OPEN ACCESS Freely available online

International Journal of Physical Medicine and

Rehabilitation Research Article

Physiotherapy Guideline for Children with Supracondylar Fracture of

Humerus for Hospital Setting of Low-Income Countries: Clinical Commentary
Moges Gashaw*, Melisew Mekie Yitayal
Department of Physiotherapy, University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia

ABSTRACT
Background: This clinical commentary is aimed to intended to evidence based physiotherapy assessment and treatment of
children with supracondylar humerus fracture and post fracture complication that could be used for physiotherapists working
in university hospital setting and a base line, information resource and a quick reference for physiotherapists, and community
based rehabilitation workers, nurses, orthopedist and pediatrician in the management of children with supracondylar
humerus fracture and to prevent its complications.
Findings: The purpose of this clinical commentary is to summaries simple assessment tools based on international classification
of functioning and disability and simples’ physiotherapy intervention program for children with supracondylar humeral
fracture. It is very important to establish an appropriate clinical guideline for physical rehabilitation based on setting resource.
Implication: Evidence based at the same time simple and cost-effective assessment, referral imputes and physical therapy
treatment protocol can be more beneficial and easier to implement in resource limited pediatric care settings.
Keywords: Physical therapy; Rehabilitation; Exercise; Children; Fracture

ABBREVIATIONS: distal humerus and displaces it posterior; this can occur with or
ER: External Rotation; ICF-CY: International Classification of without a valgus or varus force [3]. A supracondylar fracture is
Functioning, Disability and Disease Child Youth; MeSH: Medical more common in children than in adults and often combination
Subject Headings; PEDro: Physiotherapy Evidence Database; PT: with other injuries such as a sprained or dislocated elbow or
Physiotherapy; RCT: Randomized Control Trials; ROM: Rang other fractures of the upper limb. Physiotherapy has major role
of Motion; RTA: Road Traffic Accident; SCHF: Supracondylar in SCHF of children during immobilization period as well as post
Humeral Fracture; TENS: Transcutanouse Electrical Nerve immobilization to prevent and treat complication [4,5].
Stimulation. Supracondylar fractures of humerus are classified based on
mechanism of injury as Extension type (97%-98%). It occurs
INTRODUCTION
while falling on the palm when the elbow region of the arm is
Fracture of supracondylar humerus is one of the most common extended, and arm is in abduction (5-7). According to Garlands’
fractures encountered in pediatric age group at all levels both rural classification extension type based on severity and the degree of
and urban, which had a greater rate of poor results than any other fracture displacement classified as. Type I without displacement
type of extremity fracture [1,2]. It is the second most common of fragment, Type II with displacement of fragment with contact.
injury in pediatrics’ population after distal radial fracture as Type III complete displacement without cortical contact, Type IV
result of fall on an out stretch hand and fall from the height. the extended elbow exposed to rotation which has neurovascular
Cubitusvarus with elbow range of motion (ROM) limitation is the sign. Flexion type (2%-3%) Flexion type of supracondylar
most common associated deformity associated with supracondylar fractures of humerus is considerably less frequent, and it occurs
fracture in children. the most common mechanism of injuries as a consequence of a direct stroke on the back-elbow region [6,7].
was Hyperextension during fall on out stretching hand (FOOSH)
Upper extremity fractures are more common than lower extremity
with the elbow in extension, which indirectly puts force on the
fractures in children. While the overall worldwide prevalence

Correspondence to: MogesGashaw, Department of Physiotherapy, University of Gondar Comprehensive Specialized Hospital, Gondar, Ethiopia, Tel:
+251924509390; E-mail: [email protected]
Received date: July 24, 2020; Accepted date: August 10, 2020; Published date: August 17, 2020
Citation: Gashaw M, Yitayal MM (2020) Physiotherapy Guideline for Children with Supracondylar Fracture of Humerus for Hospital Setting of Low-
Income Countries: Clinical Commentary. Int J Phys Med Rehabil. 8: 564. DOI: 10.35248/2329-9096.20.8.564
Copyright: © 2020 Gashaw M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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of SCHF is 16.6% of all childhood fractures with the annual effects more likely to be continued into adulthood [12,13]. The
incidence of SCHF is 177.3/100,000 children [8]. Supracondylar indication for physiotherapy intervention after supracondylar
fractures mostly occur between the ages of 5-10, in males and humeral fractures in children are not seen in the hospitals and
on the non-dominant side. There are variations among incidence in the literature, even if the presence of elbow joint motion
and prevalence estimates of 14.7%-34.4% from studies conducted limitation and significant cubitusvarus and valgus deformities
in different years. There are many factors that can affect the seen. The authors therefore developed physiotherapy guideline
by reviewed literatures to reduce late complication, disability in
estimates of SCHF such as gender, age, type of fracture, type
children and addressing developmental skill of children [14].
of study, study population, and socio-economic status. In the
study done in Malawi the prevalence of SCHF among children List of problems in SCHF in children according to ICF-
was reported to be 4.11/1000 which, most commonly occurred CY model
in 3-12 years children [8]. The retrospective study done in black The problem related to supracondylar humeral fractures are
lion hospital in Ethiopia showed that the prevalence of SCHF is different.It depends on the age, the type of fracture, the severity
2.96/1000 children mostly occurred in 6-13 years with fall down and the type of treatment. Most of the problems occur in the age
failedby road traffic accident (RTA) [9]. of 5-16 years of children and most of the time all problems may
not happen in a child with SCHF (Table 2) [15-17].
The clinical presentation of children with supracondylar fracture
depends on the type of injuries, mechanism of injuries, cause Table 2: Shows the list of problem seen in children with
of injuries and the severity of fracture. Physiotherapist should supracondylar fracture according to international classification
screen for Neurovascular compromise. Swollen, localized of functioning, disability, and health children and youth version
tenderness, ecchymosed, painful elbow with decreased range of (ICF-CY).
motion and gentle passive range of motion will be overtly painful,
child typically presents to the external rotation (ER) holding arm Body function and Participation
Activity limitation
structure restriction
straight in pronation and refusing to flex the elbow secondary
Difficulty of playing
to pain, for displace fracture, soft tissue injuries, bleeding,loss of
Bone fracture and loss of Difficulty of eating with peers, family
pulse,exposed bone are observed [10,11]. bone integrity on the affected side members, spouses
The prognosis of SCHF in children depends on the type of and others
fracture and early intervention of appropriate treatment. If Difficulty of
Soft tissue injuries like Less in rigorous
treated properly, elbow fractures typically heal within 6 to 8 weeks grasping, holding,
skin, nerves,arteries, and recreational
reaching, washing,
for adults and 4 to 6 weeks in children. An understanding of the veins and muscles with activities and
combing hair on the
fracture presentation, anatomic details, and surgical applications swelling,pain full elbow
affected side
playing activities
with early physiotherapy rehabilitation can optimize the chances ROM limitation in elbow, Difficulty of lifting missing/withdraw
for successful outcomes [12]. shoulder commonly ER and carrying bags from schooling
The complication of supracondylar fracture depends on the Elbow dislocation/
type of fracture and the type of treatment. The most common sublaxation, Mal union
complications of supracondylar fracture are shown on (Table 1). Post immobilization
stiffness
Table 1: Shows the most common noticeable complication of Scare and Wound
supracondylar fracture [9,12]. infection
Weakness,disuse atrophy
Early complication Late complication Compartment
Vascular injury Infection syndrome(pain,
Skin and soft tissue damage Elbow joint stiffness paresthesia, paresis,
Arm, for arm muscle weaknessand pulselessness)
Nerve injuries Deformity, cubitusvarus
atrophy
Associated for arm injuries Scar and contracture (gun stoke deformity)
Gun stoke deformity Environmental
Personal related factor
related factor
Volkmann’s ischemic contracture
Lack of family
Myositis ossificants Cooperativeness,alertness support/over
Code 71
Compartment syndrome support,
Mal union, non unionand delayed Age of child, type of Address of the
union fracture, children
Rationale of the guideline and physiotherapy interventions Stigma/social
other medical treatment rejection and
Incidence of early childhood fracture may lead long-term loneness
effects like impairments of gross and fine motor skills, lifelong Motivation problem Maternal depression
complication, psychological effect, and physical disability. These Depression, Lack of stimulation

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METHODS management [12].

Sampling A RCT aimed to determine importance of physical therapy
in treatment of displaced supracondylar humeral fractures in
This article reviews the best available evidence-based literature children with a full range of motion in the elbow joint following
pertaining the assessment and rehabilitation of children with the treatment of supracondylar humeral fractures were assessed,
supracondylar fractures. Using this information in combination together with the effects of physical therapy on improvement
with the interdisciplinary exert opinion including the present in the range of motion., with experimental group with
authors, we present a physical rehabilitation protocol for children SCHFtreated with closed reductions with early physiotherapy
with supracondylar fracture. (PT) intervention thermotherapy,interferential current, TENS
The search strategy was designed to this local physiotherapy and active and passive exercise of elbow without come measure
guideline by using PICO of pain (pediatrics’ pain rating scale) and elbow ROM (plastic
goniometry) and control group resulted that early physiotherapy
P=children with supracondylar fracture, post SCHF intervention recover full elbow ROM and function. In patients
I=conservative treatment, physiotherapy, rehabilitation who underwent physical therapy following cast removal, there was
with surgical intervention/physiotherapy treatment, during a significantly greater recovery of motion at eight weeks compared
immobilization/post immobilization. to the group that did not undergo physical therapy [19]. However,
the randomized control study done by [20] aimed to evaluate the
C=conservative treatment with surgical management efficacy of physical therapy in restoring function and mobility
O=improve elbow range of motion, functional activity, weakness, after pediatric supracondylar humeral fracture showed the return
and reduce complication of elbow motion following a supracondylar humeral fracture in
children, noting that recovery of motion took longer after a more
Electronic databases of Pub Med, Google scholar, PEDro, severely displaced fracture but early PT intervention and active
Google and Cochrane data base were used to search the articles. functional training improve the quality of life of children.
Articles published between 2000 and recent were included.
Searching was limited to physiotherapy management of children Systematic review study described the role of physiotherapy
with supracondylar fracture using the key words. Supracondylar in supracondylar fracture in pediatrics’ population Joint
humeral fracture in children during immobilization or post mobilization to improve ROM; Electrotherapy (therapeutic
immobilization, post SCHF complication and physiotherapy, ultrasound) to reduce pain and facilitate the healing process;
rehabilitation, ROM, exercise, functional activity, full search taping or bracing to prevent further damage and facilitated
was then undertaken using all identified keywords and index healing; Exercises to improve strength and flexibility; exercises to
terms across all included databases using Boolean letters like improve strength and flexibility; and family and patient Education
“AND”, and “OR” on MeSH term.Finally, the reference lists and home based exercise improve range of motion and functional
of some identified systematic reviews and RCT’s ware searched activities [21]. This study was supported with a prospective cohort
for additional studies. Full text articles written in English and study on the effect of PT on post traumatic elbow contracture in
studies done on children and adolescent until age 18 with SCHF childrenrecommend thatphysical therapy and rehabilitation on
and studied done on children post SCHF complication, which the range of the motion of the elbow joint in the post-traumatic
are considered to be, relevant to physiotherapy assessment and elbow contractures in the childhood has a good out come in
intervention were included. range of motion [22] and the study on the effect of rehabilitation
treatment on elbow contracture after supracondylar fracture in
The level of evidence of all articles has been ranked based on children recommends that thermotherapy and kinesiotherapy
the criteria of Oxford’s Centre for Evidence-Based Medicine [18] increase soft tissue elasticity to increase ROM and TENS to
(Appendix A). A systematic review included in this review was relieve pain. Passive joint mobilization and active stretching with
level AI while the rest of studies were on level AII. The level of home base exercise are effective in improving elbow joint ROM
evidence of individual studies relates to the significance of the and the functional activity of children [23].
overall conclusion about the effectiveness of an intervention.
Assessment of children with supracondylar fracture
The synthesis and results of the included studies on this
pediatrics’ protocol A well-integrated holistic assessment which includes medical,
psychosocial plan of management or advice a long with physical
A randomized control trial radiographic assessment in the therapy intervention plan is more likely to improve outcomes
treatment of supracondylar humeral fracture in children is to [24]. Assessment of children with supracondylar fracture begin
identify the healing stage after physiotherapy treatment with a in a patient enter in the OPD or in the examination room.
result of incidence of complications is low, with excellent outcome Before assessing a child with SCHF or post fracture begin with
of treatment and a faster return of children to their daily activities establishing and maintaining a good relationship with the child
[8]. Another therapeutic randomized control trial done to assess as well as with the care givers. Positive interaction will contribute
the Effectiveness of Physiotherapy after operative treatment to better therapeutic processes [25].
of supracondylar humeral fractures in children to improving
the elbow range of motion concluded that postoperative Subjective assessments are important domain in guiding the
physiotherapy is unnecessary in children with supracondylar physical examination and to set out treatment plan. Taking
humeral fractures without associated neurovascular injuries it subjective history is a key marker for the total assessment and
may be due to the severity of the fracture and the complication indicator of patient, family/caregiver expectation. History taking
was mild and the early intervention and the quality of surgical provides the time and room to build a sense of understanding

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between the family and the physiotherapist. During interview and strengthen arm, for arm and hand muscle [12,26].
patients use simple and direct communication and start with by
Early physiotherapy treatment in displaced supracondylar
introduce the name with demographic data of the patient such as;
humerus fractures in children with other medical discipline
name, age, gender, address, parent’s name with its relationship to
reduce the complication, transcutaneous electrical nerve
children, and asking Request for help/presenting complaint[26].
stimulator, active and passive elbow range of motion exercise
History of present illness which is the main part of subjective are effective for improve elbow range of motion and functional
assessment, a full patient history should be realized, including: activity and reduce pain after crossed reduction without sensory
time of injury, onset, mechanism of injury, is it a flexion or deficit. Children sustained closed supracondylar humeral
extension injury?, was the hand supinated or pronated?, the time fracture without nerve injury treated either with casting or with
of the fall/trauma, review what type of treatment was done, is closed reduction. Cryotherapy reduce swelling and immediately
there improvement, if there has been any loss of consciousness, after removing cast active strengthening exercise and elbow range
if the parents or himself is able to offer appropriate explanations, of motion exercise are effective for improving elbow and hand
the location of the pain, the type,nature, and frequency of pain. function [15].
Identify status of the child during objective assessment (depressed, Early physiotherapy active/active assisted, mechanical resistance
shyness, alert/cooperative, not focused and follow only what he/ exercise of children after supracondylar elbow fracture highly
she want to do). As much as possible, use attractive new things for recommended have better elbow functioning, with treatment
them and interactive way of playing by considering their cognitive supposed to begin within two weeks after removal of cast
effect [15]. immobilization. For children with displaced supracondylar
fracture associated with nerve injury after open reduction of
Observation is the integral part of objective assessment which
6-week muscle reeducation with biofeedback, kinesio taping and
including facial expression, localized swelling, ecchymosed,
electrical nerve stimulation are highly effective [27,28]. Children
deformity, and other skin changes at the fracture site, physical
with supracondylar fracture have difficulty of fine motor activity
deformities especially on the hand, elbow and shoulder and
like writing gripping, grasping, holding, pick objects due to
the position of the elbow, Signs and symptoms of compartment
for arm muscle weakness, range of motion limitation and lack
syndrome (pain, pulselessness, par aesthesia, pallor, paralysis),
of coordination. Functional activity training, hand muscle
the attitude of limb, and functional activity like eating, grasping,
strengthening, and coordination training in the form of play are
holding toys. In addition, palpation of temperature, isolated
the basic treatment.
point tenderness over area of humerus that was fractured and
lateral supracondylar humeral fractures tend to present with CONCLUSIONS AND RECOMMENDATIONS
greater deformity than lateral humeral supracondylar fractures
are a part of objective assessment [12]. TSupracondylar fracture is an injury with great magnitude and a
considerable soft tissue injury. Although the metaphysical bone
Assessment based on body functions and structure level in pediatrics age is healing rapidly, after removal of the cast after
It is important to remember that gunstock deformity and elbow three weeks, loss of range of motion is common. The major
and wrist joint were the main common complication associated functional problem appears to be changes in elbow mobility,
with supracondylar fracture.In order to measure used plastic either loss of flexion or loss of extension or hyperextension.
goniometry with use range of motion for children according to Active range of motion is started at the child’s own pace followed
(Bern beck) (Appendix B). by physiotherapy. The goals of physical therapy are rapid recovery
Through examination will be one of the key components in the of motion and avoidance of late complications. Physiotherapy
assessment of children with SCHF. Among them measuring the has vital role during immobilization and post immobilization
range of motion of elbow, shoulder wrist; muscle strength with in children with supracondylar fracture to maintain and restore
manual muscle testing; neurological examination like sensation; range of motion, prevent complication. Elbow range of motion,
assess radial nerve injury with wrist extension and sensation elbow function, reduce pain, swelling good hand function and
in the dorsal aspect of the first web space and assess median radiological finding are the main outcome indicator for discharge.
nerve injury with the patient’s ability to make the “ok sign” and
Children with displaced supracondylar fracture associated with
sensation over the palm tip of the index finger (autonomous area
of the median nerve) ulnar nerve injury with strength testing of nerve injury after open reduction muscle reeducation with
intrinsic muscles of the hand and sensation over the palm tip biofeedback, kinesio taping are highly effective and passive
of the little finger; muscle girth measurements; and vascular mobilization with activity modification stretching are the best
examination by check the pulse [15]. treatment for elbow contracture followed with supracondylar
Physical therapy interventions for children with humeral fracture.
supracondylar fracture ACKNOWLEDGEMENTS
The management of supracondylar humeral fracture is a We thank you University of Gondar, school of Medicine for
multidisciplinary team the physiotherapist should involve
their help in access to University subscribed databases and
in decision making, assessment and treatment. For older
children from age 4-16 passive joint mobilization with soft BalamuruganJankrman (Associate professor of physiotherapy) for
tissue manipulation and active functional exercise after surgical his unlimited technical comments.
intervention are highly recommended for improving elbow ROM FUNDING

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No funding agency or organization. This guideline will be done physiotherapy after operative treatment of supracondylar humeral
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recovery of elbow range of motion after treatment of supracondylar
AVAILABILITY OF THE DATA AND MATERIALS and lateral condylar fractures of the distal humerus in children. J
Not applicable Orthop Trauma. 2009;23(2)120-125.
14. Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective
ETHICAL APPROVAL AND CONSENT TO
longitudinal evaluation of elbow motion following pediatric
PARTICIPATE supracondylar humeral fractures. J Bone Joint Surg Am. 2010;92(4):
Not required 904-910.
15. Coppola SM, Collins SM. Is physical therapy more beneficial than
COMPETING INTERESTS unsupervised home exercise in treatment of post surgical knee
The authors declare no conflict of interest disorders? A systematic review. Knee. 2009;16(3): 171-175.
16. Organization WH. International Classification of Functioning,
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medicine 17. Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of
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