New York State Medical Treatment Guidelines for Elbow Fractures in workers compensation patients

The guidelines crafted by the New York State Workers Compensation Board are here to aid doctors, podiatrists, and other healthcare pros in delivering the right treatment for Elbow Fractures, which encompasses Non-Displaced Radial Head Fractures.

Healthcare providers, including physicians and podiatrists, can turn to these Workers Compensation Board guidelines for insights when deciding on the most fitting care for patients dealing with Elbow fractures

It’s crucial to note that these guidelines don’t replace the importance of clinical judgement or professional expertise. Ultimately, the decision about care should be a collaborative one between the patient and their healthcare provider.


Elbow Fractures, including Non-Displaced Radial Head Fractures

Elbow fractures usually happen because of falls, especially when someone lands on an outstretched hand. If the fracture is sizable, displaced, or complex (Type III), or if there’s a significant fracture with a displaced piece (Type II), it’s crucial to consult a surgeon. Uncommon capitellar fractures often occur when falling on an outstretched hand.

While there might be attempts at non-surgical treatment, most cases are believed to benefit from surgical fixation. Surgical procedures are often necessary for these fractures.


Diagnostic Criteria of Elbow Fractures, including Non-Displaced Radial Head Fractures

After digging into the victim’s medical background, analyzing the nature of the injury, and detecting significant tenderness during the physical examination, a clinical impression is pieced together, with particular attention to any concentrated discomfort over a bone. It’s crucial to assess elbow function and inspect for any deformities.

Confirming the initial impression often involves obtaining two or three x-ray views that clearly reveal a fracture. In the realm of differential diagnoses, elbow sprain and dislocation take the spotlight. If x-rays don’t show anything but suspicion persists, the next step is typically a CT scan.


Special Studies and Diagnostic and Treatment Considerations of X-rays for Elbow Fracture

To pinpoint elbow fractures, it’s recommended to conduct specialized studies and consider diagnostic and treatment aspects of X-rays. Utilizing X-rays with a minimum of two to three views proves beneficial for accurate identification.

When it comes to the primary care of elbow fractures, including cases like Non-Displaced Radial Head Fractures, certain protocols and procedures need to be follow


Cast Immobilization/Splints and Slings

Traditionally, fractures in the elbow and elsewhere have been addressed with casting, and for non-dislocated radial head fractures, slings have been a go-to treatment.

When dealing specifically with occult and non-displaced radial head fractures, it’s recommended to use elbow slings. Occult fractures, not visible on x-rays, can be suspected if there’s evidence of effusion or if the elbow can’t fully extend.

For non-displaced radial head fractures, the prescription is a sling (or splint) worn for seven days. If the fractures are clinically apparent but not visible on an x-ray, a shorter immobilization time, even as low as three days, may be considered. After seven days, a gradual transition to mobilization is advised, followed by gentle range-of-motion activities within pain tolerance.

Moving on to casts and cast bracing for select elbow fractures, these are recommended for occult or non-displaced radial head fractures. Casting, cast bracing, or post-open reduction internal fixation fractures are considered appropriate treatments for elbow fractures with minimal displacement.

The usual duration for casts is around six weeks or until sufficient healing is evident on x-rays. After a successful recovery, the next step is progressive mobilization.

In terms of medications for elbow fractures, including non-displaced radial head fractures, first-line treatments for most patients include ibuprofen, naproxen, or other NSAIDs from an earlier generation. If NSAIDs are not suitable, acetaminophen (or paracetamol) can be a viable alternative, although research suggests it might be slightly less effective than NSAIDs.

There’s evidence supporting the idea that NSAIDs are not only less risky but also equally effective in managing pain compared to opioids like tramadol.

When it comes to treating acute, subacute, chronic, or post-operative elbow fractures, using Non-Steroidal Anti-inflammatory Drugs (NSAIDs) is recommended. These medications are particularly useful for postoperative, chronic, subacute, or acute elbow fractures, and starting with over-the-counter options is a sensible approach.

There isn’t conclusive evidence favoring one NSAID over another for these indications, so using them as needed is a reasonable choice for many patients. The decision to discontinue NSAID use can be based on reduced elbow pain, ineffectiveness, or the emergence of side effects that warrant stopping the treatment.

For individuals at high risk of gastrointestinal bleeding, it’s recommended to use NSAIDs along with cytoprotective drugs like misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors. These are especially important for patients with a high-risk profile and indications for NSAIDs, particularly if a prolonged course of treatment is planned. Factors like a history of gastrointestinal bleeding, age, diabetes, and smoking increase the risk.

When considering patients at risk for cardiovascular adverse effects, acetaminophen or aspirin are the first-line treatment options due to their perceived safety. If non-selective NSAIDs are necessary, they are preferable to COX-2-specific medications. To avoid compromising the protective effects of low-dose aspirin, it’s advised to take NSAIDs at least 30 minutes after or eight hours before the daily aspirin for individuals using it for primary or secondary cardiovascular disease prevention.


Acetaminophen is recommended for addressing elbow discomfort, particularly in patients who can’t use NSAIDs.

This treatment is suitable for all patients dealing with acute, subacute, chronic, and post-operative elbow pain. The usage should align with the manufacturer’s recommendations and can be adapted as needed. However, it’s crucial to stay within the limit of four grams per day to avoid potential liver toxicity. Discontinuation can be considered when the discomfort resolves, negative effects emerge, or intolerance is noted.

When it comes to opioids, they are suggested for specific cases of severe elbow fracture pain.

Select patients, who haven’t responded well to previous treatments like acetaminophen and NSAIDs or have contraindications to NSAIDs, may benefit from opioids. Their use is particularly relevant for individuals with more severe fractures or in the initial days post-surgery. However, caution is advised, and minimal doses should be administered, as elbow fractures typically require short-term care. The frequency and dosage can be adjusted as needed, and discontinuation may be prompted by undesirable effects, deviation from prescription guidelines, or adequate pain relief that eliminates the need for opioids.


Surgery of Elbow Fractures, including Non-Displaced Radial Head Fractures

While the common belief is that surgical treatment with fixation is needed for displaced fractures and fracture fragments, there’s a lack of reliable data specifically addressing displaced fractures. In cases involving widely displaced fractures and/or comminuted pieces, radial head excision and/or radial head implant may become necessary.

Certain individuals, such as those with extensively displaced pieces, individuals requiring a speedier recovery (e.g., professional athletes), or those with the dreaded triad, might be more suitable candidates for surgical treatment of elbow fractures. The decision to undergo surgery for elbow fractures should be a collaborative one between the orthopedist and the patient, reaching an agreement based on individual circumstances and preferences.

Surgical Fixation of Displaced Elbow Fractures

For displaced elbow fractures, it is recommended to opt for surgical fixation as the preferred course of treatment.


Therapeutic Exercise (Active and Passive)

Rehabilitation, particularly supervised formal therapy following a work-related injury, should focus on restoring the functional abilities necessary for fulfilling the patient’s daily and occupational responsibilities. The ultimate aim is to facilitate the injured worker’s return to work, striving to bring them back to their pre-injury state as much as practically possible.

Active therapy involves the patient actively engaging in specific activities or tasks, requiring internal effort. On the other hand, passive therapy relies on modalities administered by a therapist without the patient exerting effort.

While passive therapies are often used to complement active therapy and achieve simultaneous functional gains, it’s crucial to prioritize interventions that require the patient’s active participation.

To maintain and enhance the achieved improvements, patients are encouraged to continue both active and passive therapies at home as an extension of the overall therapeutic process.

Assistive devices may be incorporated into the rehabilitation strategy as supplementary measures to facilitate functional gains.

Physical or Occupational Therapy of Patients After Cast Removal

It is advisable to undergo physical or occupational therapy after the removal of a cast.

The frequency, dosage, and duration of therapy sessions depend on the individual’s progress. For those with minor functional deficits, as few as two to three sessions may be sufficient, while individuals with more severe deficits may require 12 to 15 sessions. If there’s evidence of progress toward specific functional goals, such as improved grip strength or range of motion, more than 12 to 15 visits might be necessary to address persistent impairments. Additionally, a home exercise regimen should be integrated into the rehabilitation strategy and performed alongside formal therapy.

Discontinuation of therapy can be considered when elbow discomfort resolves, there is intolerance, the treatment proves ineffective, or the patient fails to comply, including neglecting the recommended at-home exercises.


What our office can do if you have Elbow Fractures

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

We understand that this is a stressful time for you and your family. If you would like to schedule an appointment, please contact us so we will do everything we can to make it as easy on you as possible.

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