Professional Documents
Culture Documents
Gashaw & Yitayal (2020)
Gashaw & Yitayal (2020)
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.
Int J Phys Med Rehabil, Vol.20 Iss.08 No:1000564 Volume 20 • Issue 8 • 1000564
Gashaw M OPEN ACCESS Freely available online
Page 2 of 5
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
Page 3 of 5
Page 4 of 5
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
Page 5 of 5
No funding agency or organization. This guideline will be done physiotherapy after operative treatment of supracondylar humeral
without help of government/research organization. Rather it is fractures in children. J PediatrOrthop. 2005;25(3): 314-316.
by the interest of the authors. 13. Wang YL, Chang WN, Hsu CJ, Sun SF, Wang JL, Wong CY. The
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,
SUPPLEMENTARY DATA Disability, and Health: Children and Youth Version: ICF-CY, World
Appendix A: Criteria of Oxford center for evidence-based Health Organization. 2007.
medicine 17. Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of
elbow motion after percutaneous pinning of pediatric supracondylar
Appendix B: Range of motion for children according to Bernbeck
humerus fractures. ClinOrthopRelat Res. 2009;467(8): 2007-2010.
REFERENCES 18. Group OLOEW. Oxford Centre for Evidence-Based Medicine 2011.
1. Kumar V, Singh A. Fracture supracondylar humerus: A review. J 2018. Awailable from: https: //www. cebm. net/2016/05/ocebm-
ClinDiagn Res. 2016;10(12): RE01-RE06. levels-of-evidence.
2. Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper 19. Bogdan M, Mikov A. The role of physical therapy in the treatment
extremity injuries. PediatrClin North Am. 2006;53(1): 41-67. of post-traumatic contracture of the elbow in children. Med Pregl.
2017;70: 58-61.
3. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in
children. J Bone Joint Surg Am. 2008;90(5): 1121-1132. 20. Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of benefit
of physical therapy on function following supracondylar humeral
4. Abzug JM, Herman MJ. Management of supracondylar humerus fracture: A randomized controlled trial. J Bone Joint Surg Am.
fractures in children: Current concepts. J Am AcadOrthop Surg. 2014;96(11): 944-950.
2012;20(2): 69-77.
21. Vigneron CJM. Supracondylar humeral fracture in the pediatric
5. Mostafa KM. Displaced supracondylar fractures of the humerus in population: role of the physiotherapy. University of Zagreb. School of
children. Egypt Orthop J. 2017;52(2): 153-157. Medicine. Chair of Pediatrics. 2014.
6. Awasthi B, Raina SK, Chauhan N, Sehgal M, Sharma V, Thakur L. 22. Popovic DB, Popovic MB, Sinkjær T, Stefanovic A, Schwirtlich L.
Anthropometric characterisation of elbow angles and lines among Therapy of paretic arm in hemiplegic subjects augmented with
Indian children. Adv Hum Biol. 2017;7(2): 71-74. a neural prosthesis: Across-over study. Can J PhysiolPharmacol.
7. Pirone A, Graham H, Krajbich JI. Management of displaced 2004;82(8-9): 749-756.
extension-type supracondylar fractures of the humerus in children. J 23. Divjakovic M, Mikov A. Effects of rehabilitation treatment and
Bone Joint Surg Am. 1988;70(5): 641-650. characteristics of elbow contracture after supracondylar fractures in
8. Young S, Fevang JM, Gullaksen G, Nilsen PT, Engesæter LB. childhood. ExerQual Life. 2010;2(2): 51-62.
Deformity and functional outcome after treatment for supracondylar 24. Babal JC, Mehlman CT, Klein G. Nerve injuries associated with
humerus fractures in children: A 5 to 10 year follow-up of 139 pediatric supracondylar humeral fractures: A meta-analysis. J
supracondylar humerus fractures treated by plaster cast, skeletal PediatrOrthop. 2010;30(3): 253-263.
traction or crossed wire fixation. J Child Orthop. 2010;4(5): 445-453.
25. Shrader MW. Pediatric supracondylar fractures and pediatric physeal
9. Admassie D, Ayana B, Girma S. Childhood limb fracture at elbow fractures. OrthopClin North Am. 2008;39(2): 163-171.
TikurAnbessaSpecialised Hospital (TASH), Addis Ababa, Ethiopia.
East Cent Afr J surg. 2015;20(1): 27-31. 26. Jha SC, Shakya P, Baral P. Efficacy of Physiotherapy in Improving
the Range of Motion of Elbow after the Treatment of Pediatric
10. Mulpuri K, Wilkins K. The treatment of displaced supracondylar Supracondylar humeralfracture. BJHS.2018;3(2): 432-436.
humerus fractures: evidence-based guideline. J PediatrOrthop.
2012;32(2): S143-S152. 27. Jandric S. Therapeutically effect of the physical procedures on the
elbow contractures in children with supracondylar humerus fractures.
11. Garg S, Weller A, Larson AN, Fletcher ND, Kwon M, Schiller J, et al. ActaChirIugosl. 2007;54(2): 39-43.
Clinical characteristics of severe supracondylar humerus fractures in
children. J PediatrOrthop. 2014;34(1): 34-39. 28. Hackl M, Leschinger T, Uschok S, Müller LP, Wegmann K.
Rehabilitation of elbow fractures and dislocations. ObereExtremität.
12. Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of 2017;12: 201-207.