Fractures of the shoulder region

Nonoperative Treatment

->90% scapular fractures minimally displaced -Fractures of body rarely need treatment. -Usually non-displaced and supported by soft tissue. -Treatment in sling and swathe with gradual increase of functional use for first 6 weeks -x-rays at 2 week intervals until 6 weeks -At 6 weeks osseous union usually present and sling/swathe discontinued -Full recovery may take 6 months to 1 year

Closed reduction for humeral shaft fractures

-Align fracture under anesthesia -May be fixed with pins or spica or ORIF -Sling initially with cast brace -3 - 4 weeks: AAROM -6 weeks: AROM started >Progress to stretching and resisted exercises as tolerated -6 - 12 month recovery period is expected -Goals depend on patient's age, and activity level

Physical Therapy Management: Mobilization Phase

-Assess for impairments body structure and function -Common impairments and interventions >Decreased ROM: Thermal modalities, P/AA/AROM, stretching (self, C/R), joint mobilizations (self, PT) >Decreased strength: Progress from isometrics to strengthening protocols using overload >Decreased proprioception: PNF**, UE balance >Decreased skilled movement: Motor re-learning**, skill specific training

Physical Therapy Management: Immobilization phase

-Assess for impairments, functional limitations and disabilities -Modulate pain as appropriate -Minimize effects of immobilization -Early motion including pendulum exercises can be started week 1 in stable fractures -Unstable fractures, start pendulum exercises at 3 weeks (when hard callous appears) -Progress to AAROM and AROM (no stretching)

Associated injuries with scapular fractures

-Clavicle fractures 15 - 40% -Rib fractures 25 - 50% -Pulmonary injuries 15 - 55% -Humeral fractures 12% -Brachial Plexus 5-10% -Skull fractures 25% -Lower Limb fractures 11% -Major Vascular injury 11% -Splenic lacerations 8%

Management One-part Fractures (3 phases)

-Displacement <1cm or 45 degrees -Treat by immobilization for 1-2 weeks -Begin ROM when the head & shaft rotate together -Neer 3-phase program: 1)Passive exercises -including Codman's (2-6 weeks) 2)Active exercises - including stretching (6-12 wks) 3)Resistive exercises (3 months +)

Why would you do an ORIF?

-Failed closed treatment >Loss of reduction >Poor patient tolerance/compliance (wont take care of their own arm so its easier to do this) -Open fractures -Vascular injury/neurologic injury

Shoulder Fracture Complications

-Frozen shoulder or elbow -Radial nerve damage (humeral shaft) -Rotator cuff injury -Avascular necrosis -GH dislocations and labral tears -Secondary OA -Sprains of SC, AC, fractured ribs -Suprascapular nerve involvement -Mal-union or non-union -Excess callous formation (TOS from clavicle fx) -Acute injury to subclavian artery or brachial plexus or axillary nerve -Pleural penetration by fracture fragments

Grouping of fractures

-Group I: Middle third >Most common (80% of clavicle fractures) -Group II: Distal third >10-15% of clavicle injuries -Group III: Medial third >Least common (~ 5%)

What movements would be painful or hard with a clavicular fracture?

-Guarded shoulder motions and difficulty elevating the arm beyond 60 degrees -Clavicular deformity -Exquisite tenderness to palpation or percussion over the fracture site -Horizontal adduction is painful -Diagnosis confirmed with radiograph

Scapular fractures

-History of trauma -Tenderness, edema and ecchymosis over affected area -Protective posturing: arm held in adduction, pain with any attempt to abduct

Physical Therapy Management: Early strengthening

-If fracture is stable, submax isometrics week 1 -If fracture is unstable, wait until bony union as muscle pull could disrupt the reduction -Following submax isometrics, move into isometrics and light T-Band exercises after bony union has begun

Physical Therapy Management

-Minimize effects of injury on whole patient: -Maintain ROM and strength in uninvolved joints and extremities (elbow and wrist!) -Maintain aerobic capacity -Maintain skin integrity -Patient education regarding the fracture, fracture healing, precautions, when to call MD -Instruct patient in safe transfers (chair, car) -Address home situation and ADL's -Appropriate referrals to OT, home health, etc

Clavicular fractures

-Most commonly fractured bone in childhood -MOI: FOOSH, fall on tip of shoulder or a direct blow

Non-surgical treatment

-Most humeral shaft fractures are amenable to closed, nonsurgical treatment >rigid immobilization is not necessary for healing >perfect alignment is not essential for an acceptable result -Want down at the elbow: -<30 degrees of varus -< 3 cm of shortening of the arm

Scapular fractures etiology

-Not common: 1% of all fractures and 5% of fractures involving the shoulder -Historically typically high energy injury (80-95% incidence other injury) -Direct impact on scapula or force transmitted up through humerus (high energy) -Most are stable (muscles hold them together) -Glenoid rim fractures most often from fall onto a flexed elbow

Proximal Humeral Shaft Fracture

-Prox. Humerus is common site for metastases in cancer -MOI: Direct impact or FOOSH -Typical Patterns: Transverse or comminuted -Compound fractures (trough the skin) frequently have associated nerve damage and risk of non-union (radial nerve will be most likely involved) - Start with: Immobilization: Sling, splint, traction, external fixators -ORIF with plates and screws or IM rod

Proximal humeral fractures: can we treat conservatively?

-Proximal 1/3 fractures are most common -Young skeletally immature: presents as an epiphyseal fracture of the proximal humeral growth plate -Elderly: osteoporotic fracture following minimal trauma >> Typically stable with no displacement: treat conservatively -Sling until pain and discomfort subsides (approx. 2 weeks if non-displaced) -Perform wrist AROM (supination, pronation for circulation to decrease edema) -Gentle full PROM exercises for the elbow and shoulder around 6 weeks (after radiographic confirmation of boney union) -PRE's initiated 6-8 weeks

Surgical treatment for clavicular fractures

-Reserved for cases involving neurovascular compression, an open fracture, associated fractures and marked displacement -"Reduce" fracture- bring back together and ORIF (open reduction internal fixation)

Operative indications

-Significantly displaced -Floating shoulder: Fractures of both the clavicle and surgical neck of the scapula

Treatment for scapular fractures

-Sling 7-10 days -Progressive regimen of pendular and gentle PROM exercises as comfort and control allowed -When healing sufficient (per radiographs) proceed with gentle AAROM and AROM exercises -Strengthen mm that attach to scapula at the earliest opportunity

How long does it takes for fractures to come back together?

-around 4 weeks for soft callus -6-8 weeks for hard callus, -12 weeks for full rehab

Fractures of the anatomic neck of the humerus

-can be a serious fx if displaced -MOI: FOOSH -Elderly and adolescents

Treatment for closed treatment

-patients age -displacement (surgical neck, tuberosities, articular surface) -functional demand -arm dominance -ability to salvage with an arthroplasty later if needed -Methods of closed treatment -Sling -Sling and swath -Hanging cast -Abduction pillow

Conservative treatment for clavicular fractures

1) Approximation/reduction of fracture ends followed by a sling and figure 8 strap for 3-6 weeks 2) AAROM and then AROM exercises for shoulder once union established (in 2-3 weeks), isometric, isokinetic, etc. 3) Joint mobilizations after immobilization 4)Strengthening: >Delts, Pec major and UT when appropriate >Scapulohumeral rhythm

How long is full recovery?

6-12 months

Fractures to consider hemiarthroplasty

Young/middle age: -Non-reconstructable articular surface (severe head split) or extruded anatomic neck Elderly: -many 4 parts -some severe 3 parts -most 3,4 part fracture dislocations

compound fracture

bone breaks through the skin

What management will you do for stable 1 part or greater tuberosity 2 part fractures?

conservative treatment

What is a complication of proximal humeral fractures?

lots of blood vessels- so lots of bleeding and rotator cuff issues causing subluxation and axillary nerve damage