rehabilitation of proximal humerus & clavicular fractures · deltoid and rotator cuff...

Rehabilitation of Proximal Humerus & Clavicular Fractures

19th Annual Primary Care Orthopaedic & Sports Medicine SymposiumJanuary 25, 2019

Jeremy Sherman, PT, MPT

Disclosures

No financial disclosures to note.

Jeremy Sherman, PT

Sport & Spine Clinic – Edgar Director/Physical Therapist

Sports Medicine coverage Edgar High School

PT University of Wisconsin – Madison

Objectives

Identify evidence-based exercise programs for patients with humerus or clavicular fractures to increase ADL independence.

Develop progressions of exercises for return of upper extremity functional independence.

Identify benefits of evidence based exercise to improve funcitonal outcomes following upper extremity fracture.

Functional Limitations seen Following Upper Extremity Fractures

Limited shoulder AROM for ADLs: Overhead and behind the back

Weakness for lifting, carrying, push/pull

Difficulty sleeping in bed

Limitations with household activities

Compensatory movement patterns

Proximal Humerus Fractures

6% of fractures

MOI: usually Trauma Fall directly on shoulder Forceful collision Car accident

Osteoporosis factor

Female > Male

Displaced vs. Non-displaced

Humerus Fracture Symptoms

Pain

Swelling

Bruising

Severe shoulder motion restriction

Numbness/Tingling in arm, forearm, or hand

Deformity

Post-operative vs. Non-operative Treatment

Sling for 6 weeks Elbow and wrist ROM immediately after injury

Koval et al. – Improved outcomes if Physical Therapy initiated within 14 days of injury Decreased rates of stiffness and improved ability to perform ADLs

Pendulum exercises at 3 weeks

Active ROM at 6 weeks

Full ROM and strength restrictions lifted after full healing seen on films.

Interventions for Proximal Humerus Fractures

Range of Motion: Pendulums

Pulleys

Cane Exercises

Wall slides

Table slides

Interventions for Proximal HumerusFractures

Strengthening Exercise: started once fracture union is seen Deltoid and Rotator Cuff Isometrics

Scapular stabilization exercises Scapular retraction, low trap setting, rhythmic stabilization, rows

Active exercises starting supine and then moving to seated/standing

Active Resistive = Deltoid and RTC as AROM improves

Daily Home Exercise Program

Strengthening Exercises


Manual Therapy: to improve functional movement Shoulder mobilizations – when indicated Glenohumeral and scapular

Soft tissue mobilizations

Scar mobilizations for post-operative

PROM

Dry needling of trigger points


Functional Training: Reaching into an overhead cupboard

Push/pull a cart to mimic household chores

Functional lifting from different heights

Opening/closing door

Transfers

Return to work activities

Compensatory techniques if needed


When to return to Daily Activity: Diagnostic testing reveals closure of fracture and physician

approves full return

Can be 6 months to full year for full return Expect some limitations

Ease into activity to avoid overuse and remember to ice if needed

Outcomes following Proximal HumerusFracture

Most patients have functional pain-free shoulder May take up to 2 years for full recovery

Rapid improvements within first 6 months, near full recovery in 1 year

Counsel patient there will be some strength and motion deficits

Patient Screening

Check for: Falls Risk Reduction Strategies

For Contact Sports => proper protective equipment

Low Bone Density Possible supplementation of Calcium and Vitamin D

Rehabilitation and Interventions for Clavicular Fractures

Clavicle Fracture 35% of all shoulder injuries

Most common cause = trauma Direct blow or fall

Most often diagnosed = <20 y.o. Sports injuries

Age increases = result of fall

Midshaft = 75-80% of clavicle fractures

Clavicular Fractures

Signs and Symptoms: Pain over injury site Arm pain or changes in sensation in severe cases

Bruising

Swelling

Inability to lift arm

Grinding sensation with movement

Bump or step-off at injury site


Sling

6-8 weeks

Figure 8 Brace


Early Range of Motion Exercises: Distal extremity motion

Pendulums

Cane exercises

Table slides

Early intervention Prevent weakness and stiffness

After 4 weeks if physician sees good position and stability, Physical Therapist will guide to achieve full shoulder ROM

Rehabilitation and Interventions for Clavicular Fracture

When to start strenuous exercise: Both non-operative and operative usually begins around 6-8

weeks after injury/surgery Appropriate healing needed Age, health, complexity of injury/surgery factors

Active ROM progression Strengthening exercise Work on shoulder complex as a whole for good stabilization Scapular stabilizers, RTC, biceps, rhythmic stabilization


Strengthening Exercise: Phase I (0-6 weeks): isometric exercises at neutral, elbow/forearm

exercises, scapular retraction Phase II (7-12 weeks): theraband ER/IR, Row, side lying ER,

prone Y/T/I, standing scaption, isotonic biceps curl Phase III (13-18 weeks): standing forward flexion, rhythmic

stabilization and proprioceptive training drills, push up progression, add progressive resistance 1-5#, limited weight training near week 13

Phase IV – closed kinetic chain exercises, plyometrics for throwing and overhead athletes, interval sport programs, return to weight training based on physician’s advice.


When to Return to Daily Activity: Nonstrenuous activity after about 6 weeks Strenuous job duties = 9-12 weeks

Return to Sport: Non-operative 9-11 weeks following trauma (Faldini et al) Operative: ~12 weeks gradual return to activity

~16-18 weeks – full sports based on healing and physician approval

Functional Testing

Upper Limb Functional Testing

Seated Medicine Ball Test (Harris et al) Sit on the floor with back against the wall, legs extended and

apart for balance

Bring ball to chest and throw while keeping the back against the wall

Best of 3 trials

Males use 6 lb. ball, Females 4 lb. ball


Seated Medicine Ball Toss

Highly reliable test of upper body power in older adults

Rating Distance (meters)

Excellent 5.76+

Good 5.00-5.75

Average 4.25-4.99

Below Average 3.50-4.24

Poor 0-3.49


Single Arm Seated Shot Put Test (Negrete et al.) Seated in a chair without armrests

Feet and legs placed on chair in front

Nonthrowing arm placed across the chest and a strap placed across the chest to secure the subject to the chair

6 lb. medicine ball

4 warm up puts and then 3 trials

At least 90% symmetry in distance side to side


Timed Push Up Test (Negrete et al) Widely used in lots of settings to test upper body strength Significant reliability 90% confidence in minimal detectable change represents true

improvement (2 reps)

How many you can do in 1 minute Male: > 18 reps, Female: > 12 reps

Also can do to exhaustion12

Male: >39, Female: >27

Safe, inexpensive, repeatable, practical


Modified Pull-up Test ( Ervin et al) Used in schools age 5-15

Test of strength focused on the back, shoulder, forearm, and arm strength

Complete as many as possible until break form or pause for more than 2 seconds

Adjustable bar positioned to allow participant to grab bar with back flat on surface. Strap hangs down 8 inches and chest has to touch strap.


Modified Pull-Up Test

Boys Girls

5-6 ≥ 27 ≥ 3

5-6 ≥ 2

8 ≥ 49-10 ≥ 5

7 ≥ 3

11 ≥ 612 ≥ 7

8-15 > 4

13 ≥ 814 ≥ 9

15 ≥ 10


Upper Quarter Y Balance Test (Gorman, Westrick, Butler) Weight bearing on the contralateral limb Test medial reach, inferolateral reach, superolateral reach Start with right and do in that order, repeat on left Best of 3 trails, allowed 1 practice trail

Reach as far as possible without loss of balance Challenges balance, proprioception, strength and ROM Normalize reach distance Measure arm length from C7 to the most distal tip of the right middle

finger Must have good form Cannot touch down with reach hand, fall off platform, shoved the

sliding platform, used sliding platform for support, failed to come back to starting position, and lifted feet off floor


Upper Quarter Y Balance Test Reliable test for measuring UE reach in a closed chain

position13

No difference in baseball and softball players

No difference in throwing and non-throwing in un-injured athletes

Not at good measure of strength


Closed Kinetic Chain Upper Extremity Stability Test (Tucci, Roush, Butler) Push up position, or modified push up position

Hands 36 inches apart

Count how many times one hand can touch the other hand in 15 secs Hand must come back to the starting position each time

3 trials with rest up to 45 secs between sets


Closed Kinetic Chain Upper Extremity Stability Test

Improvement of 3-4 touches is considered significant

Reliable tool for healthy, subacrominal impingement, and different levels of physical activity

Collegiate-level baseball players no differences existed in scores by position

Clinically relevant for use in upper extremity function

Effect of Exercise

Bruder et al. - Exercise reduces impairment and improves activity in people after upper limb fractures Early commencement of exercise beneficial for conservatively

managed proximal humerus fractures

Supervised exercise and home exercise program leads to reduction in impairment, particulary ROM.

References

Bruder et al. Exercise reduces impairment and improves activity in people after some upper limb fractures: a systematic review. Journal of Physiotherapy. 2011; 57(2):71-82.

Herzog MM, Whitesell RC, Mac LM, Jackson ML, Culotta BA, Axelrod JR, Busch MT, Willimon SC. Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents. J Child Orthop. 2017; 11:310-317.

MacIntyre NJ, Kwan LL, Johal H, Lefaivre KA, Guy P, Sprauge S, et al. Rehabilitation of Proximal HumerusFractures-A Scoping Review. SM J Trauma Care. 2017; 1(1):1001

Canbora MK, Kose O, Polat A, Konukoglu L, Gorgec M. Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study. Int J Shoulder Surg. 2013 Jul-Sep; 7(3):105-109.

Hauschild et al. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg. 2013 Oct; 133(10):1385-1393.

Faldini et al. Nonoperative treatment of closed displaced midshaft clavicle fractures. J Orthopaed Traumatol.2010; 11: 229-236.

Harris C, Wattles AP, DeBeliso M, Sevene-Adams, PG, Berning JM, Adams KJ. The Seated Medicine Ball Throw as a Test of Upper Body Power in Older Adults. Journal of Strength and Conditition Research. 2011; 25(8): 2344-2348.

References

Negrete RJ, Hanney WJ, Kolber MD, Davies GJ, Ansley MK, McBride AB, Overstreet AL. Reliability, Minimal detectable change, and normative values for testes of upper extremity function and power. J Strength Cond Res. 2010;24: 3318-3325.

Ervin RB, Fryar CD, Wang CY, Miller IM, Ogden CL. Strength and body weight in US children and adolescents. Pediatrics. 2014 Sep 1;134(3):782-9.

Gorman PP, Butler RJ, Plisky PJ, Kiesel KB. Upper quarter Y balance test: reliability and performance comparison between genders in active adults. J Strength Cond Res. 2012;26 (11): 3043-3048.

Westrick RB, Miller JM, Carow SD, Gerber JP. Exploration of the Y-balance test for assessment of upper quarter closed kinetic chain performance. International Journal of Sports Physical Therapy. 2012;7(2):1139-147.

Butler RJ, Myers HS, Black D, Kiesel KB, Plisky PJ, Moorman CT, Queen RM. Bilateral Differences in the Upper Quarter Function of High School Aged Baseball and Softball Players. The International Journal of Sports Physical Therapy. 2014; 9(4): 518-524.

Tucci HT, Martins J, Sposito G, Camarini P, Oliveira A. Closed kinetic chain upper extremity stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC Musculoskeletal Disorders. 2014;15: 1474- 2474.

Roush JR, Kitamura J, Chad Waits M. Reference values for the closed kinetic chain upper extremity stability test (CKCUEST) for collegebaseball players. North American Journal of Sports Physical Therapy. 2007;2(3):159-163.

Butler R, Arms J, Reiman M, Plisky P, Kiesel K, Taylor D, Queen R. Sex differences in dynamic closed kinetic chain upper quarter function in college swimmers. Journal of Athletic Training. 2014;49(4):442-446.

rehabilitation of proximal humerus & clavicular fractures · deltoid and rotator cuff...

Documents