Muhammad Hafzi bin Abdul Hamid1, Ng Kim Swan1, Zubaidah Binti Jamil1, Mary S Cardosa1
1)Malaysia
One of the obstacles to movement in post-injury rehabilitation of children is fear of pain, making it more challenging to manage these patients. We report a case of a child with post-traumatic contracture of the left elbow who showed remarkable improvement in the range of movement of the affected joint after intervention by a clinical psychologist.
A nine-year-old girl was in hospital for management of fixed flexion deformity of her L elbow. 10 months prior to admission, she had sustained a L Monteggia fracture which was treated conservatively with prolonged immobilization, resulting in limitation of range of movement of the elbow (70-90 degrees). Manipulation under general anesthesia found that passive ROM was almost full but when the patient was awake she refused to move her elbow.
The patient was referred to the Acute Pain Service (APS) for pain management with the aim of rehabilitation was to enable her to perform activity daily function. As analgesia with regular paracetamol and ibuprofen was inadequate, a continuous peripheral nerve block was established, using 0.1% levo-bupivacaine administered through an axillary catheter at 1ml/h and 3ml/demand at 15min lockout interval. However, the patient continued to refuse to move her elbow and re-assessment found that she had a lot of fear of pain on movement. She was referred to our clinical psychologist who taught her relaxation and counselled her about the pain. After a single session with the clinical psychologist, the patient was less fearful of elbow movement and was able to do more effective physiotherapy.
Fear of pain in children is an under-recognised obstacle to rehabilitation after injury. Inclusion of psychological interventions in combination with analgesic medications and nerve block techniques can result in better outcomes.
