University of North Dakota UND Scholarly Commons Physical Therapy Scholarly Projects Department of Physical Therapy 2007 Rehabilitation following Pinning of an Ulnar Fracture with Radial Head Dislocation Sandra R. Jungwirth University of North Dakota Follow this and additional works at: https://commons.und.edu/pt-grad Part of the Physical Therapy Commons Recommended Citation Jungwirth, Sandra R., "Rehabilitation following Pinning of an Ulnar Fracture with Radial Head Dislocation" (2007). Physical Therapy Scholarly Projects. 502. https://commons.und.edu/pt-grad/502 This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has been accepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information, please contact [email protected]. ~~~~--~-- Rehabilitation Following Pinning of an Ulnar Fracture with Radial Head Dislocation by Sandra R. Jungwirth Bachelor of Science in Physical Therapy University of North Dakota, 1981 A Scholarly Project Submitted to the Graduate Faculty ofthe Department of Physical Therapy School of Medicine University of North Dakota in partial fulfillment ofthe requirements for the degree of Doctor of Physical Therapy Grand Forks, North Dakota October 2007 -----1----------- ------------ --------------- This Scholarly Project, submitted by Sandra R Juugwirth in partial fulfillment of the requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy uuder whom the work has been done and is hereby approved. ~~~~ (Chairperson, Physical Therapy) II --- ,-~------ ---------- ----~ ~-----__c---~ PERMISSION Title Rehabilitation Following Pinning of an Ulnar Fracture with Radial Head Dislocation Department Physical Therapy Degree Doctor of Physical Therapy In presenting this Scholarly Project in partial fulfillment ofthe requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in her absence, by the Chairperson ofthe department. It is understood that any copying or publication or other use of this Scholarly Project or part thereoffor fmandal gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and the University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project. Date It -23.-{) '7 tll -------------------, ~------ TABLE OF CONTENTS List of Tables .......................................................................................... v Acknowledgements ................................................................................... vi Abstract .................................................................................................. vii Chapter 1. Introduction .............................................................................. 1 Chapter II. Case Description" ............ " ........... ,., ... ,"", ... ,' ..... , .. , .... ,.......... , .... 3 Chapter m. DiscussionIReflection "'" ....... ,', ......... ,"", ........ , .. ,', ....................... 12 Appendix ..................................................... , ..... , ..... , ......... ,., ........... , ...... 16 References ................. , ...... , .................................. , ................................... 18 IV ------------- ------------ ----------- ~~~~------~ ---- LIST OF TABLES Table Page 1, Upper Extremity Range of Motion at Initial Evaluation ............................................ .4 2. Upper Extremity Strength with Manual Muscle Testing atInitial Evaluation ..................... 5 3. Upper Extremity Range of Motion: Initial and Outcome Measurements ................. , ......... 9 4. Upper Extremity Strength with Manual Muscle Testing: Initial and Outcome .................... 9 v -------------------- ----------------- ACKNOWLEDGEMENTS Thank you so much to the faculty of the University of North Dakota School of Medicine Physical Therapy Program for their time, knowledge, and expertise in preparing me for this scholarly project. Your passion and dedication to the physical therapy profession is evident! Grateful appreciation to Dave Reiling, P.T., Ph.D. and Peggy M. Moln, Ph.D., P.T. for their assistance with this scholarly project. Special thanks to my family, friends, colleagues, and coworkers for their words of encouragement and support along the way. This scholarly project is dedicated to my husband, Michael and to our children, Amber, David, April, Dallas, Alicyn, and Autnnm for their love and support, V! ABSTRACT Study design: Case report. Background and Purpose: Although upper extremity injuries and fractures are common in children, fractures of the ulna with dislocation of the radial head represent a small portion of the upper extremity fractures. The purpose ofthis case report is to describe the physical therapy intervention of such a fracture-dislocation in a child. Ca s e Description: The patient was a 6-year-old girl diagnosed with a fracture of the ulna with dislocation of the radial head. She had a pinning of the ulnar fracture. Six and one half weeks after injury, physical therapy was initiated, consisting of 6 visits over a 3-week period. Physical therapy intervention included range of motion and strengthening exercises, manual therapy techniques, and instruction in a home exercise program. Outcomes: The patient demonstrated improved range of motion, strength, and functional use of her right arm. Discussion: The use of manual therapy techniques in combination with range of motion and strengthening exercises may lead to beneficial initial effects of elbow range of motion and arm function. Ke y Words: ulnar fracture, radial head dislocation, manual therapy, joint mobilization. VB ------------------------------------------- -------- 1 CHAPTER I INTRODUCTION Upper extremity injuries and fractures are extremely common in children. l In children, upper extremity fractures are much more common than those ofthe lower extremity. Fractures ofthe elbow represent approximately 10-12 %1-3 of all pediatric fractures, whereas elbow dislocations account for less than 6% of pediatric elbow injuries4 Fractures of the ulna with dislocation of the radial head have been named after Monteggia as he first described this fracture 5 pattern in 1814. ,6 Three main mechanisms of injury for this type of fracture have been suggested. 5 One mechanism of injury is a direct blow to the posterior forearm that first causes a break in the ulnar diaphysis and then forces the radial head into an anterior dislocation. However, there is no evidence to substantiate this mechanism of injury in children. A hyperpronation mechanism was 5 proposed over a half century ago. ,6 It was theorized that there was a hyperpronation force applied to the outstretched ann that fractured the ulnar shaft and forced the radial head to dislocate. This idea was based on fracture patterns experimentally produced by a single maximum load to failure model in dissected amuscular cadaver forearms. The ulnar fracture pattern is oblique as compared to the spira! seen from a rotational mechanism. Three decades ago a mechanism was proposed suggesting an elbow hyperextension mechanism of injury. This explanation is the most currently accepted one. This injury is thought to occur in three phases. 3 8 First, elbow hyperextension occurs as the child tries to arrest a fallon an outstretched ann. ,5.7. Secondly, during elbow hyperextension, the biceps contraction resists the extension moment dislocating the radial head. Lastly, after radial head dislocation, the body weight is transmitted ------------ -----.------------- 2 to the forearm, concentrated on the ulnar diaphysis which fails in tension, causing a complete oblique or a greenstick fracture, Unlike fractures of the clavicle and proxirnai humerus, elbow fractures are more likely to require accurate surgicai intervention, l Indications for surgical intervention are failure to maintain ulnar reduction and the radial head in an anatomic position, Radial head stability is directed by reduction and stability of the ulnar fracture, 5 Monteggia injuries can be caused by low-energy trauma, such as a fall from standing, or a high-energy mechanism, such as a motor 6 vehicle accident or a fail from a height ,9 In the literature, 5,6,10 outcomes for Monteggia lesions are recognized to be quite good in children in comparison to adults, Early recognition of Monteggia-type fracture-dislocation is the key to a good outcome, as if missed, Monteggia IeSlOns, 0 ften resuI t m' Iong-term d'lsa b'l' I Ity and' pam," 4611-13 Although there is an abundance ofliterature on the reduction of the injury, a literature review yielded relatively scarce information of the physical therapy intervention for such injuries, 5,8,9 The purposes of this case study are to describe the rehabilitation of a patient following pinning of an ulnar fracture with radial head dislocation and the use of manuai therapy in combination with range of motion and strengthening exercises, ------------- ----------- ------------------------------------- -----r--------- 3 CHAPTER IT CASE DESCRIPTION Examination, Evaluation, and Diagnosis This patient incuned an