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:-
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History of fall followed by pain, swelling, S-shaped deformity, and inability to move the affected elbow.
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When presented early-unusual prominence of the point of the elbow (Tip of olecranon).
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When presented late-radial and ulnar pulses may be absent with or without signs of ischaemia.
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Injury to the median nerve (pointing index) or radial nerve (wrist drop).
Treatment –
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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.
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Closed reduction.
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ORIF.
Complications-
1. Intermediate
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Injury to the brachial plexus.
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Injury to the peripheral nerves – the median nerve is most commonly injured.
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Radial and Ulnar nerves are also affected.
2. Early
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Volkmann’s ischaemia.
3. Late
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Malunion – leads to gunstock deformity (cubitus varus).
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Myositis ossificans.
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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:-
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Elbow extensor and flexor.
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Forearm supinator and pronator.
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Wrist flexor and extensor.
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Deltoid.
Occupational Therapy Management –
Day Of injury to week 1 –
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No internal/external rotation of the shoulder.
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No passive ROM of the elbow, (to prevent myositis ossificans).
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Weight-bearing is not allowed on the affected extremity.
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Begin AROM of the finger and MCP joint.
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Instruct the patient in gentle pendulum exercises to allow shoulder ROM.
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Flexion and extension exercises of the fingers and adduction and abduction exercises for Intrinsic strengthening are instituted.
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Gentle active elbow flexion and extension allowed for stable fractures treated in ORIF.
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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-
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No weight bearing on the affected extremity.
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Continue AROM of the digit.
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If the fingers are swollen, instruct the patient in retrograde massage from the tips of fingers towards the palm.
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Continue pendulum exercises at the shoulder to prevent adhesive capsulitis.
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Internal and external rotation of the shoulder should be avoided.
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Ball squeezing or Therapeutic Putty is used to strengthen the finger grasp (grip strengthening).
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The un-involved extremity is used for ADL.
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No PROM to the elbow.
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Gentle active flexion and extension exercises for the elbow for fractures treated with ORIF.
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Gentle AA flexion and extension for non-displaced stable fractures.
4-6 weeks-
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Weight-bearing is not allowed on the affected extremity.
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Continue ROM of the fingers and pendulum exercises of the shoulder.
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Continue grip strengthening and isometric exercises for the forearm musculature.
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AAROM to the Elbow in gravity eliminated position, use of roller skates.
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Active flexion and extension of the elbow are initiated in the prone position or using a Knee rachet or roller skates.
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Relaxed swinging elbow flexion with supination and elbow extension with pronation is ideal.
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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-
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If the fracture is united, PROM exercises should be combined with the active programme.
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Emphasis should be placed on achieving full flexion, extension, supination and pronation.
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ROM exercises of the fingers, wrist and shoulder are continued.
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Gentle resistive exercises can begin with elbow flexion/extension.
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Weights (starting with 1-2 pounds) are used against gravity.
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Kinetic activities are taught, such as shoulder wheel or wand exercises (raising it above the head and moving it side to side).
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Grip strengthening is continued.
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Avoid heavy lifting or pushing.
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Involved extremity is used for ADL (Self-care and personal hygiene).
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Full weight-bearing by 12 weeks.
