Fracture of the epicondyles of the humerus: rehabilitation and physical therapy

Fracture of the epicondyle of the humerus

A supracondylar humerus fracture is a fracture of the distal end of the humerus just above the elbow joint. The cross-section of the shaft of the humerus is somewhat circular in shape, becoming progressively flatter as it descends downward to meet the distal end of the humerus [1].

The distal end of the humerus consists of both articular and non-articular structures. The non-articular part consists of the medial epicondyle, lateral epicondyle, anterior coronoid and radial fossa and posterior olecranon fossa. While the articular part includes the lateral head, which articulates with the radial head, and the medial acetabulum, which articulates with the ulna.

The medial epicondyle is the common origin of the forearm flexor musculature, and the ulnar nerve passes in a groove on the posterior aspect of this epicondyle. The lateral epicondyle is the site of the common origin of the extensor muscles of the forearm. These muscle attachments are responsible for the displacement and rotation of the distal fragment [2]. In the anterior part of the distal humerus, the brachial artery and median nerve may pass through [1]. The brachial artery, which is usually involved in a supracondylar fracture of the humerus, runs along the anteromedial part of the distal humerus, located superficial to the brachialis muscle [2]. The radial nerve passes between the brachialis and brachioradialis muscles before crossing the elbow and entering the supinator [2].

Epidemiology

Supracondylar humeral fractures are the most common humeral fracture in children, with an average age of 6 years and a peak incidence between ages five and eight years.
This is the second most common bone injury among the pediatric population [3].
It accounts for 55% to 80% of all pediatric elbow fractures and up to two-thirds of pediatric elbow injuries requiring hospitalization.
Their incidence is estimated at 177.3 cases per 100,000 people.
A higher incidence of supracondylar fractures is observed in boys, affecting the non-dominant hand 1.5 times more often.
About 10-20% of displaced supracondylar fractures are accompanied by changes in vascular status. In most cases, fracture reduction restores perfusion.
Injuries to the nervous system occur in 6.5 - 19% of cases associated with displaced fractures. Most of them are neuropraxia [4].

Mechanism of injury/etiology

Children are predisposed, especially at an age when the supracondylar bone undergoes skeletal maturation and has a thin and weak cortex. The process of ossification of the distal humerus occurs at different ages. The supracondylar region undergoes remodeling between 6 and 7 years of age and is typically thinner and with a thinner cortex, predisposing this region to fracture [5][2].

The anatomy of the distal humerus is particularly prone to injury because its configuration as two columns connected by thin bone represents an area of weakness [4].

Supracondylar fractures usually occur as a result of a fall from a height, sports or recreational activities, or a fall on an outstretched arm.

Extensor type injuries (97% to 99%) are more common than flexion type injuries (1-3%) [4].

When a fall occurs on an outstretched arm, the olecranon engages the olecranon fossa, and as elbow extension progresses, the olecranon finally acts as a fulcrum on the fossa. While the anterior capsule of the elbow joint creates an anterior tensile load, leading to fracture and destruction of the anterior periosteum. Therefore, the bone begins to break first from the front, and the fracture progresses from the back. If the energy is high, the posterior cortex is destroyed and finally there is complete posterior displacement of the distal fragment, with the posterior periosteum acting as a hinge. This is the mechanism of extension type fractures [4].

Flexion-type fractures are usually caused by direct trauma to a flexed elbow. In these cases, the anterior periosteum acts as a hinge and the progression of injury is from the posterior to the anterior portion of the distal humerus. The distal fragment also tends to be translated into the coronal plane [4][2].

Clinical picture

A supracondylar fracture is often associated with associated forearm fractures, soft tissue injury, neurological injury, and a significant risk of compartment syndrome, so careful evaluation of the entire upper extremity should be performed. It includes: [2][4]

Anamnesis

The classic story of a fall on an outstretched arm followed by pain and swelling over the elbow with loss of upper limb function, the onset of pain deserves special attention.
It is very important to know whether the pain is caused by a fracture or muscle ischemia, which occurs late (several hours after injury) [2].

Inspection

Painfully swollen elbow and forearm with poor mobility [2].
Ecchymosis, skin wrinkling (this sign appears when the proximal fragment crosses the brachialis muscle, “wrinkling” the deep dermis), bruises [4]
Bleeding puncture wound (indicates an open fracture)
In displaced extensor-type fractures, a so-called “S-strain” is usually present [4].

Vascular status assessment:

Vascular compromise exists in 10-20% of displaced fractures. Both the radial and ulnar pulses should be palpable at the wrist of the injured limb. In the case of pulselessness (pulseless arm), other signs of perfusion should be checked, namely color (arm should be pink), temperature, capillary refill (less than 2 seconds) and oxygen saturation on a pulse oximeter [2].

Classification:

Class I - good perfusion (warm and red) with radial pulse
Class II – good perfusion, but no radial pulse
Class III – poor perfusion (cold and blue or pale) and absent radial pulse

Neurological status:

The extent of the lesion and possible progression/regression of nerve symptoms are mandatory before and after treatment. Neuropraxia is common and usually resolves with restoration of normal alignment and length [2]. Neuropraxia usually resolves within two to three months.

The anterior interosseous nerve branch (AIN) of the median nerve is most susceptible to involvement in posterolateral displacement of the distal fracture fragment. On physical examination, the child may have no loss of sensation in the hand but a weak "OK" sign (eg, more like a pincer grasp than an "OK" sign).
Radial nerve injury most often occurs when the distal fracture fragment is displaced posteromedially. It can be detected by decreased sensation in the dorsum of the hand and weak wrist extensors.
The ulnar nerve is susceptible to flexion injuries such as supracondylar fractures, and loss of sensation in its branches can be detected with weakness of the intrinsic muscles of the hand [2][4].

Compartment syndrome: Severe swelling and/or ecchymosis, wrinkling of the anterior skin and impaired vascularity with severe pain.

Diagnostic procedures

Radiographs should include an anterior view of the distal humerus (not the elbow) and a lateral view of the elbow. With minimal or no displacement, these fractures may not be visible on radiographs. The only sign will be a positive fat pad sign [2].

Lateral projection

The lateral view also allows assessment of the degree of displacement and integrity of the posterior cortex of the bone.

The following radiological parameters are visible on the lateral image: Anterior humeral line; Coronal line; Fish tail sign; Sign of a fat pad; (In the front and in the back).

Orientation of the anterior humeral line to the head of the condyle in lateral projection

The normal line of the elbow continues the anterior cortex of the humerus and should intersect the head along its middle third line.
Extensor type injury: head posterior to line
Flexion type injury: head in front of the line [3]

Front projection

Helps assess direction of displacement, presence of varus or valgus alignment, and extent.

Bauman's angle (brachial capillary angle) on the anterior projection

The angle between a line perpendicular to the long axis of the humeral shaft and the line of the head of the condyle is used to assess varus or valgus alignment of the distal humerus.
Normal range – 64° to 82° degrees
Decreased angle – varus rotation with possible fragmentation of the medial column

Ulnar displacement angle in anterior projection

The angle formed by the diaphyseal axis of the humerus and the axis of the proximal third of the ulna.
It is also used to assess varus or valgus deformity and is more accurate and useful than Baumann's angle [4].

Classification of supracondylar fracture

Modified Gartland (2006) classification of supracondylar fractures (based on lateral radiograph): [5][4][7]

Type I

Not displaced or minimally displaced (<2 mm) with an intact anterior line of the humerus
No periosteal rupture – stable fracture
Only signs of a fat pad can be found

Type II

Displaced (>2 mm) with hinged intact posterior cortical bone
On lateral radiographs, the anterior humeral line does not pass through the middle third of the head
There is no rotational deformity on the anterior radiograph

Type III

Displacement without significant cortical contact, usually extension in the sagittal plane and rotation in the frontal/horizontal plane
Significant damage to the periosteum, soft tissues, blood vessels and nerves
Destruction of the medial column and collapse with malrotation in the frontal plane

Type IV

Multidirectional instability
Incompetent periosteal hinge circumferentially, with instability in flexion and extension

Complications of a supracondylar fracture [2]

Immediate complications are associated with damage to the neurovascular system, including

Vascular insufficiency/pink pulsating arm—brachial artery involvement is most commonly associated with type II and III supracondylar fractures, which are common in posteriorly displaced fractures.
Compartment syndrome: It may occur in 0.1-0.3% of cases. Associated forearm fractures and elbow flexion >90° increase compartment pressure. To minimize the risk of compartment syndrome, the elbow should be immobilized to approximately 30° of flexion in the emergency department and 60° to 70° postoperatively [2].
Neurologic deficits account for 10 to 20 percent of supracondylar fractures and are primarily associated with type III supracondylar fractures [4].
Open or associated fractures of the forearm

Long-term complications in children are due to the fact that the bones in this age group are in a growth phase and also have the ability to remodel. Thus, the long-term functional outcome and radiographic appearance of the fracture may differ slightly from that immediately after treatment.

Elbow varus deformity: This is caused by malalignment and is also known as “butt” deformity. Post-traumatic elbow varus has important problems that are associated with delayed ulnar nerve palsy, delayed posterolateral rotational instability, displacement of the medial head of the triceps muscle, and secondary distal humerus fractures. Modern surgical techniques (eg, closed reduction with percutaneous fixation) have reduced its incidence from 58 percent to approximately 3 percent in children treated for supracondylar fractures. Humeral osteotomy is used to correct this deformity and prevent such late complications [4].
Volkmann's ischemic contracture: If compartment syndrome is not promptly treated, the associated ischemia can progress to infarction and subsequent development of Volkmann's ischemic contracture: fixed elbow flexion, forearm pronation, wrist flexion, and extension of the metacarpophalangeal joint [2].

Treatment

Medication

Treatment of a supracondylar fracture is determined based on the type of fracture based on the Modified Gartland classification.

Type I (Undisplaced fracture)

Immobilization with a cast or splint over the entire arm.
With elbow flexion up to 80°-90° and moderate pronation-supination, it is well tolerated for ~3 weeks.
Elbow flexion in a cast should not exceed 90° as this may increase pressure on the forearm and impede distal vascular flow.
X-ray control after 1 and 2 weeks

Type II

Closed reduction and percutaneous fixation rather than immobilization are recommended as the risk of complications is low. The pins are removed in the hospital approximately three weeks after surgery [8].

Type III and Type IV

Closed reduction and percutaneous fixation is the gold standard for all displaced fractures and is widely used for type III and IV fractures.
Open reduction shown:

Impossibility of closed reduction
When soft tissue entrapment occurs (eg muscle, median nerve, brachial artery) or
When the cold arm remains unperfused after a closed reduction has been attempted.

With open reduction, there is an increased incidence of infection, stiffness, and myositis ossificans. The anterior approach is the most widely used approach for open reduction, primarily when vascular repair is required. The lateral approach is standard for elbow surgery, but a supracondylar fracture increases the risk of radial nerve injury and stiffness. The bilateral posterior approach (Alonso-Lames approach) is not recommended because it has a high rate of reported complications such as stiffness, unsightly scarring, and the risk of osteonecrosis of the acetabulum.

Physiotherapy

Physical therapy treatment is vital for all patients with a supracondylar fracture to promote healing and ensure optimal outcome. The purpose of physiotherapeutic treatment is:

Achieve painless and full mobility of the elbow joint.
To enhance the healing process.
To strengthen affected muscles.
To improve the overall functional abilities of children.

Outcome measures that can be used to compare and evaluate treatment outcomes include:

Numerical Pain Rating Scale (NPRS)/Facial Pain Scale
Range of Motion - Goniometry
Manual muscle testing (MMT)
ASK-p (Activity Scale for Children - Performance Version) [8]
Flynn's criteria include two factors: “cosmetic factor” (loss of angle in a resting position) and “Functional factor” (loss of movement in degrees) [9].
Neurovascular assessment is necessary after surgery and during rehabilitation.

Proof

Physiotherapeutic treatment in children is very controversial both in its effect and in its necessity. A randomized controlled trial was conducted by Schmale et al. in 2014 showed that children with a supracondylar fracture treated with either a cast or closed reduction with percutaneous fixation followed by casting did not benefit from a short course of physical therapy (six sessions of physical therapy given over five weeks, starting the week after cast removal) from the point in terms of restoration of function or movement [8]. In support of the above study, another study was conducted in 2021, which also showed that children who underwent closed reduction for an uncomplicated supracondylar fracture with immobilization for three weeks independently regained their functional range of motion within 12 weeks after mobilization, without additional benefit from physical therapy [9].

Physiotherapy treatment did not show a significant difference, this may be due to encouraging children (5–10 years) to participate more actively in daily household activities from an early age and encouraging them to move for play [9]. This is also important because the therapist may have been overly aggressive or overly conservative during treatment [9][8].

On the contrary, in more severe types of trauma involving the neurovascular system and in adult patients, physiotherapeutic treatment plays a significant role [8]. And in children, there was no evidence that upper limb strength resulted from physical therapy treatment.

Hence,

Optimal weight-bearing (pain-free activities) is very necessary for children with a supracondylar fracture, as activities that aggravate pain can delay the healing process and cause further damage as they are in the growth phase [8].
Thus, active physical exercise and active participation in sports and daily activities are recommended rather than passive joint mobilization and stretching exercises [9].
Activities such as lifting, carrying, or pushing that place greater stress on the humerus should also be avoided during the first week after immobilization is lifted [9].
You can do progressive strengthening exercises.

Tips and exercises during immobilization

Typically the elbow is immobilized for 3 weeks, so during this period the adjacent joints (shoulder, wrist and hand) should be given active motion or active, supported exercises frequently throughout the day.
The elbow should not be dislocated and the use of the arm sling should be correct.
Postural training (sitting upright with a relaxed shoulder and scapular abduction).

1-2 weeks after plaster removal

Warming up can be used to relieve joint stiffness.
Gentle soft tissue release can be performed in the muscles of the arms and forearms.
Gentle, active and vigorous exercise using a pole in a pain-free range - often throughout the day.
You can do isometric exercises for the muscles of the arms and forearms.
Teach parents and child to use the affected hand in daily activities such as brushing teeth, writing, eating, dressing, etc.
Avoid activities that involve heavy lifting and pushing.

Tips and exercises after 2 weeks of cast removal

A progressive and interactive range of movement and strengthening exercises such as passing the ball, dressing and undressing.

Conclusion

Supracondylar fractures of the humerus are the most common fractures in children, with the highest incidence between the ages of five and eight years.
A fall on a straight arm is the most common mechanism of supracondylar humerus fracture.
Neurovascular assessment is necessary before and after surgery.
Closed reduction with percutaneous fixation is the recommended treatment for displaced fractures without neurovascular compromise.
Active physical exercise is recommended for fractures in children.

Sources

Gray H. Anatomy of the human body. Lea & Febiger; 1878.
Kumar V, Singh A. Fracture supracondylar humerus: A review. Journal of clinical and diagnostic research: JCDR. 2016 Dec;10(12):RE01.
Zhang XN, Yang JP, Wang Z, Qi Y, Meng XH. A systematic review and meta-analysis of two different managements for supracondylar humeral fractures in children. Journal of orthopedic surgery and research. 2021 Dec 1;13(1):141.
Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT open reviews. 2021 Oct;3(10):526-40.
Brubacher JW, Dodds SD. Pediatric supracondylar fractures of the distal humerus. Curr Rev Musculoskelet Med 2008;1:190-196.
nabil ebraheim. Supracondylar Fractures Of The Humerus In Children. Available from: https://www.youtube.com/watch?v=Z46LtJko9SY [last accessed 22/6/2020]
Alton TB, Werner SE, Gee AO. Classifications in brief: the Gartland classification of supracondylar humerus fractures.
Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of benefit of physical therapy on function following supracondylar humeral fracture: a randomized controlled trial. The Journal of Bone and Joint surgery. American Vol. 2014 Jun 4;96(11):944.
Jha SC, Shakya P, Baral P. Efficacy of Physiotherapy in Improving the Range of Motion of Elbow after the Treatment of Pediatric Supracondylar Humeral Fracture. Birat Journal of Health Sciences. 2021 Sep 5;3(2):432-6.

Treatment

In elderly and senile patients with severe osteoporosis, in the vast majority of cases, conservative treatment is indicated, which consists of abandoning plaster immobilization and early initiation of active movements in the damaged joint. In middle-aged and young patients, it is necessary to strive for one-stage closed reduction with short-term immobilization with an orthotic bandage.

If closed reduction fails in this group of patients, osteosynthesis with the earliest possible start of active movements is indicated. In this case, both external osteosynthesis with plates with angular stability and intramedullary blocked osteosynthesis are used.