Distal humerus fracture — rehabilitation protocol

This protocol assumes stable fixation of both distal humeral columns. The goals are safe movement, protection of healing and progressive functional recovery. A parallel or perpendicular plate arrangement does not, by itself, determine rehabilitation speed.

Before treatment, check the operative report for fixation stability, whether and how an osteotomy was fixed, triceps preservation or repair, associated injuries and individual restrictions. The surgeon specifies permitted motion, active extension and any brace requirement. ^[1]

No osteotomy, triceps insertion preserved: early active-assisted and then active movement is usually possible within the permitted range, without added resistance. Fracture loading restrictions still apply.

Olecranon osteotomy: the divided olecranon also needs to unite. Fixation method and intraoperative stability guide extensor mechanism protection. Do not independently introduce active extension against gravity; the surgeon should explicitly state whether it is allowed. Until clarified, use assisted extension with gravity eliminated. Avoid resisted extension and forceful passive flexion.

No osteotomy, but triceps elevated or repaired: the repair requires additional protection. Absence of an osteotomy does not automatically allow unrestricted extension exercises. A fixed-duration ban on active extension is not imposed on every patient; the surgeon defines it individually. ^[1],[2]

Suggested follow-up schedule for individual adjustment: around days 10–14 for wound review and exercise planning; around weeks 6 and 12 for clinical review and X-rays as directed. If an osteotomy was performed, assess its union too.

• More movement: good tolerance, no wound deterioration, no increasing pain or swelling, and permission consistent with repaired tissues.
• Start strengthening: sufficient clinical and radiographic healing, stable fixation and fulfilment of triceps precautions.
• Higher loads and weight-bearing: confirmed union, task-appropriate function and surgical clearance.

Identical angle targets at a fixed postoperative week are not required of every patient.

Goals: manage pain and swelling, protect the wound and begin safe movement.

• Use a sling or splint briefly according to the surgeon and soft-tissue condition. Do not extend immobilisation independently. A hinged brace is not mandatory for every stably fixed fracture.
• Support the whole limb at rest with the hand elevated; avoid pressure on the wound and back of the elbow. Move the fingers and wrist.
• In the first few days, once cleared: gentle active-assisted flexion and extension with gravity eliminated, plus forearm rotation. A physiotherapist selects the position and teaches home exercises.
• Use frequent short movement sessions rather than one intensive session. Adjust repetitions to tolerance; pain and swelling should not increase afterwards.
• No weights, resistance bands, weight-bearing or strengthening. Light personal care only within the surgeon’s instructions.

Begin movement as soon as appropriate, but wound condition, additional repairs and stability take priority over the calendar. ^[1],[3]

Continue regular physiotherapy and the taught home programme. Gradually improve flexion, extension, pronation and supination. Monitor extension: an increasing deficit calls for reassessment of the programme, not forceful stretching.

Avoid sudden mobilisation, long lever arms and pushing through a hard, painful block. Seek surgical review if stiffness increases or progress stops. Any corrective splinting should be selected individually after assessing healing.

Continue to avoid lifting, pushing, pulling and supporting body weight. This includes pushing out of a chair or loading the operated limb through crutches or a walking frame. Individual extension precautions remain in place after osteotomy or triceps repair. ^[2],[3]

Reaching week 6 does not automatically permit strengthening. Continue unloaded movement. The surgeon reviews tenderness, stability, function and X-rays.

Resistance may begin once sufficient healing is established. AO guidance usually places this no earlier than around 8–12 weeks after injury; it may be later. After osteotomy, both healing sites must be reviewed. ^[2]

Following clearance, the physiotherapist introduces low resistance and short sets, progressively improving strength and movement control. Resisted extension additionally requires clearance based on triceps and osteotomy healing. There is no single weight allowance suitable for every patient.

Increase loading only after union is confirmed and the surgeon permits it. Gradually introduce functional tasks, endurance exercises and work-related activities. Supporting body weight through the operated limb requires secure bony union. ^[2]

Return to heavy work, contact sport or activities with a fall risk also depends on strength, control and useful movement. There is no universal return date. Driving requires safe vehicle control, no restrictive immobilisation or impairing medication, and medical clearance.

Recovery may continue for many months. A small extension deficit may persist after a complex fracture despite appropriate treatment. The aim is the best possible function without overloading healing structures. ^[3]