Prompt Physiotherapy Rehabilitation a Boon for Early Resolution of Trait in a Patient with Supracondylar Fracture: A Case Report
Sakshi Shah1, Neha Agrawal1, Dr Junneshwar Bidve2, Dr Tushmeetkaur Bhatia3, Dr Ashwin Kshirsagar4
1. Undergraduate student, MGM School of Physiotherapy 2. Associate Professor, MGM School of Physiotherapy.
3. Assistant Professor, MGM School of Physiotherapy.
4. Assistant Professor, MGM School of Physiotherapy.
1. Sakshi Shah1
Undergraduate student, MGM School of Physiotherapy, Aurangabad Contact No. +9180808006747, Email: [email protected]
2. Neha Agrawal1, Undergraduate student MGM School of Physiotherapy, Aurangabad.
3. Dr Junneshwar Bidve2
Associate Professor, MGM School of Physiotherapy Cardiorespiratory Physiotherapy Department, Aurangabad.
Contact No.: +919619660779, Email: [email protected] 4. Dr Tushmeetkaur Bhatia3 (Corresponding Author)
Assistant Professor, MGM School of Physiotherapy Sports Physiotherapy Department, Aurangabad.
Contact No.: +919049607007, Email: [email protected] 1. Dr Ashwin Kshirsagar4
Assistant Professor, MGM School of Physiotherapy Sports Physiotherapy Department, Aurangabad.
Contact No.: +919579076688, Email:[email protected]
ABSTRACT
BACKGROUND- A supracondylar fracture of humerus is a fracture of the distal end of the humerus. Most of these fractures arise as a result of fall from a height or due to fall on an outstretched hand. Undisplaced fractures are best managed by immob ilizing the area using a cast or a splint. Displaced fractures are managed surgically by closed reduction and percutaneous pinning fixation.
CASE DESCRIPTION- Presenting a case of 49 Y/O Male with a supracondylar fracture
of humerus who fell off of his bike on right side and was diagnosed with X-ray. He was managed surgically by closed reduction and percutaneous pinning fixation. Patient presented with the following complains post-operatively, i.e., pain at the incision site, swelling around the elbow joint and reduced movement at the elbow and shoulder joint.
Patient underwent a 6 weeks physical therapy rehabilitation program after the surgery and showed tremendous improvement in pain score, range of motion, muscle strength and functional activities.
RESULT- The results demonstrated significant improvement in range of motion, muscle strength and pain reduction.
CONCLUSION- Immediate and prompt Physiotherapy Rehabilitation program for a post- operative case of supracondylar fracture can facilitate the activities of daily living and improved quality of life.
KEYWORDS- Physical Therapy, Supracondylar fracture, Closed Reduction, Rehabilitation
INTRODUCTION
Elbow fractures are more common in children than they are in adults. Supracondylar humeral fractures account for up to 18 per cent of all paediatric fractures and up to 60% of all elbow fractures.1The majority of elbow fractures occur when a child falls on an outstretched arm, causing hyperextension. A fall on a flexed elbow can cause flexion-type fractures; although they are uncommon.2The AO/ASIF group recommends open reduction and internal fixation with two plates as the “gold standard” of treatment for this fracture.3 For closed injuries, surgical management involves closed reduction and percutaneous pinning with K-wires.Displaced fractures may require surgical care, which is dependent on the type and severity of the fracture. A plate or a Seidel nail is used to treat transverse and short
oblique fractures. For segmental fractures or diaphyseal fractures associated with humeral
neck fractures, multiple flexible intramedullary wires are used.4 In patients who have been deconditioned by illness, surgery, or trauma, physical therapy may
help them regain their normal function.5-10 Changes in elbow mobility, such as loss of flexion, extension, or hyperextension, tend to be
the main functional issue. Physical therapy aims to help patients regain their range of motion quickly and prevent late complications. In children with supracondylar fractures, physiotherapy is critical during and after immobilisation to preserve and regain range of motion and avoid complications. The key outcome indicators for discharge are elbow range of motion, elbow function, reduced pain, swelling, strong hand function, and radiological findings.11 Following supracondylar humerus fractures, elbow joint stiffness is a common complication.
The complexities of establishing a complete range of motion in the elbow joint following the treatment of supracondylar humerus fractures, as well as the impact of physical therapy on range of motion improvement, were investigated in a prospective review.12
PATIENT INFORMATION
Presenting a case of 49 y/o male, Teacher by occupationwith a history of fall from his bike on right side on 9th January 2021. The patient fell with his hand (arm?) completely extended. He was taken to the hospital immediately and was admitted to orthopaedic ward. The patient's right elbow was temporarily managed by plaster and further investigations were carriedout.
No history of head injury was present. The patient was well oriented to time, place and person. Patient has a known medical history of Type 2 Diabetes Mellitus and Hypertension since past 10 years and is on regular medications for the same.
X-ray of right elbow was done on the same day of fall which revealed supracondylar fracture of humerus on right side.
Operation was planned after 12 days because of increased sugar level and which is now managed by medications. Meanwhile the patient was managed by a plaster cast. Closed Reduction and percutaneous pinning fixation was done. Patient was shifted to ward for further management and rehabilitation. Physiotherapy was started after 1 month of surgical intervention.
CLINICAL FINDINGS
A proper informed consent was taken from the patient prior to treatment. Patient presented with chief complaint of pain at the right elbow at the site of incision. Physical examination was done and all of his vitals which involved pulse rate, blood pressure, SPO2 and
temperature were within the normal limits.
Patient was examined in supine position. On inspection, patient’s right elbow appeared angulated and the upper extremity was shortened. Flexion attitude (30° - 35°) of right limb was observed. Marked swelling was present on right elbow along with grade 2 tenderness.Range of motion of right elbow joint , shoulder joint and wrist joint was reduced owing to stiffness of these joints. Patient showed postural deviations which involved forward head posture, protracted shoulders.
Pain Assessment :
Intensity- 9 on NPRS at rest (Pre rehabilitation) 0 on NPRS at rest (Post rehabilitation) 1 on NPRS on activity (Post rehabilitation)
Area of pain – Right elbow joint Type of pain- Sub-acute pain
There were no 24-hour behavioural changes noted.
Sleep –Disturbed because of pain in elbow and shoulder
The Range of Motion was assessed using goniometer and readings are mentioned in Table 1.
The strength was assessed using Manual Muscle Testing and readings are mentioned in Table 2.
Activity limitation-Eating, Dressing, Combing hair, driving vehicle.
Diagnostic Criteria –
Radiological investigations were done which involved X-ray imaging. The preoperative X- ray taken on the day of the accident showed Right supracondylar fracture of humerus.
Subsequently, instantaneous post-operative X-ray was taken which exhibited successful open reduction, internal fixation using screws, metal plates and K-wires.
Blood investigations were done as well.
Physiotherapy goals-
To reduce swelling at Right elbow joint.
To reduce pain at Right elbow joint.
To reduce pain at Right Glenohumeral joint.
To reduce joint stiffness at Right Elbow joint To improve ROM at Right elbow joint.
To improve ROM at Right Glenohumeral Joint.
To improve strength at Right Glenohumeral joint.
To improve strength at Right elbow joint.
Therapeutic Intervention –
Week 0-1 – Electrotherapeutic modality which included Transcutaneous Electrical Nerve Stimulation (TENS) was initiated for 15 minutes. This aided in reducing pain at right glenohumeral and right elbow joint. Early mobilization at the elbow joint involved Grade 1 dorsal and volar glide in order to improve elbow flexion and extension. In addition to this, grade 1 PA glide as well as inferior glide was imparted to improve shoulder ROM. Passive ROM exercises at Right shoulder and right elbow were given. Isometric contraction exercises were initiated. Contrast bath therapy for 15 minutes was provided thrice a day.
Dosage for TENS - Mode- Continuous Frequency- 120 Hz
Duration- 15 minutes, everyday Intensity- As tolerated by the patient.
Week 2-4 – Patient was progressed from passive ROM exercises to Active-Assisted ROM exercises using the wand for shoulder and elbow. Maitland mobilization technique involving grade 2 dorsal and volar glide at right elbow joint was given and grade 2 PA glide and inferior glide for the shoulder. Electrotherapeutic modality, TENS was continued till the end
of 2nd week. AAROM exercises were then switched to Active ROM exercises of right shoulder and right elbow. Simultaneously, strengthening for scapular muscles was initiated by performing wall push-ups. Muscle Energy Technique (MET) by using Hold and Relax method at different ranges for shoulder and elbow joints were performed. Pendular exercises of the shoulder were practiced.
Week 4-6 – Progressive Resistance Training was gradually begun. Repetitive Maximum was calculated using Delorme’s principle and exercises were prescribed accordingly. Equipment’s such as Thera-bands and dumbbells were used for improving the strength of the shoulder and elbow muscles.
The post treatment analysis of ROM and Manual muscle testing is given in Table 3 and Table 4 respectively.
Result – The results were calculated based on the pre-rehabilitation and post-rehabilitation readings which demonstrated significant improvement in range of motion, muscle strength and pain reduction at right glenohumeral and right elbow joints.
Discussion – A study reported that the physiotherapist should be included in the decision- making, evaluation, and care of supracondylar humeral fractures as part of a multidisciplinary team. Since surgical operation, passive joint mobilisation with soft tissue massage and aggressive physical exercise are strongly recommended for older children aged 4 to 16 to improve elbow ROM and reinforce shoulder, arm and hand muscle.13,14
Another study revealed that early physiotherapy procedure of displaced supracondylar humerus fractures of children with other medical disciplines reduces complication, and transcutaneous electrical nerve stimulator, active and passive elbow range of motion exercises are successful in improving elbow range of motion and functional performance, as well as reducing discomfort after crossed contraction without sensory deficit.15
One more study suggested that TENS is helpful at reducing discomfort and pain following orthopaedic surgery, and it's recommended that it can be used in conjunction with medicine to get the best results.16
In addition, a study recommended isometric motions therapy as the efficient tool for relieving discomfort and reversing muscle strength of injuries, and it is also prescribed by orthopaedic physicians since it speeds up healing and allows patients to return to daily activities sooner.17
Furthermore, in another study the joint mobilisation care provided to the participants resulted in a substantial increase in AROM and a decrease in joint stiffness during a treatment session.
When tested both actively and with managed force, this shows that joint mobilisation changes the mechanics of the joint and increases excursion.18A study also reported that in a recovery environment, a supervised strength-training regimen is implemented. These patients will benefit from high-intensity resistance exercise, which can help them improve their body function, strength, and coordination. Functional efficiency adaptation seems to be influenced by resistance exercise experience.19Thus, classical surgical approach and well-structured physical rehabilitation program aids in improving the functional goals progressively which majorly influences a successful recovery rate.
Conclusion – Immediate and prompt Physical Rehabilitation program for a post-operative case of supracondylar fracture can facilitate the activities of daily living and improved quality of life.
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