This material is presented for educational purposes only and does not constitute medical advice. Consult with a board-certified orthopedic surgeon for specific recommendations for your child.  

Introduction

A study by Schmale and colleagues at Seattle Children's Hospital studied the impact of a short course of physical therapy (PT) on function after treatment of pediatric supracondylar humerus fracture.[1]  The authors studied 61 children of age 5-12 years who sustained supracondylar humerus fractures treated in a cast or with surgery and randomized them to no-PT group and a PT group which received six visits of hospital-based PT after cast removal. The authors reported that "there were no differences between the groups with respect to elbow motion in the injured arm at any time." The study is reported as Level of Evidence I.

The authors also reported that "severity of injury had no impact on function or elbow motion in either the PT or the no-PT group."  Yet a UCLA study found that surgical patient with both Gartland Type II and Type III fractures experienced motion loss well above that cited in the Schmale study, and cited numerous other articles documenting range of motion risks with supracondylar fractures.[2]

In another study, only approximately 53% of pediatric orthopedic surgeons and 37% of hand surgeons noted that stiffness after pediatric supracondylar humerus fractures was not problematic at all, 29% of pediatric orthopedists and 42% of hand surgeons reported it was "relatively not problematic," and 12-14% of pediatric and hand surgeons reported it was somewhat problematic.[3] The Pediatric Orthopedic Society of North America advises surgeons to "inform families that there may be a mild difference in postoperative range of motion compared to the contralateral side."[4]  These data demonstrate the widespread perception among surgeons, grounded in clinical experience, many children with supracondylar humerus fractures experience somewhat diminished range of motion that is not functionally symptomatic, and that is at least occasionally problematic. Moreover, the stiffness is perceived as being a greater risk in children who require surgery, as acknowledged in the POSNA article.

Several limitations of the Schmale article are noted.  First, the study population included only 10 patients with the more severe Gartland Type III fractures in the PT group and 13 in the no-PT group.  This is the fracture type generally viewed as being most at risk for stiffness.  These are very small numbers, and the risk of a Type II or β error - of failing to find a difference because of insufficient data points - is high. That the study also failed to find any impact of severity of fracture type on motion or function, notwithstanding other research demonstrating such differences, suggests that the study was underpowered.  It's not clear that the Level I designation is warranted in view of the study's low power.

The larger issue is that the study does not evaluate actual clinical practices, limiting its relevance.  In the absence of accompanying nerve injuries or polytrauma (both of which were excluded from the Schmale study), most orthopedists whose practices I am familiar with refer patients to physical therapy only if they are struggling with range of motion after a trial of home exercises.  No one routinely refers all patients to physical therapy, which virtually all practitioners acknowledge is unnecessary for most patients.

Well-designed interventional studies base their intervention on actual clinical practice.  Formulating the proper question is a necessary prerequisite to obtaining proper answers. This study instead poses a "straw man" construct which does not reflect the actual utilization of physical therapy for children with supracondylar humerus fractures in pediatric orthopedic practices nationwide.  Its findings therefore are of limited relevance to practitioners.

As other articles acknowledge, there is considerable individual variation and only a subset of patients experience meaningful stiffness.  The article therefore does not answer the key clinical question regarding the role of physical therapy in selected patients struggling to progress after a trial of home exercises, or patients deemed to be at high risk of developing stiffness due to specific clinical factors.

References

[1] Schmale GA, Mazor S, Mercer LD, Bompadre V. Lack of Benefit of Physical Therapy on Function Following Supracondylar Humeral Fracture: A Randomized Controlled Trial. J Bone Joint Surg Am. 2014;96(11):944-950. doi:10.2106/JBJS.L.01696

[2] Zionts LE, Woodson CJ, Manjra N, Zalavras C. Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res. 2009 Aug;467(8):2007-10. doi: 10.1007/s11999-009-0724-y. Epub 2009 Feb 7. PMID: 19198963; PMCID: PMC2706343.

[3] Lee S, Park MS, Chung CY, et al. Consensus and different perspectives on treatment of supracondylar fractures of the humerus in children. Clin Orthop Surg. 2012;4(1):91-97. doi:10.4055/cios.2012.4.1.91. Graph here

[4] "Study Guide: Supracondylar Humerus Fractures." Pediatric Orthopedic Society of North America [undated article].  https://posna.org/physician-education/study-guide/supracondylar-humerus-fractures 

Any opinions expressed are solely those of the author and not those of Cure 4 The Kids Foundation.