FITNESS FOR YOUR HEALTH

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.

Humeral fractures usually occur with great force and if this has not happened then a serious condition such as cancer must be considered. When the physio examines the arm they may find very limited shoulder movement, severe swelling and bruising, some shortening in shaft fractures and pain on movement of the elbow or shoulder. The radial nerve, which supplies the extensors of the wrist and fingers and thumb extensors and abductors, can be damaged but this is more common in shaft fractures and less so in fractures of the humeral neck.

Shoulder Fracture Management

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.

Fractures with three or four parts plus displacement often need surgical treatment, with open reduction surgical fixation (ORIF) more often required in younger patients. In older people the humeral head may be replaced as the fracture may not heal or give an acceptable pain or movement result. Shaft fractures usually heal without surgery (plating or nailing) and are managed in a functional brace. Complications include frozen shoulder, avascular necrosis of the humeral head in multi-part fractures and nerve injury in shaft fractures. Six to eight weeks is typical healing time with older people often suffering a permanent reduction in shoulder movement.

Physiotherapy Management of Shoulder Fractures

The physiotherapist will start the examination by assessing the pain levels (which can be very variable), the bruising and swelling and the appropriate joint ranges of the hand, wrist, elbow and shoulder. Loss of sensibility or weakness of muscles could be pain related but also could be a sign of damage to the radial nerve. The sling is maintained for two to three weeks in conservative treatment and early exercises can be started by the physio if the fracture is stable and the pain is reasonable. Continued mobility of the shoulder joint can be maintained by pendular exercises, allowing the arm to move freely when bent over at the hips.

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.