PT Considerations for the Nonoperatively Treated Proximal Humerus - - PowerPoint PPT Presentation

PT Considerations for the Nonoperatively Treated Proximal Humerus Fractures

John Cavanaugh PT MEd ATC SCS

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Proximal Humerus Fractures - Intro

• Incidence: 4-6% of all fractures

 3rd most common fx pattern seen in elderly

• Injury ratio: 2:1 female to male

 ↑’ed age correlates with increasing fracture risk in women

• Mechanism of injury:

 Low-energy falls elderly with osteoporotic bone  High-energy trauma young individuals

• Concomitant soft tissue and neurovascular injuries

(axillary nerve)

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Non-Operative Management

• 85% PHF are minimally displaed & managed

non-operatively

 1, 2, 3 part surgical neck fractures  Greater tuberosity fractures displaced < 5mm

• Good to Excellent outcomes ~85%

– Koval KJ J Bone Joint Surg Am. 1997 – Gaebler C, Acta Orthop Scand. 2003 – Kruithof RN J Orthop Traumatol 2017

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Non-Operative Management

Fracture healing: 3 distinct but overlapping stages

 Inflammatory stage  Repair stage  Late remodeling stage

Rehabilitation: 3 distinct but overlapping phases

 Maximum Protection Phase  Moderate Protection Phase  Return to Function Phase

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Proximal Humerus Fracture Non-Operative Rehabilitation Guielines

• General Principles

 Phyisician directed  Radiograph evidence of healing  Realistic Goals  Early Mobilization

– Hodgson J Shld Elbow Surg 2007 – Lefevre-Colau JBJS 2007

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• Randomized, prospective/controlled trial of minimally displaced PHF
• Group A: (N 44) Immediate ROM
• Group B: (N 42) 3 weeks of immobilization
• Craft Shoulder Disability Questionnaire

 Group A 42.8% (1 year) 43.2% (2 year)  Group B 72.5% (1 year) 59.5% (2 year)

– Reported 3x more pain on movement, 2x night disturbance

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• RCT: 74 patients with an impacted PHF (1,2,3 part)
• Group A: 37 passive mobilization within 3 days of frx
• Group B: 37 sling immobilization x 3 weeks
• Constant Global Score (3 months f/u)

 (A) 71 vs (B) 61.1  Mean change in pain (6 weeks→3 mo) (A) 34.9 vs (B) 19.2

• Fracture-healing rate 100% (A & B)
• Compliance to PT sessions = 70% (A & B)

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Proximal Humerus Fracture Non-Operative Rehabilitation Guielines

• General Principles

 Physical Therapist guided

– MD directed clinical guideline

• Individualized
• Criteria based progression
• Communication w/MD

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Maximum Protection Phase (0-6 weeks)

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Goals: Control pain and swelling

Protect fracture site / Allow for healing Maintain ROM/Function distal extremity Improve AAROM: Elevation to 110° and ER to 30° Independent with home exercise program

Maximum Protection Phase (0-6 weeks)

• Treatment Interventions:

 Modalities (Ice / TENS ) (Moist Heat after 10 days)  Sling immobilization (duration / schedule per MD)  Cervical & distal extremity AROM  Postural correction

(as indicated)

 Codman’s / Pendulum execises

(when tolerated)

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Maximum Protection Phase (0-6 weeks)

• Treatment Interventions:

 PROM: Elevation / ER  AAROM (when tolerated):

– Elevation / ER

 Aquatic therapy

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• Re-education for

dyssynergic shoulders

• Adjunct to traditional

therapeutic exercise

• Proprioceptive input

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Maximum Protection Phase (0-6 weeks)

• Treatment Interventions

 Scapular and Deltoid

strengthening (when tolerated)

 Soft Tissue Massage  Home exercise program

– consider insurance situation

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Maximum Protection Phase (0-6 weeks)

• Criteria for Advancement

 Tolerating sling discontinuation

with self-care, ADL’s

 AAROM: Elevation to 110°

ER to 30°

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Moderate Protection Phase (4-12 weeks)

• AAROM: Wand FF/ER
• Pulleys (when appropriate)

 120 degrees FF  Humeral Head Control

• Active IR ROM (Towel pass)

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Moderate Protection Phase (4-12 weeks)

• Glenohumeral mobilization
• Scapular stabilization

exercises

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Moderate Protection Phase (4-12 weeks)

• Airdyne Bike

Upper Body Ergometer

• Scapular and

Deltoid PRE’s

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Moderate Protection Phase (4-12 weeks)

• Rototor cuff Isometrics

 Dictated by gains in ER ROM

• Scaption (PRE)

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Moderate Protection Phase (4-12 weeks)

• Criteria for Advancement / Goals

 AAROM :

Elevation to 150° ER to 65°, IR to 70°

 Improve scapulohumeral rhythm to WNL < 90° elevation

(scapular plane)

 Improve muscle strength to > 4/5  Independent with home exercise program as instructed

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Strengthening / Function Phase (10-? Weeks)

• Goals:

 Improve scapulohumeral rhythm to

WNL < 120°elevation (scapular plane)

 Improve muscle strength to 5/5  Maximize ROM, strength, flexibility so to meet the

demands of ADL and/or sports participation where indicated

 Independent with home exercise program as instructed

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Strengthening / Function Phase (10-? Weeks)

• Treatment Interventions

 Towel Stretch (IR)  Posterior capsule stretching  Pect Minor Streching  Rototor cuff Isotonics

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Strengthening / Function Phase (10-? Weeks)

• Treatment Interventions

 PNF (Manual resistance → theraband)  Sport Specific Activites (if and when indicated)

– e.g. golf, tennis, etc)

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Summary

• Rehabilitation Guidelines: PHF

 Directed by MD, Guided by PT  Radiological evidence of healing  Early Mobilization  Criteria for advancement

• Succesful Outcome

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