EXERCISE AND QUALITY OF LIFE
Research article
Volume 2, No. 2, 2010, 51-62
UDC 616.717-001.5-053.2:615.8
EFFECTS OF REHABILITATION TREATMENT AND
CHARACTERISTICS OF ELBOW CONTRACTURE
AFTER SUPRACONDYLAR FRACTURES IN
CHILDHOOD
Maja Divjakovi„ and Aleksandra Mikov
Faculty of Medicine Novi Sad
Institute for Children and Youth Health Care of Vojvodina
Clinic for Children Habilitation and Rehabilitation Novi Sad
Abstract
Supracondylar fractures of humerus are the most frequent arm fractures in childhood.
Complications of these fractures most often take the form of elbow contractures. The aim of this
paper was to determine effects of rehabilitation treatment and characteristics of elbow
contractures. During five-year period
(2005-2010),
61 patients with posttraumatic elbow
contracture were treated at the Institute for Children and Youth Health Care of Vojvodina.
Flynnís three-grade scale was applied to determine the elbow mobility level, prior to treatment
and at its end. After the completed physical treatment, there is a highly statistically significant
difference in terms of increased flexion and extension of elbow (p0.0001). In 90.16% children,
the result was satisfactory upon completed physical treatment. By means of combined
application of different forms of physical therapy, treatment results of elbow contractures after
supracondylar fractures have significantly improved.
Keywords: rehabilitation, contracture, elbow, supracondylar fracture, children
Introduction
Elbow fractures account for
7-9% of all fractures at childhood age
(1), whereas
supracondylar fractures of humerus represent the most frequent elbow fractures with frequency
of
60-75% (G‡jdobr‡nski, M‡ri„, T‡ti„,
-uri„-Nosek i Mikov,
2003; J‡ndri„,
2007; De
Pellegrin, Brivio, Pescatori, & Tessari, 2008; Solazzo, Bertolani, & Traina, 2000; »ekanauskas,
Degliute, & Kalesinkas, 2003; De Coulon, Ceroni, De Rosa, Pazos, & Kaelin, 2005; Carmichael,
& Joyner, 2006; Foead, Penafort, Saw, & Sengupta, 2004; Patrice Eiff, & Hatch, 2004; Ayadi,
Trigui, Tounsi, & Ellouze, 2006). Most of these fractures occur in children up to 10 years of age,
most often between 5th and 8th year of age (Gajdobranski et al., 2003; De Pellegrin et al., 2008;
Corresponding author. Faculty of Medicine Novi Sad, Institute for Children and Youth Health Care of Vojvodina,
Clinic for Children Habilitation and Rehabilitation Novi Sad, Hajduk Veljkova
3,
21000 Novi Sad, e-mail:
driva@eunet.rs
2010 Faculty of Sport and Physical Education, University of Novi Sad, Serbia
51
M. Divjakovi„ and A. Mikov
Solazzo et al., 2000; ¿rena, Vermiglio, Terranova, Vermiglio, & Arena, 2006). High incidence
of these fractures at childhood age is explained by increased laxity of collateral ligament
structures at this age, immaturity of the structure of supracondylar region of humerus and
specific relation of bone structures in the joint during hyperextension within elbow joint
(Gajdobranski et al., 2003). Sex-dependant frequency of supracondylar elbow fractures indicates
that these fractures are more frequent in boys than in girls (De Pellegrin et al., 2008; Solazzo et
al., 2000; Arena et al., 2006; He, Zhang, & Tan, 2009), whereas in terms of sides, they tend to be
more frequent in left elbow due to its defense function during fall (58%), as opposed to the right
one (42%) which is more frequently used for catching (He at al., 2009).
Supracondylar fractures of humerus are classified as extensory and flexion types,
depending on the mechanism of occurrence.
Extensory type of supracondylar fractures of humerus is far more frequent (up to 95%),
and it occurs while falling on the palm when the elbow region of the arm is extended, and arm is
in abduction (Gajdobranski et al., 2003; Patrice Eiff, & Hatch, 2004; Arena et al., 2006; Gris,
Van Nieuwenhove, Gehanne, Quintin, & Burny, 2004). Supracondylar fractures of humerus can
be classified according to several different classification systems (Gartland 1959, Holmberg
1945, Von Laer 1997, Wilkins 1996), based on the appearance of radiograms (Platt, 2004).
Currently, the most frequently applied one is Gartlandís classification which is based primarily
on the extent of dislocation. According to this classification, and on the basis of radiograms,
supracondylar fractures of humerus are divided in three degrees: I degree without dislocation of
fragments, II degree with dislocation of fragments being still in contact (back cortex is intact),
and III degree with a complete dislocation of fragments without cortical contact (most frequent
type >50%). III degree of supracondylar fractures of humerus occurs when the extended elbow is
exposed to rotation. If there are any clinical signs of neurovascular jeopardy, then this fracture is
classified as supracondylar fracture of humerus of IV degree
(Gajdobranski et al.,
2003;
»ekanauskas et al., 2003; Patrice Eiff, & Hatch, 2004; Arena et al., 2006; Temple, Bache, &
Gibbsons, 2006; Kaiser, Kamphaus, Massalme, & Wessel, 2008).
Flexion type of supracondylar fractures of humerus is considerably less frequent, and it
occurs as a consequence of a direct stroke on the back elbow region (Gajdobranski et al., 2003;
Arena et al., 2006; Temple et al., 2006; Banovi„, 1989). These fractures are mostly open due to
the effect of direct force on the back lower part of upper arm (Banovi„, 1989).
In the clinical features, the predominant symptoms are pain and oedema in elbow joint
region, haematoma, sensitivity of both condyles and classical S-shaped deformity in elbow
region (Gajdobranski et al.,
2003; Patrice Eiff, & Hatch, 2004). The relationship between
olecranon and epycondyle is not impaired, for which reason these fractures are different from
elbow luxation. During clinical examination, it is necessary to pay attention to the condition of
soft tissues and a neurocirculatory finding due to a high percentage of associated injuries
(Gajdobranski et al., 2003). Oedema and bleeding, if marked, may damage artery blood supply
of forearm (Banovi„, 1989). Pulse a. radialis may be weak or absent, for which reason it should
be checked permanently (Patrice Eiff, & Hatch, 2004; Banovi„, 1989; Griffin, Walsh, Markar,
Tang, Boyle, et al., 2008). It is necessary to control motor i.e. sensitive deficit due to the
possibility of injury of nerves (n. radialis, n. medianus, n. ulnaris).
52
Rehabilitation of elbow contractures in children
Within the supracondylar fractures in children, different complication may occur:
- Deformity
- Vascular injuries
(occlusion of brachial artery, compartment syndrome, Volkmannís
contracture)
- Neurological injuries (pareses or paralyses of n. medianus, n. radialis, n. ulnaris) (Jandri„,
2007; Patrice Eiff, & Hatch, 2004).
During clinical examination, it is necessary to pay attention to possible interference of
neuron-vascular structures, especially with extension fractures in which proximal fragment,
when sharp can get in contact by its sharp edge with the brachial artery and n. medianus, n.
radialis, and more rarely with n. ulnaris, with an immediate possibility of neuro-vascular
complications (Arena et al., 2006). Lesions of nerves are, first of all, contusions, extensions, or
compressions, occurring predominantly in n. medianus and n. radialis, including an
accompanying reduced function of muscles innervated by them, in addition to reduction of
sensibility of the relevant parts (Ayadi et al, 2006). Vascular complication may be manifested for
several hours after trauma under the clinical features of ìacute ischaemia syndromeî, in which
ischemic damages are still reversible, however, if the treatment is applied more than 4-6 hours
after occurrence of the symptoms, Volkmannís syndrome is inevitable in three-week time, which
is surely the most serious complication of supracondylar fractures of elbow (Arena et al., 2006;
Griffin et al., 2008). Owing to a correct orthopedic treatment, Volkmannnís contracture occurs
only in extreme cases nowadays (Arena et al., 2006). Among late complications, axial deviation
of elbow (deformities varus-valgus) is certainly the most significant sequela (Arena et al., 2006).
Action of different factors related to injuries, diagnostics, and therapeutic interventions
on cutaneous structures, soft tissue, and other structures in elbow region may result in occurrence
of posttraumatic elbow contractures, as a recognizable sequela in these injuries. Posttraumatic
elbow contractures with different degrees of movement reductions in elbow joint, even with
functional limit in activities of everyday life, may occur after correctly applied orthopedic
treatment of supracondylar fractures in children. Reduced functions in elbow joint may be
followed by other neurovascular complications mentioned above (Jandri„, 2007).
The purpose of rehabilitation treatment after supracondylar fractures is to achieve
painless and full mobility of the elbow joint, as well as prevention and healing of complications
(Arena et al.,
2006). Rehabilitation treatment should include active and actively supported
exercises for joint mobilization as soon as the condition of certain tissues makes it possible. In
order to prevent contractures and reduced mobility of elbow joint, patientís rehabilitation should
start as soon as possible, depending on the fracture and stability of soft-tissued structures in these
fractures (Tanno, Tanaka, Mukai, Hayashi, & Takenouchi, 2008). Choice and execution of the
treatment will depend on the clinical features and radiogram finding of the patient (Arena et al.,
2006). While in supracondylar fractures of humerus of I degree, therapeutic procedure is a
uniform one (cast immobilization with forearm in pronation, during three weeks, followed by a
physical treatment), therapeutic procedures in supracondylar fractures of II degree, especially III
degree, are rather different. Supracondylar fractures of humerus of IV degree represent an
absolute indication for an urgent surgical treatment (Gajdobranski, 2003). In rehabilitation after
supracondylar fractures of humerus, different physical procedures are applied, in order to
achieve functional and esthetical restoration after fracture. Medical treatment consists of a
combination of active and passive therapeutic programs. Active therapeutic procedures include
kinesitherapy, hydro-kinesitherapy and work therapy, whereas the passive ones include electro-
therapeutic ones, hot procedures, and cold procedures (Jandri„, 2007).
53
M. Divjakovi„ and A. Mikov
Method
The sample included 61 patients treated at the Clinic for Children Habilitation and
Rehabilitation of the Institute for Children and Youth Health Care of Vojvodina in Novi Sad,
during 2005-2009. All patients had posttraumatic contracture of elbow with different degrees of
reduced mobility in the joint that occurred after supracondylar fracture of elbow.
Assessment of effects of physical treatment in this research was performed by measuring
active range of both elbows (injured and healthy one) in terms of degrees, when the patient was
received, during treatment, and upon treatment completion). The degree of elbow mobility at the
beginning and at the end of treatment was assessed by Flynnís three-grade scale for each patient
(Flynn-1974). Satisfactory results were marked as 3, 2, and 1, whereas the unsatisfactory one
was marked as 0. Mark 3 refers to the full range of elbow joint or reduction up to 5o, mark 2
stands for reduced amplitude of elbow movement of 5 o to 10 o, mark 1 was equivalent to reduced
movement amplitude of 10 o to 15 o. Mark 0 represents a bad therapeutic result with loss of elbow
mobility for more than 15 o. All patients were included in the proper program of physical
therapy, according to the degree of clinical finding. The treatment was initiated after removal of
cast immobilisation, mostly within
5 days after removal. This program included
kinesitherapeutic procedures as well as other forms of physical therapy (thermo-therapy, work
therapy, interference currents, diadynamic currents, electrophoresis with potassium iodide (KJ),
laser, massage with green vac apparatus, galvanic current, hydrotherapy, magnet, transcutaneous
electric nerve stimulation (TENS). Physical procedures were included depending on clinical
finding during treatment. Therapeutic program during treatment was adjusted according to the
therapy progress.
Results
Within our sample, 61 children were treated for elbow contracture after supracondylar
fracture. The sample included 41 boys (67.21%) and 20 girls (32.79%) (Figure 1). The relation
between boys and girls was 2.05:1. Out of 61 children, 29 had left arm fracture (47.54%),
whereas 32 had the right arm fracture (52.46%) (Figure 2).
Figure 1. Relations boys-girls.
Relation boys-girls
33%
67%
boys
girls
54
Rehabilitation of elbow contractures in children
Figure 2. Relations of sides.
Relation of sides
48%
left
right
52%
Table 1
Characteristics of the sample
Characteristics
Number
Average age
Age
7,31±2,91
(years) ± SD
Average duration of rehabilitation
69,92±48,91
treatment (days) ±SD
Average duration of cast immobilisation
24,83±7,13
(days) ± SD
Average number of days before
commencement of physical treatment after
4,45±3,52
removal of cast immobilisation (days)
Number of children subjected to surgical
treatment before commencement of
68,85%
rehabilitation treatment (%)
Average age of patients was 7.31 2.91 years. Average duration of immobilization was
24.83 7.13 days, whereas duration of rehabilitation treatment was 69.92 48.91 days. Physical
treatment was commenced 1-12 days after removal of immobilization, i.e. average number of
days before commencement of physical treatment after removal of cast immobilization was 4.45
3.52 days. Before commencement of physical treatment, 42 patients were subjected to surgical
procedures (68.85%) (Table 1). All patients were treated by osteosynthesis by Kirschnerís
needles. During the treatment, Kvengelís apparatus was applied with two patients only.
Results of treatment by physical procedures were classified as satisfactory or
unsatisfactory, while elbow mobility was assessed according to Flynn. Within the range of
satisfactory results, we differentiated between excellent, good, and favourable results (Table 2).
55
M. Divjakovi„ and A. Mikov
Table 2
Assessment of elbow joint mobility (Flynn)
Functional factor (loss of
Result
Degree
movement in degrees)
Excellent
0°-5°
3
Good
5°-10°
2
Satisfactory
Favourable
10°-15°
1
Unsatisfactory
Bad
>15°
0
Table 3
Assessment of elbow joint mobility (Flynn) at the beginning and end of treatment
Commencement of therapy
End of therapy
MARK
Number of
Number of
%
%
children
children
3
0
0
43*
70,49
2
0
0
8
13,11
1
0
0
4
6,56
0
61
100
6
9,84
TOTAL
61
100
61
100
Table 3 indicates that all children showed unsatisfactory degree of mobility
at
the
beginning of treatment, i.e. all children were assessed by 0 according to Flynnís classification.
From the same table, it can also be seen that the excellent result was recorded with 43 patients
(70.49%), good result in 8 (13.11%), and favourable one in 4 patients (6.56%). Unsatisfactory
result was observed with 6 patients (9.84%).
“able 4
Frequence of lesions of nerves and assessment of elbow mobility at the beginning end of
treatment
Assessment of
Assessment of
elbow mobility at
elbow mobility at
Number of
Injury affected nerve
the beginning of e-
the end of e-
patients
treatment (Flynn)
treatment (Flynn)
3
2
1
0
3
2
1
0
n. ulnaris
7
-
-
-
7
5
2
-
-
n. medianus
1
-
-
-
1
1
-
-
-
n. ulnaris + n.radialis
1
-
-
-
1
1
-
-
-
n. medianus + n.radialis
1
-
-
-
1
1
-
-
-
n.ulnaris+n.medianus+n.radialis
1
-
-
-
1
1
-
-
-
56
Rehabilitation of elbow contractures in children
Transitory neurological injuries were recorded with 11 patients. 7 patients had lesion of
n. ulnaris, 1 patient had lesion of n. medianus, 1 patient had lesion of n. ulnaris and n. radialis, 1
patient had lesion of n. medianus and n. radialis, and 1 patient had lesion of three nerves (u.
ulnaris, n. medianus, and n. radialis). All patients showed satisfactory results
at
the
end of
treatment, out of which 9 patients got mark 3, and 2 patients got mark 2 (Table 4).
Figure 3. Average values of flexion before and after treatment.
AVERAGE VALUES OF FLEXION BEFORE AND AFTER TREATMENT
140°
131,72 °
120°
96,88 °
100°
80°
60°
40°
20°
°
flex ion before trea tm ent
flex ion a fter trea tm ent
average value in degrees °
p<0,0001
Figure 4. Average values of extension before and after treatment.
AVERAGE VALUES OF EXTENSION BEFORE AND AFTER TREATMENT
°
extension before treatment
extension after treatment
-10°
-2,88 °
-20°
-30°
-40°
-41,64 °
-50°
average value in degrees °
p<0,0001
There is a highly statistically significant difference in terms of increased elbow flexion
and extension after completed physical treatment (p0.0001). Average flexion value at the
beginning of the treatment amounted to 96.88 degrees (96.88 14.12), and after the treatment it
reached 131.72 (131.72 8.89) (Figure 3). The average value of extension before the treatment
was -41.64 degrees (-41.64
17.39), while after the treatment it was -2.88 degrees (-2.88
6.47) (Figure 4).
During physical treatment, different therapy types were used. Thermotherapy and
kinsitherapy were applied in the highest number of patients. Sequence of applied therapies as per
their frequency is the following: work therapy, therapy with interference currency, therapy with
diadynamic currency, electrophoresis with KJ, therapy with galvanic currency, TENS,
laserotherapy, green vac, magnetic therapy, hydrotherapy, and electrostimulation
(Table
5,
Figure 5).
57
M. Divjakovi„ and A. Mikov
Table 5
List of applied physical methods in treatment of contractures after supracondylar elbow fracture
Number of days
Applied
(for those where it was applied)
Type of therapy
Num-
Average number of
%
Standard deviation
ber
days
Kinesitherapy
55
90,16
42,25
42,25±38,56
Thermotherapy
57
93,44
20,12
20,12±11,86
Work therapy
53
86,88
18,28
18,28±9,73
Interference currency
41
67,21
10,78
10,78±4,59
Diadynamic currency
28
45,9
11,0
11,0±5,66
Electrophoresis with KJ
18
29,51
11,0
11,0±4,46
Lasertherapy
9
14,75
10,11
10,11±1,62
Green vac
9
14,75
12,22
12,22±3,19
Electro-stimulation
5
8,2
30,4
30,4±19,7
Galvanic currency
11
18,03
22,45
22,45±15,0
Hydrotherapy
8
13,11
10,62
10,62±4,95
Magnetic therapy
9
14,75
13,0
13,0±6,4
“ÅNS
11
18,03
5,64
5,64±3,17
Figure 5. Frequency of application of different types of physical therapy.
Frequency of application of different types of physical therapy
60
50
40
30
20
10
0
Number of patients
58
Rehabilitation of elbow contractures in children
Discussion
Children age of our sample, including
61 patients with elbow contractures after
supracondylar fracture, ranged between 2-14 years, amounting to average 7 years of age. This
finding was in accordance with literature sources, where average age for this type of elbow
fracture ranges between 6 and 8 years (Gajdobranski et al., 2003; Jandri„, 2007; »ekanauskas et
al.,
2003; He et al., 2009; Gris et al., 2004; Bombaci, Gereli, Kucukyazici, & Gorgec, 2000;
Karapinar, Ozturk, Altay, & Kose, 2005; Sibinski, Sharma, & Bennet, 2006; Gadgil, Hayhurst,
Maffulli, & Dwyer, 2005; Keppler, Salem, Schwarting, & Kinzl, 2005). In our sample, over two
thirds of patients were boys, which is also in accordance with literature sources (1, 2, 5, 6, 11,
13, 20, 21, 22, 23, 24). Most children got injured due to fall during play. Such increased
frequency of injuries in boys is explained by different types of games practiced by boys and
girls.
Average length of rehabilitation treatment in our sample was about 70 days, whereas
average duration of cast immobilization was 25 days. Period of rehabilitation treatment in our
sample is somewhat longer than that found in literature sources, which was averagely 5 to 8
weeks (Jandri„, 2007; Arena et al., 2006). This can be explained by the fact that all patients in
our sample had marked elbow contractures at the beginning of the treatment (according to Flynn,
all of them were within unsatisfactory range), for which reason a longer rehabilitation treatment
was necessary for the best possible functional recovery. Duration of cast immobilization
complies with the accessible literature sources, with an average of 3 weeks (Gajdobranski, 2003;
»ekanauskas, 2003; Keppler et al., 2005).
Surgical treatment of supracondylar fractures in our sample was applied in about 69% of
patients. All patients were treated by the method of orthopedic reposition and percutaneous
fixation of fragments, using two Kirschnerís needles controlled by radiogram. In the accessible
literature sources, this method is referred to as the most frequently applied one, owing to its
simple application procedure and minimum invasiveness, as well as excellent results in treatment
of these kinds of fractures (Gajdobranski et al., 2003; »ekanauskas et al., 2003; Arena et al.,
2006; Gris et al., 2004; Karapinar et al., 2005). According to analyses of He, Zhang and Tan
(2009), surgical method of placing two parallel wires proved the most efficient one since 93.18%
patients treated by this method achieved positive results at the end of the treatment. In groups
treated by other methods, effects were considerably lower (He et al., 2009). Some authors
believe that the method of placing two parallel needles laterally only is the best method due to
reduced possibility of iatrogenous nerve injury of ulnar nerve (Bombaci et al., 2005; Slongo,
Schmid, Wilkins, & Joeris, 2008).
In 18% of our sample, i.e. in 11 patients, lesion was observed in peripheral nerves, most
frequent of which was n. ulnaris. According to the research of Ayadi et al. (2006), injury of n.
radialis was the most frequent one, whereas the injury of n. ulnaris was the most rarely
diagnosed nerve injury. However, according to our research the latter was the most common
nerve injury (Ayadi et al., 2006). In our sample one of the patients had lesion of all three nerves,
7 patients had lesion of n. ulnaris, 1 had n. medianus lesion, whereas isolated lesions of n.
radialis were not observed, but they occurred in combination with lesion of n. ulnaris i.e. n.
mediannus in both combinations in 1 patient. All 10 patients with lesion of nerves at the end of
the treatment showed satisfactory recovery results in terms of range of movements and paresis of
nerves. Frequency of neurological complications after supracondylar fracture of elbow is
slightly higher in our sample than the finding of a group of authors, according to which it ranged
between 9 and 11% (»ekanauskas et al., 2003; Karapinar et al., 2005; Tiwari, Kanojia, &
Kapoor,
2007). This frequency difference in terms of neurological complications can be
explained by different characteristics of the sample in terms of severity and extent of the
59
M. Divjakovi„ and A. Mikov
fracture. The fact that our sample showed full recovery of paresis of affected nerves, after the
applied physical treatment, suggests the lightest form of injury of the nerve neurapraxia.
According to the findings of Ayadi et al. (2006), lesions of nerves observed immediately after
fracture mostly heal spontaneously during treatment of the fracture itself, which is in contrast to
those observed after the completed treatment when the treatment of an injury itself is longer-
lasting, and requires grafting in certain cases (Ayadi et al., 2006).
Prior to commencement of rehabilitation treatment in our sample, all patients had elbow
contracture which was over 15 degrees. Average flexion in the elbow was about 97 degrees,
while full extension tell short for about 42 degrees on an average, before the treatment. After
completed treatment, there was a statistically highly significant increase of flexion and extension
of elbow, which contributed to reduction of the existing contractures. 90% of examined patients
achieved satisfactory result at the end of rehabilitation treatment. 10% patients maintained over
15 degrees contractures, so that flexion at the end of rehabilitation treatment was about 119
degrees on an average, with 12 degrees missing for full extension. According to the obtained
results, we can conclude that these values did not significantly affect functional ability of
patients in terms of mobility of the elbow and limitations of everyday life activities, even though,
according to the applied Flynnís classification, they belong to a group with bad treatment results.
According to Keppler et al. (2005), children with elbow contractures after supracondylar
fracture treated by physical therapy commenced a couple of days after removal of cast
immobilization showed faster recovery than the children who were not treated by physical
therapy (Keppler et al., 2005). According to »olovi„ et al. (2008), early rehabilitation of children
after supracondylar elbow fracture results in significantly better elbow functioning, with
treatment supposed to begin within 15 days after removal of cast immobilization (Divjakovi„,
Mikov, & Gajdobranski, 2010), which is in compliance with our treatment since it began 1-12
days after removal of immobilization.
With patients from our sample who showed unsatisfactory results, there was statistically
significant difference in movement range (flexion and extension in elbow) before and after the
treatment, but other parameters (duration of treatment, applied surgical procedure, and physical
therapy procedures) did not show any significant difference. The fact that all accessible physical
procedures were applied and that there was no difference between groups with satisfactory and
unsatisfactory results in terms of applied procedures, we can draw a conclusion that
unsatisfactory treatment results may also be a consequence of a more complicated fractures
which caused major damages in elbow region with a consequence of incomplete recovery in
terms of achieving full range of movements.
During physical treatment of patients with elbow contractures, after supracondylar
fractures, the following therapies were most frequently applied: thermotherapy, kinesitherapy,
work therapy, and electric therapy. Kinesitherapy was applied in almost all patients, with an
average duration of 6 weeks. Our results, as well as results of other authors (Jandri„, 2007; Arena
et al., 2006; Divjakovi„ et al., 2010) indicate that movement as a therapeutic instrument, applied
through a complex of exercises within active treatment methods (kinesitherapy, and work
therapy), including applied effects of other physical agents (thermotherapy, and electrotherapy)
as an introduction to active methods of therapy, may account for a significant share of the overall
treatment of contractures.
60
Rehabilitation of elbow contractures in children
References
Ayadi, K., Trigui, M., Tounsi, N., & Ellouze, Z. (2006). Supracondylar fractures of the humerus
in children. Revue de Chirurgie OrthopÈdique et RÈparatrice de l'Appareil Moteur,
92(7), 651-6.
¿rena, S., Vermiglio, G., Terranova, A., Vermiglio, M., & Arena, P. (2006). Trattamento
ortopedico e riabilitativo nelle fratture sovracondiloidee di omero in et‡ evolutiva. Acta
Chirurgica Mediterranea, 22, 169-173.
B‡novi„, M. D. (1989). Tr‡um‡tologij‡ koöt‡no-zglobnog sistem‡. Gornji Mil‡nov‡c: DeËije
novine.
Bombaci, H., Gereli, A., Kucukyazici, O., & Gorgec, M. (2005). A new technique of crossed
pins in supracondylar elbow fractures in children. Orthopedics, 28(12), 1406-1409.
Carmichael, K. D., & Joyner, K.
(2006). Quality of reduction versus timing of surgical
intervention for pediatric supracondylar humerus fractures. Orthopedics, 29(7), 628-632.
»ekanauskas, E., Degliute, R., & Kalesinkas, R. J. (2003). Treatment of supracondylar humerus
fractures in children, according to Gartland classification. Medicina, 39(4), 379-383.
»olovi„, H., St‡nkovi„, I., Dimitrijevi„, L., éivkovi„, V., & Nikoli„, D.
(2008). Zn‡Ë‡j
modifikov‡nog DASH upitnik‡ u proceni funkcijskog st‡nj‡ l‡kt‡ n‡kon
supr‡kondil‡rnih fr‡ktur‡ humerus‡ kod dece. Vojnos‡nitetski pregled, 65(1), 27-32.
De Coulon, G., Ceroni D., De Rosa, V., Pazos J. M., & Kaelin, A. (2005). Nonoperative
treatment of displaced supracondylar fractures in children: Rigault type 2 fractures. Acta
Orthopaedica, 76(6), 858-861.
De Pellegrin, M., Brivio, A., Pescatori, E., & Tessari, L. (2008). Frattura sovracondiloidea di
omero in et‡ infantile. Osteosintesi percutanea in posizione prona. G.I.O.T, 34, 199-204.
Divjakovi„, M., Mikov, A., & Gajdobranski, -. (2010). Effect of physical therapy on treatment
of contractures of elbow after supracondylar humerus fractures in children. Medicina
danas, 9(1-3), 90-97.
Foead, A., Penafort, R., Saw, A., & Sengupta, S. (2004). Comparsion of two methods of
percutaneous pin fixation in displaced supracondylar fractures of the humerus in children.
Journal of Orthopedic Surgery, 12(1), 76-82.
Gadgil, A., Hayhurst, C., Maffulli, N., & Dwyer, J. S. M. (2005). Elevated, straight-arm traction
for supracondylar fractures of the humerus in children. Journal of Bone and Joint
Surgery, 87(1), 82-87.
G‡jdobr‡nski, -., M‡ri„, D., T‡ti„, M., -uri„-Nosek, D. i Mikov A. (2003). Osteosintez‡
Kirönerovim igl‡m‡ u leËenju dislocir‡nih supr‡kondil‡rnih prelom‡ humerus‡ kod dece.
Medicinski pregled, 56 (7-8), 355-361.
Griffin, K. J., Walsh, S. R, Markar, S., Tang, T. Y., Boyle, J. R, & Hayes, P. D. (2008). The pink
pulsless hand: a review of the literature regarding management of vascular complications
of supracondylar humeral fractures in children. European Journal of Vascular and
Endovascular Surgery, 36(6), 697-702.
Gris, M., Van Nieuwenhove, O., Gehanne, C., Quintin, J., & Burny, F. (2004). Treatment of
supracondylar humeral fractures in children using external fixation. Orthopedics, 27(11),
1146-1150.
61
M. Divjakovi„ and A. Mikov
He, B. X., Zhang, B., & Tan, Y. J. (2009). Comparsion of clinical effects of various external
fixation for the treatment of humeral supracondylar fracture. Zhongguo Gu Shang, 22(3),
190-192.
J‡ndri„, S. -. (2007). Ter‡pijski efek‡t fizik‡lnih procedur‡ n‡ kontr‡kture l‡kt‡ kod djece s‡
supr‡kondil‡rnom fr‡kturom humerus‡. Acta Chirurgica iugoslavica, 54(2), 39-43.
Kaiser, M. M, Kamphaus, A, Massalme, E., & Wessel, L. M. (2008). Percutaneous closed pin
fixation of supracondylar fractures of the distal humerus in children. Operative
Orthop‰die und Traumatologie. 20(4-5), 297-309.
Karapinar, L., Ozturk, H., Altay, T., & Kose, B. (2005). Closed reduction and percutaneous
pinning with three Kirschner wires in children with type III displaced supracondylar
fractures of the humerus. Acta Orthopaedica et Traumatologica Turcica, 39(1), 23-29.
Keppler, P., Salem, K., Schwarting, B., & Kinzl, L. (2005). The effectiveness of physiotherapy
after operative treatment of supracondylar humeral fractures in children. Journal of
Pediatric Orthopedics, 25(3), 314-316.
Patrice Eiff, M., & Hatch, R. L.
(2004). Doctor/Pediatria/Ortopedia Retrieved from
www.medweb.it
Platt, B. (2004). Supracondylar fracture of the humerus. Emergency Nurse, 12, 22-30.
Sibinski, M., Sharma, H., & Bennet, G. C. (2006). Early versus delayed treatment of extension
type-3 supracondylar fractures of the humerus in children. Journal of Bone and Joint
Surgery, 88(3), 380-381.
Slongo, T., Schmid, T., Wilkins, & K., Joeris, A. (2008). Lateral external fixation: A new
surgical technique for displaced unreducible supracondylar humeral fractures in children.
Journal of Bone and Joint Surgery American Volume, 90, 1690-1697.
Solazzo, V., Bertolani, G., & Traina, F. (2000). Le complicanze vasculo-nervose nelle fratture
sovracondiloidee di omero nel bambino: nostra esperienza. G.I.O.T., 26, 196-200.
Tanno, M., Tanaka, H., Mukai, E., Hayashi, Y., & Takenouchi, K. (2008). Supracondylar and
condylar fracture of the humerus. Clinical Calciium, 18(9):1332-1338.
Temple, A., Bache, C. E., & Gibbsons, P. J. (2006). Fractures of the elbow : supracondylar
fractures. Trauma, 8, 123-130.
Tiwari, A., Kanojia, R. K, & Kapoor, S. K. (2007). Surgical management for late presentation of
supracondylar humeral fracture in children. Journal of Orthopedic Surgery, 15(2), 177-
182.
Submitted November 3, 2010
Accepted December 14, 2010
62