Physiotherapy Treatment of Shoulder Fractures
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.
Humeral fractures are typically caused by a fall on the arm, force being transmitted from the elbow or hand or by a fall onto the side of the upper arm. The upper arm is the site of attachment of many of the arm muscles and the pull these exert at the time of injury can displace the fracture. Older people are more susceptible to these fractures with a typical age of around 65 being the peak occurrence, while if this fracture occurs in young people it is due to road accidents or sporting injuries.
A forceful incident is normally required to fracture the humerus and if there is no history of this the physician will suspect a cause such as cancer. The physio examination will show significant pain on attempted movement of the shoulder or elbow, reduced movement of the shoulder, widespread bruising or swelling in the whole arm and in shaft fractures some arm shortening is possible. Checking for nerve damage is important as the radial nerve can be injured especially in shaft fractures, impairing control of wrist and thumb muscles.
Management of Arm Fractures
Acutely the patient is kept still and given adequate analgesia to relieve the initial pain. Fractures of the upper part of the arm bone can mostly be managed without operation if there is little or no displacement but rotator cuff injury could occur if the greater tuberosity is fractured, especially if it is displaced any distance, great force was involved or the patient is older. A collar and cuff sling allows upper humeral fractures to traction themselves straight and in line, while shaft fractures can be braced but are difficult to control.
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
Initially the physio assesses the arm, asking the patient about their pain level as this varies greatly, examining the swelling and bruising of the arm. The physiotherapist then checks the available range of movement of the shoulder, elbow, forearm and hand. Any muscle weakness and sensory loss is noted as this may denote nerve damage. If not operated on, a sling is continued with and if the fracture is not too painful or severe, early exercises are started by the physiotherapist. Pendular exercises, with the patient bending over at the waist, are important in the early stages as they allow movement of the shoulder joint without much force.
Three weeks after the fracture bone healing will be well under way so the physiotherapist will instruct the patient in auto-assisted exercises, using the other arm, to help reduce stress on the injury. Unassisted exercises are the next step as the arm becomes stronger, to practice lateral and medial rotation and flexion. At six weeks the bone will be clinically sound so the physio can progress to more vigorous movements with resistance and gentle end-range stretching. Joint mobilisations can be useful to free up the sliding and gliding movements of the joint and strengthening and joint range work continued with Theraband.
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