Physiotherapy Treatment of Shoulder Fractures

Up to 5 percent of fractures are of the humerus so this is a common presentation at Emergency Departments, with up to 80 percent of fractures either not displaced or displaced minimally. As older people suffer mostly from this fracture, there is a relationship with osteoporosis and people often have a fractured forearm on the same side. These fractures occur mostly at the upper arm, known as the humeral neck (shoulder fractures), and at the middle of the arm bone, with artery or nerve damage possible but not common.

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.

Management of Humeral Fractures

Initial management is to restrict the patient’s movement and give them enough painkillers to make them comfortable. Upper humeral fractures can be managed conservatively if not displaced but if the greater tuberosity is fractured then an injury to the rotator cuff must be considered, more common in older people, injuries with high forces involved and where there is a lot of displacement. The typical treatment is a collar and cuff sling, allowing the elbow to hang in mid air and keep the humerus in line. Shaft fractures may be managed by humeral bracing.

Open reduction internal fixation (ORIF) is often performed for displaced fractures with three or four fragments and more commonly in younger patients, while older patients have humeral head replacement to prevent pain and stiffness in the shoulder. Nailing or plating is used in shaft fractures if necessary but these usually heal without surgery. Humeral fractures can have complications including injury to the radial nerve in shaft fractures, frozen shoulder and death of the humeral head due to loss of blood supply. Although normal healing time is 6-8 weeks, older sufferers may never re-establish normal range of 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.

The fracture will have started to heal at the three week point so the physio will start auto-assisted exercises, the patient assisting the movement of the fractured arm with the healthy one. Progression from here it to unassisted exercises where the affected arm does the movement alone, practicing flexion, medial and lateral rotation. Healing time for the humerus is six weeks so the physio will increase the force behind the exercises, gently stretching the joint to increase the available movement. Joint mobilisation techniques can be uses to free up the accessory movements and Theraband used to perform strengthening exercises and maintain gains in movement.