the third
and sixth month, though the recovery of exion proved to be slower than that of the other elbow
movements. Thereafter, improvement continued, though at a lower rate, until the end of the rst
year, when approximately 80% of the patients had recovered the functional ROM.
Conclusions: Following CEI surgical treatment, a rehabilitation programme needs to be started
promptly and continued for at least 6 months because a signicant improvement of ROM occurs
prevalently in this period, which should be considered the critical time period to obtain a functional
elbow in a majority of patients.
2013 Elsevier Ltd. All rights reserved.

Introduction
Fracturedislocations of the elbow are complex injuries
historically associated with unsatisfactory outcomes [15]. In
the last decade, advances in our knowledge of functional anatomy
combined with improved implants and surgical techniques have

* Corresponding author at: Via Emilio Repossi 15, C.A.P. 00185 Rome, Italy.
Tel.: +39 3484934300; fax: +39 0687198146.
E-mail address: giannicola.giuseppe@gmail.com (G. Giannicola).

00201383/$ see front matter

2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2013.11.033

translated into better outcomes for patients affected by complex

elbow instability (CEI) [610]. To date, the primary goals of surgery
are the anatomical and stable ostheosynthesis of all articular
fractures and the reconstruction of ligament injuries to recover
elbow stability, which allow early motion and thus avoid elbow
stiffness [914]. In this regard, several studies recommend that
rehabilitation should be initiated as early as possible because an
extended postoperative period of immobilisation is associated
with signicant functional impairment [1518]. Although it is well
known that functional outcomes are better in patients who
undergo early rehabilitation, no study has ever examined how,
and

G. Giannicola et al. / Injury, Int. J. Care Injured 45 (2014) 540545

to what extent, the range of motion (ROM) is recovered during

the various stages of a prompt rehabilitation programme [18].
Indeed, previous studies on this topic have only analysed the
clinical results of CEI treatment and reported the ROM achieved
at the nal follow-up, without
however providing any
information on the recovery of ROM in the various stages of
rehabilitation [4,5,7,8,13].
The purposes of the current study were: (1) to prospectively
analyse the pattern of ROM recovery in a series of patients with
CEI who underwent an early rehabilitation programme and (2)
to identify the period of time during rehabilitation in which
the greatest degree of elbow joint motion recovery is made.
The hypothesis of this study is that immediate postoperative
elbow mobilisation ensures a recovery of functional ROM in the
majority of cases.

Materials and methods

Between 2005 and 2011, a single surgeon (G.G.) performed
surgery on 76 patients (78 cases) with CEI. The patients
comprised
41 females and 35 males. All the patients were skeletally mature
and had a mean age of 52 years (range 1686 years). Two patients
had a bilateral injury.
The injury patterns included: ve radial head fracture
dislocations, ve coronoid fracturedislocations, 22 terrible triads,
35 fracturedislocations of the proximal ulna and radius (Monteggia-like injury) and 11 capitulum humeri and trochlea
fractures with ligament injuries.
The same diagnostic and therapeutic algorithm was applied to
all the patients. Radiography and a computed tomography
(CT) scan with three-dimensional (3D) reconstruction were
performed before surgery in
all
the patients. Surgical
treatment was performed a mean of 3 days (range 17 days)
after trauma. All the operations were performed according to a
one-step procedure. A posterior or extended postero-lateral skin
incision was used in all the patients. The Kocher interval was
used to expose the lateral compartment while an over-the-top
approach, or elevation of the exorpronator muscles from the
subcutaneous and medial border of the ulna, was adopted to
expose the medial compartment.
Briey, surgical treatment consisted of open reduction and
internal xation (ORIF) of all the fractures and radial head
replacement in unreconstructible Mason III injuries. Following
ORIF, soft tissue lesions of the lateral compartment were repaired
in all patients. A uoroscopic assessment of elbow stability was
performed. If elbow stability was not achieved, the medial
collateral ligament (MCL) was exposed and repaired. If elbow
instability was still present at the end of surgery, a hinged elbow
xator (HEF) was positioned. At the end of the surgical
procedure, one intra-articular drainage and one subcutaneous
drainage were applied.
Postoperative management
The elbow was immobilised in extension and raised position
for the rst 48 h with a plaster splint. The HEF device, in the
nine patients in whom it was implanted, was locked in extension
for the same period of time. In patients with anterior coronoid
fractures repaired with transosseous sutures (12 cases), the elbow
extension was limited to 308 until 25 days postoperatively.
Cryotherapy was applied
and
analgesic
therapy
was
performed. Indomethacin (100 mg
daily) was administered
for 5 weeks to prevent heterotopic ossication (HO). After
removal of the drainages (after
48 h), either a hinged elbow brace was applied for 45 days or the
HEF was unlocked. The elbow rehabilitation programme began
within 2 days of surgery. The HEF was removed between 6 and 7
weeks after surgery.

29

The rehabilitation programme was divided in three phases: (1)

the acute phase dened as a stage of bone nonunion, usually
lasting between 0 and 6 weeks post injury, or until union
occurred; (2) the sub-acute phase, dened as the next stage
after bone healing, which occurred between 6 and 12 weeks post
injury; and (3) the functional phase, after 3 months. In the
acute stage, patients were instructed in rest, limb elevation,
precautions, activity modication and pain management.
Furthermore, patients started exercises for passive range of
motion (PROM) (rst seven postoperative days), active assisted
range of motion (AAROM) (after rst postoperative week) and
active range of motion (AROM) (after second postoperative
week) under the supervision of
the personal therapist.
Physiotherapy was performed with a therapist ve times a week
for an hour each time. In addition, the therapist treated the wrist,
hand and shoulder to avoid secondary stiffness. Moreover,
patients started a home exercise programme, consisting of at
least ve 20-min sessions per
day.
During the extension
exercises performed in the rst 6 weeks, the forearm was
positioned in pronation or supination, respectively, in cases of
lateral collateral ligament (LCL) or MCL deciency, due to weak
reconstruction (LCL) or not-repaired lesion (MCL); when both
ligaments were repaired, the forearm was positioned in neutral
rotation. Complete forearm rotation was allowed immediately at
908 of exion.
During the second and third phases of the rehabilitation,
therapists focussed to a greater degree on the restoration of
elbow functions; in particular, patients not only continued
AROM, AAROM and PROM exercises and followed the home
programme (during the sixth to 12th week), but they also
started stretching, strengthening and functional exercises (after
the 12th week).
Clinical evaluation
Patients were followed up for 24 months postoperatively.
Clinical evaluations were performed every three weeks for the
rst
3 months, thereafter at 6 months, 1 year and 2 years after
surgery. Elbow ROM was measured by two independent surgeons
using a hand-held goniometer centred on
the lateral
epicondyle and aligned along the axis of the arm and forearm
to calculate the exion/extension arch and aligned, on the
frontal plane, along the arms axis to calculate the forearm
rotation. In case of disagree- ment between the two surgeons
values of
elbow ROM, a
third common evaluation was
performed to reach an agreement.
Statistical analysis
Due to the small numbers of some CEI patterns, statistical
analysis was performed on all 75 cases without splitting the initial
patients into different CEI groups. The paired t-test was
performed to assess the differences in elbow ROM values
obtained at each follow-up while the McNemar test was used
to assess the differences in the rate of patients who recovered
the functional ROM. A p-value <0.05 was considered signicant.
All computa- tions were carried out using SPSS software 21.0
(IBM Corporation, Armonk, NY, USA).
Results
We reviewed 75 out of 76 patients. At the nal follow-up, the
mean extension was 11.48 (range 0608), while the mean exion
(F) was 140.18 (range 1001558). The mean exion/extension arc
of movement was 128.58 (range 501558), while the mean
pronation and supination were 80.18 (5908) and 77.1 (0908),
respectively. In Table 1 are reported the mean and the extreme
values of F, extension (E), pronation (P) and supination (S)

30

G. Giannicola et al. / Injury, Int. J. Care Injured 45 (2014) 540545

obtained at each follow-up in all 75 patients. We observed a

statistically signicant

Table 1
Data of mean exion, extension, pronation and supination observed at each follow-up.

3-Week follow-up
6-Week follow-up
9-Week follow-up
3-Month follow-up
6-Month follow-up
1-Year follow-up
2-Year follow-up

Flexion

Extension

Pronation

Supination

1138 (801508)
119.48 (601508)
123.58 (601508)
130.68 (601558)
136.18 (1001558)
140.28 (1001558)
140.18 (1001558)

28.68
22.78
24.58
18.18
14.88
11.78
11.48

59.88 (0908)
69.78 (0908)
71.88 (0908)
76.58 (0908)
79.28 (0908)
798 (0908)
80.18 (5908)

61.88 (0908)
69.48 (0908)
718 (0908)
72.48 (0908)
77.38 (0908)
77.78 (0908)
77.18 (0908)

improvement in F, E, P and S between the third- and sixth-week

follow-up. F, E and S improvements were also signicant in the
next follow-up until 6 months (Figs. 1 and 2), whereas no
signicant improvement of pronation was observed after 6 weeks
(Table 2).
Fig. 3 shows the mean F, E, P and S obtained at each follow-up
in all patients.
Fig. 4 shows the percentage of patients who recovered or
exceeded the functional ROM [20] (F, 1308; E, 308; P, 508; and S,
508), during the follow-up. Statistical analysis showed a signicant
improvement of the rate of patients who obtained the functional
ROM until 1-year follow-up.
Fig. 5 shows the mean nal values of joint movements
obtained in the different CEI patterns at the last follow-up.

(0908)
(0908)
(01008)
(0908)
(0608)
(0608)
(0608)

Discussion
In this study, we prospectively analysed the recovery of ROM
patterns in a large group of patients with CEI treated according to
the current diagnostic/therapeutic algorithms, which recommend
immediate postoperative rehabilitation [714]. The aims of our
study were to investigate how and when such patients recover
functional ROM, as well as the period during the rehabilitation
programme in which the greatest degree of recovery occurs. The
results of our study show that the rst 6 months represent the
most important rehabilitation period, with more than half of the
patients recovering a functional elbow between 12 and 24 weeks,
though recovery of exion was found to occur more slowly than
that of the other three elbow movements.

Fig. 1. Terrible triad injury. (A and B) Pre-operative X-rays (after reduction of dislocation). (C and D) Post-operative X-rays shows radial head replacement with bipolar
radial head arthroplasty, coronoid osteosynthesis with 2 threaded wires and LCL reconstruction with 3 suture anchors.

Fig. 2. Post-operative R.O.M. improvement in the same patient of Fig. 1. (A) 3 weeks F-Up; (B) 3 months F-Up; (C) 6 months F-Up; (D) 1 year F-Up.

Table 2
Mean improvement of exion, extension, pronation and supination observed during the follow-up.
3rd6th week
Flexion
Extension
Pronation
Supination
*

6.4
*
5.9
*
9.9
7.6*

69th week
*

4.5
1.8
2.1
1.6

9th week3rd month

*

7.1
*
6.4
4.7
1.4

3rd6th month
*

5.5
*
3.3
2.7
4.9*

612th month
4.1
3.1
0.2
0.4

1224th month
0.1
0.3
1.1
0.6

Statistically signicant (p < 0.05).

Fig. 3. Mean extension, exion, pronation and supination ROM obtained during
each follow-up.

Fig. 4. Percentage of patients that recovered or exceeded a functional range of

motion during the follow-up.

Fig. 5. Mean exion, extension, pronation and supination ROM for the different
CEI patterns obtained at the nal follow-up. Abbreviations: T.t, terrible triad; C.t.
f.-d., capitulum humeri and trochlea fracture-dislocation; R.h. f.-d., radial head
fracture- dislocation; C. f.-d., coronoid fracture-dislocation; P.r.u. f.-d., proximal
radius and ulna fracture-dislocation.

It is well documented that the critical point regarding the

treatment of CEI is the need to restore elbow anatomy and
stability so as to allow a rehabilitation programme to be started
promptly and thus prevent elbow stiffness [9,10,1214]. In this
study, we focussed on the postoperative phase of the CEI
management by prospectively following the course of ROM
recovery. To our knowledge, no previous studies have investigated this topic. We found that the time period of rehabilitation
during which the greatest degree of recovery in elbow motion is
made, is in the rst 6 months, when more than 70% of patients
recover functional ROM. Thereafter, the recovery process continues, though at a slower rate, resulting in functional ROM
recovery in 80% of cases at the 1-year follow-up. From then
onwards, the ROM remains the same. Our ndings demonstrate
that a rehabilitation programme should be started as promptly as
possible, during the ligament and bone healing period, and that it
should be continued thereafter. In fact, in the rst 6 weeks we
observed a rapid and signicant recovery of the ROM, which
continued in the following weeks. However, the surgeons
dilemma in managing these complex elbow injuries is that
without a careful reconstruction of elbow stability and good
patient compliance, instability may recur during the rst
postoperative weeks; immobilisation is consequently recommended by several surgeons for 45 weeks, though this in turn
leads to elbow stiffness, unsatisfactory results and the need for
further surgical procedures [1519].
In this series, we noticed that the recovery of functional exion
was slower than that of other movements. Indeed, at the 3-week
follow-up, the majority of patients displayed functional pronation, supination and extension, whereas few patients could
attain a exion of 1308. As observed for the other elbow
movements, elbow exion increased prevalently during the
rst 12 weeks, though a functional level of exion was reached
above all between the ninth and 12th weeks. This
fact
conditioned the recovery of elbow functional ROM, as
demonstrated by the fact that, by the end of the third week, 16%
of the patients had recovered functional ROM, whereas by the
12th week this gure had risen to 60% of the patients. These
results may be explained, at least in part, by the fact that in the
rst 6 weeks patients were protected by a hinged brace that
prevented exion beyond 1208, and to even <1208 in patients
with a larger arm. The recovery of exion beyond 1208 was
observed between the ninth and the 12th weeks, that is after
elbow brace removal in the sixth week. Furthermore, we observed
that 63% of patients who had not recovered exion beyond 1208

within the rst 6 weeks were muscular or obese patients,

whereas the remaining 37% had a thin arm; on the contrary,
the 66% of patients who had recovered a functional exion in
the rst 6 weeks had a thin arm. These ndings are in keeping
with the fact that the elbow brace in the former type of patient
further limits the exion movement.
These observations
suggest that the patient and the therapist should be advised to
remove the elbow brace during rehabilitation to favour the
recovery of exion, or to use an elbow brace that permits a
greater range of exion. However, removal of the brace may
damage the reconstruction of capsular-ligamentous and bony
constraints as a result of incorrect movements of the arm,
particularly in patients who display low compliance; nding a
brace with a greater range of exion is, instead, currently
impossible in our country because no braces that allow the
elbow to be really exed over 1208 are available. In this regard,
we believe that new types of elbow braces should be designed to
extend ROM, and consequently allow a faster recovery of exion
movement.
As for the other elbow movements, we found that the most
signicant improvements occurred in the rst 6 months, after
which the values remained unchanged; the improvement pattern
of these other movements was, therefore, similar to that of
exion, the main difference being that a functional level was
attained for the other movements from as early as the third
week. To sum up, the recovery rate of elbow functional ROM
depends above all on the recovery of exion, which improves at
a slower rate than the recovery of other movements.
In this series, we did not observe any differences between
the different CEI patterns and recovery of ROM; however, we
did observe that recovery of ROM associated with the terrible
triad pattern was slightly less favourable, though not signicantly
so, than for the other CEI patterns. These results seem to conrm
the data in the literature [7,8,13], according to which the
prognosis for patients with the terrible triad is worse than that
for patients with other types of CEI. Three of the four patients
who developed elbow stiffness in our series had the terrible
triad; the fourth patient was affected by a proximal radius and
ulna fracturedislocation. Elbow stiffness in these four patients
was related to the development of HO and capsule contracture;
at the 1-year follow-up visit, all four patients underwent a
second operation, which led to the recovery of a functional ROM
at the nal follow-up. However, the low sample size of CEI
patterns does not allow us to draw denitive conclusions about
this topic.
The main limitation of this study is the absence of a control
group in which patients the elbow was immobilised for a period
of time. This is, however, justied by the fact that it is widely
known that postoperative immobilisation yields poor results
and it would thus be ethically incorrect to perform a study with a
control group. The second limitation is the relatively small
number of patients with each CEI pattern, as this prevented us
from drawing denitive conclusions regarding the differences
observed in the recovery of functional ROM. More patients with
each CEI pattern are
required to be able to understand
whether there are
any signicant differences in
ROM
recovery between the various patterns. In conclusion, we
believe surgical treatment for CEI needs to be followed
immediately by a period of rehabilitation because we observed a
faster recovery of functional ROM in the rst
weeks;
moreover, as the recovery of functional ROM continues,
though to a lesser extent, for up to 1 year, the rehabilitation
programme should be extended to last for this length of time.
Last but not the least, in order to achieve full recovery of
elbow function, it is mandatory that the responsibility for any
improvement be transferred to the patients, who can thus
become their own therapists by performing exercises at home by
themselves.

Conicts of interest
No nancial or other relationships that might lead to a conict
of interest are present in this article. No benets in any form
have been received or will be received from a commercial party
related directly or indirectly to the subject of this article.
Authors, their immediate family and any research foundation
with which they are afliated did not receive any nancial
payments or other benets from any commercial entity related
to the subject of this article. No funds were received in support
of this study.
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