Effect of physiotherapeutic rehabilitation after intercondylar fracture of humerus.

Introduction
Intercondylar fractures of the humerus present a challenging clinical scenario, often resulting
from high-energy trauma or falls on an outstretched hand. These fractures, located at the distal
end of the humerus, involve the separation of the two condyles and are associated with
significant morbidity and functional impairment if not managed optimally. Physiotherapeutic
rehabilitation plays a pivotal role in the comprehensive management of these fractures, aiming to
restore function, alleviate pain, prevent complications, and facilitate the return to pre-injury
levels of activity and independence [1]. The management of intercondylar fractures of the humerus
involves a multidisciplinary approach, with physiotherapeutic intervention being a cornerstone of
rehabilitation. This comprehensive approach encompasses acute management, surgical fixation if
indicated, and post-operative rehabilitation, with a focus on early mobilization and functional
restoration [2]. Physiotherapeutic rehabilitation following intercondylar fracture of the humerus
typically begins shortly after injury or surgery, with initial goals centered around pain
management, edema control, and preservation of joint range of motion. As the acute phase
subsides, rehabilitation progresses to include muscle strengthening, proprioceptive training, and
functional exercises tailored to the individual patient's needs and goals [3]. The effectiveness of
physiotherapeutic rehabilitation in improving outcomes following intercondylar fractures of the
humerus is supported by a growing body of evidence. Several studies have demonstrated that
early mobilization and targeted exercises can lead to improved functional outcomes, decreased
pain, and faster return to activities of daily living [4]. Moreover, physiotherapeutic interventions
have been shown to reduce the risk of complications such as stiffness, muscle weakness, and
joint contractures, which are common sequelae of immobilization and disuse following fracture
[5]
. The principles of physiotherapeutic rehabilitation for intercondylar fractures of the humerus
are based on promoting tissue healing, optimizing biomechanical alignment, and restoring
neuromuscular function. Manual therapy techniques, therapeutic exercises, and modalities such
as ultrasound and electrical stimulation are commonly employed to achieve these goals [6].
Additionally, patient education and compliance with home exercise programs are integral
components of successful rehabilitation, empowering patients to take an active role in their
recovery and promoting long-term adherence to therapeutic interventions [7]. Despite the evidence
supporting the benefits of physiotherapeutic rehabilitation, challenges remain in optimizing
outcomes for patients with intercondylar fractures of the humerus. These include variability in
fracture patterns, patient characteristics, and surgical techniques, which necessitate
individualized treatment approaches tailored to the specific needs of each patient [8]. Furthermore,
access to specialized rehabilitation services, socioeconomic factors, and psychosocial barriers
may influence the delivery and effectiveness of physiotherapeutic interventions, highlighting the
importance of a holistic approach to patient care [9]. In conclusion, physiotherapeutic
rehabilitation plays a vital role in the comprehensive management of intercondylar fractures of
the humerus, offering significant benefits in terms of pain relief, functional improvement, and
prevention of complications. By adhering to evidence-based principles and employing a
multidisciplinary approach, healthcare providers can optimize outcomes and facilitate the return
to pre-injury levels of function and quality of life for patients with this challenging injury [10].
Case history
History
Ten days ago, the patient reported being asymptomatic until an incident where he allegedly fell
from a chair while attempting to retrieve something, resulting in an injury to his left arm in
Salarpur, Noida, on 31/10/2023 at 10:30 am, within his home. Subsequently, the patient
experienced sudden-onset pain and swelling in his left elbow, which was not radiating. Seeking
further medical attention, the patient presented at Sharda Hospital for evaluation and
management. There is no recent trauma, but the persistent restricted ROM has prompted the need
for evaluation and intervention to optimize the outcomes of the operation and enhance overall
elbow functionality. patient had a history of diabetes in the past 5 years. He socio-economically
belongs to middle class family. There is no such family history. Tenderness can be seen over
lateral aspect of left elbow.

Diagnostic findings.
Pre-operative x-ray: Non uniform joint space loose, osteophyte formation, cyst formation
Post- operative x-ray: Nail bed and clips implant in-situ are present over lateral and medial
epicondyle of humerus are seen in x-ray.
Clinical findings
Musculoskeletal assessment was performed with elbow flexion test. A goniometer was used to
measure the range of motion of the elbow joint and the VAS was used to check the level of
improvement of the pain felt when the elbow joint was moved. Pain level rated at 7 on the visual
analog scale (VAS).

Table 1. MMT of Elbow Joint

On 1 day of On 4 week of On 8 week of
assessment assessment assessment
Elbow flexion 3 4 5
Elbow extension 3 4 5
Elbow pronation 3 4 5
Elbow supination 3 4 5

Table 2. MMT of Shoulder Joint

On 1 day of On 4 week of On 8 week of
assessment assessment assessment
Shoulder flexion 4 4 5
Shoulder extension 3+ 4 5
Shoulder abduction 3+ 4 5
Shoulder adduction 4 4- 5
Shoulder internal 3 4- 5
rotation
Shoulder external 3 4 5
rotation

Table 3. Left Elbow Range of Motion

Elbow Normal AROM on AROM AROM AROM AROM AROM
movements rom day of after 1 after 2 after 3 after 4 after 8
assessment week week week week week
Elbow 0-145 0-60 0-75 0-90 0-110 0-125 0-138
flexion
Elbow 0-10
extension
Elbow 0-90 0-80 0-80 0-80 0-80 0-90 0-90
pronation
Elbow 0-90 0-50 0-60 0-65 0-75 0-80 0-90
 supination

TREATMENT PROTOCOL

Week 1-2: Early phase of Treatment

Assessment of Comprehensive evaluation of range of motion (ROM), strength, pain level,
functional limitations and X-ray review to assess fracture healing progress.
Goal is to management of pain, Edema reduction and Preservation of joint mobility.
Treatment:
 Gentle passive ROM exercises within pain-free range.
 Soft tissue mobilization to reduce swelling and improve tissue extensibility.
 MET for pain relief and restoration of normal muscle tone.
 Education on home care techniques and activity modification.

Week 3-4: Intermediate phase of Treatment

To Assess the Progress evaluation of ROM, strength, pain and Monitoring fracture healing
status.
Main Goal is Gradual increase in joint ROM, Initiation of strengthening exercises and Functional
restoration.
Treatment:
 Active-assisted ROM exercises to improve joint mobility.
 Initiation of light resistive exercises for muscle strengthening.
 MET techniques to address any residual muscle imbalances or restrictions.
  Modalities such as heat or ice therapy for pain management.
 Education on proper body mechanics and posture.

Week 5-6:
To Assess the Continued evaluation of progress and any limitations and Reassessment of fracture
healing status.
Main Goal is looking for Further improvement in ROM and strength, Advancement of functional
activities and Promotion of independence in daily activities.
Treatment:
 Progressive resistive exercises to improve muscle strength and endurance.
 Functional training incorporating activities of daily living.
 MET for targeted muscle groups to optimize function and mobility.
 Manual therapy techniques for joint mobilization and soft tissue flexibility.
 Patient education on self-management techniques and injury prevention strategies.

Week 7-8: advanced Rehabilitation phase

Assessment:
Final evaluation of ROM, strength, and functional abilities.
Assessment of fracture healing and readiness for discharge from physiotherapy.
Goals:
Achievement of optimal ROM and strength.
Restoration of functional activities to pre-injury levels.
Treatment:
 Continued progression of strengthening exercises.
 Functional training focused on specific activities relevant to the patient's lifestyle and
occupation.
 MET for maintenance and prevention of muscle imbalances.
 Comprehensive home exercise program tailored to individual needs.
 Final education session on long-term management and injury prevention strategies.

Discussion
Left intercondylar fracture of humerus with implant inserted is a common surgical procedure to
relieve pain and restore function in patients with severe elbow movements or other degenerative
conditions. Post-operative rehabilitation plays a crucial role in optimizing outcomes and
enhancing the patient's quality of life. The Muscle Energy Technique is a manual therapy
approach that aims to improve joint mobility, reduce pain, and enhance functional movement
patterns through a combination of mobilizations and active movements. Isometrics exercises,
active range of motion, strengthening exercises, cold pack therapy and continuous Passive
Motion are all part of the Physical therapy regimen for intercondylar fracture of humerus.
According to certain authors, operation of intercondylar fracture of humerus with implant
inserted, hot pack and physical activity produced positive outcomes. Pain relief and an increase
in range of motion of knee were found to be achieved with manual therapy and passive
mobilization techniques, which include prolonged stretch.
Gupta AK et al., 2002 measured leading to more satisfactory outcomes in terms of reducing pain
and improving mobility, which could positively impact activity and participation [7]. Morry BF et
al., 2019 found that Muscle Energy Technique (MET) techniques led to significant
improvements in elbow flexion ROM and functional performance compared to standard physical
therapy interventions fracture of humerus [8]. On the other hand, Mulligan mobilization and
exercise therapy demonstrated significant improvements in enhancing functional performance
and activities of daily living and functional mobility compared to those who received
conventional physical therapy.
Conclusion
All things considered, the Muscle Energy Technique seems to be a useful supplement to
conventional physical therapies in the recovery process for patients with intercondylar
fracture of humerus. Muscle Energy Technique can reduce discomfort, enhance functional
performance, and speed up recovery from intercondylar fracture of humerus.
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