How Physiotherapists Treat Shoulder Fractures
Posted on November 29, 2008
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Humeral fractures occur commonly with up to five percent of all fractures falling into this category, eighty percent of humeral fractures being minimally displaced or undisplaced. Osteoporosis is a contributing factor in many of these fractures and a fracture of the forearm on the same side is a typical presentation. Nerve or arterial damage from the fracture is an important consideration but not common. Typical sites of fractures are the top of the arm (neck of humerus – “shoulder fracture”) and the middle of the shaft of the humerus.
A fall onto the outstretched hand, onto the elbow or onto the shoulder itself is the most common cause of a fractured arm. Since many of the arm muscles insert onto the humeral head, when the injury occurs the muscular action involved can displace the fragments and complicate the management. 65 years old is the peak incidence for this kind of fractured humerus and if younger patients suffer this fracture the likely cause will involve high forces such as traffic accidents or sports injury.
If the fracture occurred without significant force then a pathological cause such as cancer must be suspected. On physio examination pain will occur on movement of the shoulder or the elbow, there may be extensive bruising and swelling, the arm may appear short if the fracture is displaced in shaft fractures and there is very restricted shoulder movement. Radial nerve damage is rare in upper humeral fractures but more common in fractures of the shaft, leading to “wrist drop”, weakness of the wrist and finger extensors and some thumb movements.
Management of Arm Fractures
Initial management is to restrict the patient’s movement and give them enough painkillers to make them comfortable. Upper humeral fractures can be managed conservatively if not displaced but if the greater tuberosity is fractured then an injury to the rotator cuff must be considered, more common in older people, injuries with high forces involved and where there is a lot of displacement. The typical treatment is a collar and cuff sling, allowing the elbow to hang in mid air and keep the humerus in line. Shaft fractures may be managed by humeral bracing.
Displaced three or four part fractures typically require surgery, referred to as ORIF (open reduction internal fixation) and this is more likely in younger people. Older people may have a poorer result in terms of pain and movement so may have surgical replacement of the head of the arm bone. Plating and nailing is usually unnecessary for shaft fractures as they heal well normally. The side effects of humeral fractures include nerve injury in shaft fractures, adhesive capsulitis and avascular necrosis of the head of the humerus. Healing occurs in six or eight weeks and older people may never regain full movement of the shoulder.
Physiotherapy for Shoulder Fractures
Initial physiotherapy assessment consists of assessing the patient’s pain levels as these can vary hugely, the joint ranges of motion of the elbow, hand and wrist and the tissue swelling and bruising in the arm. Muscle strength is tested in the forearm as this may indicate an injury to the radial nerve, as may loss of sensory discrimination. The patient may stay in the sling for 2-3 weeks with the physio exercises beginning early if pain is reasonable and the fracture stable. The aim is to maintain the range of motion of the shoulder joint while the fracture heals, by performing bent over pendular exercises to counteract gravity.
The fracture will have started to heal at the three week point so the physio will start auto-assisted exercises, the patient assisting the movement of the fractured arm with the healthy one. Progression from here it to unassisted exercises where the affected arm does the movement alone, practicing flexion, medial and lateral rotation. Healing time for the humerus is six weeks so the physio will increase the force behind the exercises, gently stretching the joint to increase the available movement. Joint mobilisation techniques can be uses to free up the accessory movements and Theraband used to perform strengthening exercises and maintain gains in movement.
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