Supracondylar Fracture of the Humerus

The commonest fracture in children.

Mode of injury:-Caused by a fall on an outstretched hand, the elbow is forced into hyperextension, resulting in the fracture of the humerus above the condyles.

Types:-

1. Extension type – the distal fragment is displaced posteriorly. It is the commonest type (80%).

2. Flexion type-The distal fragment is displaced anteriorly. (20%)

Clinical features:-

• History of fall followed by pain, swelling, S-shaped deformity, and inability to move the affected elbow.

• When presented early-unusual prominence of the point of the elbow (Tip of olecranon).

• When presented late-radial and ulnar pulses may be absent with or without signs of ischaemia.

• Injury to the median nerve (pointing index) or radial nerve (wrist drop).

Treatment –

• An un-displaced fracture requires immobilisation in an above elbow plaster slab with the elbow in 90° flexion and Extension type. Inflexion type, the elbow is extended for 3 weeks.

• Closed reduction.

• ORIF.

Complications-

1. Intermediate

• Injury to the brachial plexus.

• Injury to the peripheral nerves – the median nerve is most commonly injured.

• Radial and Ulnar nerves are also affected.

2. Early

• Volkmann’s ischaemia.

3. Late

• Malunion – leads to gunstock deformity (cubitus varus).

• Myositis ossificans.

• Volkmann’s ischaemic contracture.
  

Occupational Therapy Goals-

- Restore and maintain the full ROM of the elbow.

- Prevent the normal carrying angle of the elbow.

- Restore the full range of shoulder motion.

- Improve the strength of the following:-

• Elbow extensor and flexor.

• Forearm supinator and pronator.

• Wrist flexor and extensor.

• Deltoid.

Occupational Therapy Management -

Day Of injury to week 1 –

• No internal/external rotation of the shoulder.

• No passive ROM of the elbow, (to prevent myositis ossificans).

• Weight-bearing is not allowed on the affected extremity.

• Begin AROM of the finger and MCP joint.

• Instruct the patient in gentle pendulum exercises to allow shoulder ROM.

• Flexion and extension exercises of the fingers and adduction and abduction exercises for Intrinsic strengthening are instituted.

• Gentle active elbow flexion and extension allowed for stable fractures treated in ORIF.

• The uninvolved extremity is used for ADL. Clothes are donned to the involved extremity first and doffed from the uninvolved extremity first.

Week 2-3-

• No weight bearing on the affected extremity.

• Continue AROM of the digit.

• If the fingers are swollen, instruct the patient in retrograde massage from the tips of fingers towards the palm.

• Continue pendulum exercises at the shoulder to prevent adhesive capsulitis.

• Internal and external rotation of the shoulder should be avoided.

• Ball squeezing or Therapeutic Putty is used to strengthen the finger grasp (grip strengthening).

• The un-involved extremity is used for ADL.

• No PROM to the elbow.

• Gentle active flexion and extension exercises for the elbow for fractures treated with ORIF.

• Gentle AA flexion and extension for non-displaced stable fractures.

4-6 weeks-

• Weight-bearing is not allowed on the affected extremity.

• Continue ROM of the fingers and pendulum exercises of the shoulder.

• Continue grip strengthening and isometric exercises for the forearm musculature.

• AAROM to the Elbow in gravity eliminated position, use of roller skates.

• Active flexion and extension of the elbow are initiated in the prone position or using a Knee rachet or roller skates.

• Relaxed swinging elbow flexion with supination and elbow extension with pronation is ideal.

• The un-involved extremity is used for ADL. If internal fixation is done, the patient uses the involved extremity for eating and light activities.

8-12 weeks-

• If the fracture is united, PROM exercises should be combined with the active programme.

• Emphasis should be placed on achieving full flexion, extension, supination and pronation.

• ROM exercises of the fingers, wrist and shoulder are continued.

• Gentle resistive exercises can begin with elbow flexion/extension.

• Weights (starting with 1-2 pounds) are used against gravity.

• Kinetic activities are taught, such as shoulder wheel or wand exercises (raising it above the head and moving it side to side).

• Grip strengthening is continued.

• Avoid heavy lifting or pushing.

• Involved extremity is used for ADL (Self-care and personal hygiene).

• Full weight-bearing by 12 weeks.