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Bryan Houseman, D.O., ATCOrthopaedicTrauma and Fracture Surgeon
New Hampshire Orthopaedic Center
September 10, 2016
I have no relevant disclosures pertaining to this talk.
From Rockwood & Green, 8th ed
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From Rockwood & Green, 8th ed
Anterior humeral circumflex
Ascending branch
PHCA
Posteromedialplexus
From Rockwood & Green, 8th ed
Hettrich et al, JBJS 2010
Gerber et al., JBJS 1990
Vessel injury
Fragment devascularization
Nonunion
Osteonecrosis
From Rockwood & Green, 8th ed
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Neer (1970): 1 cm, 45° based on “parts”
From Rockwood & Green, 8th ed
Maximize function
Stable fixation if unstable fracture
Early rehab▪Whenever possible
Minimize pain
Who and What is your patient?
Age ▪ physiologic not always
chronologic
Cognitive status
Activity level
Injury mechanism
Associated injuries
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Proximal humerus fractures have been described by many as a soft tissue injury with a bony dysfunction!
The forces placed on the fragments at the time of injury are the same that post operatively must be respected.
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The understanding of the repair is the 1st step to recovery.
The parts of the fracture that are repaired will dictate how, when, and why the recovery can be advanced.
Don’t ever be afraid to ask for more specifics about the surgery, repair, and/or case specific limitations.
The goal initially is pain management and LIMITED immobilization.
Goal:
Maintain ROM without displacing the fracture.
What can be done right away?
Elbow, Wrist and Hand motion (E/W/H)!
Koval et. al., JBJS 1997;79A:203
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Pain management
Pendulum exercises
Limited immobilization to decrease pain and not create an unstable fracture…
Supine ER with a cane. Fifteen to 20 degrees of abduction are permitted if the patient is more comfortable.
Establish a home exercise program so patient is performing exercises 3‐5 times per day for 30 min. Each session.
15‐20
New X‐rays…Stable continue…changes or loss of reduction…surgery/acceptable position?
OR
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Begin assisted forward elevation (FE).
Perform pulley exercises and teach for home program.
Perform isometric exercises for IR, ER, extension, and abduction.
Begin supine active FE.
Progressively increase patient’s position from supine to erect during FE exercises.
Use therabands of progressive strengths for IR, ER, flexion, abduction, and extension. Goal is progressive strengthening of deltoid and rotator cuff.
Begin flexibility and stretching exercises to progressively increase ROM in all directions.
Progressive return to unrestricted ROM/activity based on fracture healing, pain, and progress with rehab program
At any point the patient may need a step back to eventually more a step forward.
Communication of progress/concerns are paramount!
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The goal initially is pain management and acute immobilization.
Short Term Goal:
Maintain ROM without destroying the fixation.
What can be done right away?
Elbow, Wrist and Hand motion!
Begin elbow, wrist and hand (E/W/H) active ROM
A shoulder immobilizer is typically utilized for soft tissue rest, pain management, and control of swelling.
After 14 days, begin pendulum exercises . Want fracture to begin to heal and surgical incisions to close.
Establish a home exercise program so patient is performing pendulum and E/W/H exercises 3‐5 times per day for 10 minutes each session.
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The fracture is observed radiographically
Signs of hardware failure, AVN, loss of reduction, and or infection closely monitored.
Pain management can be achieved by a multimodal approach with medication, thermal therapies, and/or TENS units
Begin supine AAROM ER with a cane. Limit range to ~15‐20 degrees. The goal is gentle motion not gross gains. Remember early fracture healing is occurring.
Begin active assisted forward elevation (FE), supine or with a pulley/stick.
Perform pulley exercises and teach for home program.
Perform isometric exercises for IR, ER, extension, and abduction.
Introduction of gravity as a stressor is the goal
Begin supine active FE. Progressively increase patients position from supine to erect during FE exercises.
Use Therabands of progressive strengths for IR, ER, anterior, middle and posterior deltoid.
Begin flexibility and stretching exercises to progressively increase ROM in all positions (i.e. towel behind back, finger walking up the wall, etc.).
Communication is KEY. Problems stop, back‐up, call.
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Patients are placed in a shoulder immobilizer with an abduction pillow post‐operatively. Pendulum, elbow, wrist, hand ROM is started immediately.
F/U at 7‐10 days to remove sutures, check x‐rays and start passive ROM in physical therapy.
Therapy typically can be more aggressive with this method as there is less bony union needed.
Active ROM and strengthening are started after x‐ray evidence of fracture healing. Most important signs of healing are the tuberosities!
The rehab protocol would then follow that of the stable ORIF.
Abduction sling. Elbow, wrist, hand and Pendulum ROM exercises.
7‐10 days: continue sling/immobilizer until 3‐6 weeks post‐op.
Start early passive shoulder ROM( limited to 90 degrees elevation, 0 degrees ER), active elbow, wrist, hand ROM
Avoid ER for 6weeks to allow subscapularis or lesser tuberosity to heal.
Avoid combined abduction and external rotation (risks dislocation).
6 Weeks: Active supine ROM started. Generally may use arm for daily activities and driving.
Resistive exercises started at 10‐12 weeks
3 Months: activity as tolerated. Adjust home exercise program to any patient deficits.
Patient expected outcomes after RTSA for fracture and low…Want to be able to perform ADL’s
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Initially the goal of post surgical management is pain control, soft tissue quiescence, and “putting out fires”
Initially the determination of whether the fracture is operative or non‐operative…
If surgery is selected what type is the next hurdle.
Restoration of function in this patient population is the ultimate goal.
A balance of fracture healing, patient pain, and prevention of loss of range of motion is the foundation of patient outcomes.
If the timing of the foundation principals are out of sync failure can and commonly will be the result.
