Fractures of the humerus are common and make up about 5% of all fractures, with 80% of them either undisplaced or just minimally displaced. More common in people suffering from osteoporosis, it is common to have a forearm fracture on the same side. Damage to the nerves or circulatory system is possible from these fractures but not often seen. Common areas of fracture are the neck of humerus at the top of the arm(fractured shoulder) and the mid shaft of the arm bone.
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.
If the fracture occurred without significant force then a pathological cause such as cancer must be suspected. On physio examination pain will occur on movement of the shoulder or the elbow, there may be extensive bruising and swelling, the arm may appear short if the fracture is displaced in shaft fractures and there is very restricted shoulder movement. Radial nerve damage is rare in upper humeral fractures but more common in fractures of the shaft, leading to “wrist drop”, weakness of the wrist and finger extensors and some thumb movements.
Management of Arm Fractures
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.
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 for Shoulder Fractures
Initial physiotherapy assessment consists of assessing the patient’s pain levels as these can vary hugely, the joint ranges of motion of the elbow, hand and wrist and the tissue swelling and bruising in the arm. Muscle strength is tested in the forearm as this may indicate an injury to the radial nerve, as may loss of sensory discrimination. The patient may stay in the sling for 2-3 weeks with the physio exercises beginning early if pain is reasonable and the fracture stable. The aim is to maintain the range of motion of the shoulder joint while the fracture heals, by performing bent over pendular exercises to counteract gravity.
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.
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