EFFICACY OF PHYSIOTHERAPY IN IMPROVING THE RANGE OF MOTION OF ELBOW AFTER THE TREATMENT OF PEDIATRIC SUPRACONDYLAR HUMERAL FRACTURE Affiliation

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. BJHS 2018;3(2)6: 432-436. * Corresponding Author Dr Subash Chandra Jha Lecturer Department of Orhopedic Birat Medical College and Teaching Hospital Email: subash.jha@gmail.com ORCID: 0000-0002-0280-2221 https://orcid.org/ ORA 70 1* 2 3 Jha SC , Shakya P , Baral P


INTRODUCTION
Supracondylar humeral fracture is the most common 1,2 pediatric fracture around elbow.Post injury elbow s ffness is usually not the major concern in case of pediatric 3 pa ents.Including physiotherapy in fracture management protocol in case of adult is common prac ce, however, there is lack of evidence that physiotherapy has any posi ve impact on func onal improvement in children who have 4 sustained musculoskeletal trauma.Several authors 1,4,5,6,7,8,9 recommend physiotherapy while other reject it totally.Most common parental concern is "How long will it take for the elbow to func on normally?''and "Do they have to consult physiotherapist for be er outcome?''.However, evidence is inconsistent on the role of physiotherapy in management of supracondylar humeral fracture in children.Therefore, we aimed to assess the effec veness of physiotherapy in improving the post-opera ve range of mo on (ROM)a er supracondylar humeral fracturein children.

METHODOLOGY
We conducted a prospec ve randomized control trial (RCT) at Dhulikhel hospital, Kathmandu university hospital, from October, 2015 to October 2016.We calculated the sample size using the so ware G Power version 3, for 95% power and alpha 0.05.The calculated minimum sample size was 64 with 32 par cipants in each interven on and control groups.All these pa ents presented to our hospital with supracondylar humeral fracture were treated by conserva ve or opera ve methods.This single center study was approved by the Ins tu onal review commi ee of our center and was registered at clinicaltrial.gov.in.
The inclusion criteria for joining the study were age between 5-12 years; with isolated supracondylar humeral fracture (Gartland I, II, III) (Figure 1); managed by close reduc on (CR) and above elbow slab (conserva ve) or CR and percutaneous fixa on with Kirschner wire (k-wire) (opera ve); in a mentally sound child a er receiving informed wri en consent to par cipate in the study from guardian of child.Pa ents were excluded from the study if they were less than 5 or more than 12 years of age; had open fracture, or required open reduc on (OR) or had polytrauma or mul ple fractures; had delayed developmental milestones or cannot communicate in Nepali language or the presenta on to hospital was at-least a er 1 week of fracture.
A er 3 weeks of immobiliza on the above elbow slab and/or K-wires were removed and pa ents fulfilling the inclusion criteria were randomly divided into interven on and control groups, by an independent assistant other than doctor in the out-pa ent clinic by simple randomiza on method.Interven on group children were sent for regular physiotherapy sessions at hospital based physiotherapy department involving passive as well as ac ve ROM exercises as per protocol.Each child was called for regular physiotherapy sessions at every 2-3 days interval for first 2-3 weeks ll 10 to 120 degree of ROM was achieved that in the injured elbow.Then onwards children were taught home exercises and were asked for follow-up only if required.While control group pa ents were not sent for physiotherapy, rather, counselled by the a ending orthopedic surgeon and encourage to perform ac ve guarded ROM of elbow for next couple of weeks followed by ac ve normal daily life ac vi es without any extra precau ons at child convenience, but passive ROM stretching was discouraged.
Children were followed at 5, 9 and 15 weeks post-surgery and elbow ROM was assessed on each visit and documented 10 according to Flynn's criteria (Figure 2) by surgeon other than the primary inves gator.At final follow up, at 12 weeks post removal of slab or k-wires, primary inves gator did the final assessment of outcome.Fractures were classified by 8 trea ng surgeon based on the Gartland system of pediatric supracondylar humeral fracture classifica on.Type I fractures are those that were undisplaced; type II fractures were displaced with limited cor cal contact and type III fractures were displaced with essen ally no cor cal contact.Type I fractures were managed by the above elbow slab/cast whereas type II and III were managed by CR and percutaneous k-wires fixa on with above elbow splint.Our standard prac ce a er supracondylar fracture included 3 weeks of immobiliza on in cast/slab, and weekly assessment for loss of reduc on by doing plain radiograph of fractured elbow in antero-posterior and lateral views, along with pin-site dressing in case of operated pa ents.Regardless of type of fracture or treatment received slab/cast or k-wires were removed a er 3 weeks.We set the sta s cal significance at p<0.05.We conducted all the analyses using STATA so ware, version 13

Descrip ve characteris cs
Table 1 presents the comparison of baseline characteris cs between interven on (N=32) and control groups (N=32).

Associa on of physiotherapy with outcome at 12 weeks
Table 3 shows the results of mul variable logis c regression analysis.We did not find any sta s cally significant associa on between physiotherapy and outcome at 12 weeks, a er controlling for baseline characteris cs (Adjusted odds ra o/AOR=2.13,95% CI 0.17-26.29).

Efficacy of physiotherapy on outcome (elbow ROM/ Flynn's criteria)
Table 4 shows the results of GEE analysis.When controlling for follow-up visits at two, six and 12 weeks a er cast removal, we did not find any sta s cally significant difference on outcome between interven on and control groups (AOR= 1.17, 95% CI 0.46-2.98).

DISCUSSION
The importance of early mobiliza on of joints to prevent s ffness a er treatment of fractures in adults is a widely 11,12 held view.Ac ve role of physiotherapy in management of In a similar study by Schmale et al. they no ced ASK-P (Ac vi es scale for kids-performance version) score were significantly be er in the no physiotherapy group at 9 and 15 weeks a er injury (p=0.02 and 0.01, respec vely) but the difference at 27 weeks was not significant.There were no difference between groups with respect to performance of ac vi es of daily living or me to return to sports.Anxiety at 9 weeks was associated with worse ASK-P score at 9 and 15 weeks in the physiotherapy group and with be er ASK-P scores in the no physiotherapy group at these me points (p=0.01 and 0.02, respec vely).There were no difference between the groups with respect to elbow mo on in the injured arm at any me.They also postulated that severity of injury has no impact on func on or elbow mo on in either the physiotherapy or the no physiotherapy group.
In most of the studies, the immobiliza on period was prolonged ll 4-5 weeks which may have caused longer 4,7 dura on for recovery of ROM.In our study we only immobilized for 3 weeks in either of groups followed by progressive encouragement of ROM which resulted in excellent outcome at around 15 weeks post-opera ve in both groups in majority of pa ents.We also assume that children included in our study were mostly from low socioeconomic background and are more involved in daily household ac vi es from early period, as compared to western society, which may have contributed for early recovery in ROM.However, we do not have any suppor ve evidence for this hypothesis.Moreover in contrast to 18 19 Morrey and King et al. in our study the type of fracture and the treatment received barely influenced the outcome of fracture accoun ng that the reduc on is op mal and done in closed fashion.
An op mal post-opera ve program is essen al to achieve the best possible results.Children urge for mo on is par cularly evident between 5 and 10 years, so no joint mobiliza on measures are necessary in this age group, they

CONCLUSION
There is no added advantage of physiotherapy for improving func onal outcome in management of uncomplicated supracondylar humeral fracture in pediatric age.And, it may take upto 12 weeks period for the child to regain his/ her ROM for func onal ac vi es of daily living considering the period of immobiliza on is not more than 3 weeks.
Adjusted odds ra o

8 ElbowFigure 1 :Figure 2 :
Figure 1: Gartland classifica on of supracondylar humeral fracture been accepted widely.Immobiliza on of elbow in children also has risk of s ffness but usually are temporary and demonstrates no benefit to a 1, 4, 8 formal physiotherapy program.The average dura on for func onal recovery of elbow ROM has been debatable in 4 literature.Keppler et al. in their prospec ve RCT conducted in 62 pa ents of pediatric supracondylar humeral fracture, managed with OR and k-wires fixa on demonstrated that children receiving physiotherapy achieved a more rapid return of a normal or near normal elbow ROM at 12 weeks a er trauma than the children not receiving physiotherapy.The end result however was not changed at 1 year a er 7 trauma by physiotherapy.Spencer et al. in their prospec ve longitudinal study in 375 pediatric supracondylar humeral fractures, concluded that greatest increase in axis of mo on were observed within first month a er cast removal, with progressive improvement for up-to 48 weeks a er the injury.None of their pa ents were sent for physiotherapy 17 for elbow ROM exercises.Zoints et al. in a retrospec ve review of 63 pa ents, surgically treated for pediatric supracondylar humeral fracture showed progressive recovery of elbow ROM over a period of 52 weeks.1

20 move their elbow joint un l pain ensures. As suggested by 5 21 Minkowitz
et al. and McIntyre et al. general prac ce of 5-6 weeks post-opera ve immobiliza on period can be reduced to 3 weeks, as in our study, so that rapid restora on of ROM of elbow can be achieved.Ac ve exercise are more helpful in regaining elbow mo on and passive stretching 21 should be discouraged.

Table 1 :
table.All the measurements were performed by orthopedic surgeon and recorded as per Flynn's criteria on each follow-up.We conducted descrip ve analysis to compare the baseline characteris cs and outcome at 12 weeks a er the cast removal.We did it by conduc ng independent sample t-test for con nuous variable and Chi-squared test for categorical variables.We used mul variable logis c regression model to examine the associa on of physiotherapy with the outcome at 12 weeks a er the cast removal.In this model, we controlled for age, sex, type of fracture (Gartland types), and type of procedure.Lastly, we conducted Generalized Es ma on Equa ons (GEE) analysis to examine the efficacy of physiotherapy on the outcome (elbow ROM/Flynn's criteria).For GEE, we included the follow up me points at 2 weeks, 6 weeks and 12 weeks a er the cast removal.For both mul variable logis c regression and GEE analyses, we dichotomised the outcome variable (elbow ROM/Flynn's criteria) into Excellent / Good and Fair / Poor.Baseline characteris cs between the interven on and comparison groups

Table 2 :
Outcomes at 12 weeks a er cast removal

Table 3 :
Mul variable logis c regression: Associa on of physiotherapy with outcome at 12 wks