The proximal humeral fractures .pptx

Different Fractures of the humerus bone and physical therapy rehabilitation

1. Rehabilitation after Proximal Humeral Fracture (PHF)

2. Anatomy Humeral head : The proximal articular surface of the upper extremity. It articulates with the glenoid fossa of the scapula. Greater tuberosity : Located lateral to the head at the proximal end. Lesser tuberosity : Located inferior to the head, on the anterior part of the humerus . Anatomic neck: Located between the head and the tuberosities. Surgical neck: Located between the tuberosities and the shaft. Humeral shaft . Proximal humerus fracture (PHF ) It includes any fracture that occurs at or proximal to the surgical neck .

3. Essential related structures 1)Rotator cuff Function: Together these 4 tendons are responsible for stabilizing the shoulder joint maintain the head into the socket and allow the wide ROM to the arm . They are a group of 4 muscles that originate from the scapula and inserte by their tendons to the head of the humerus

4. 2) Pectoralis major ms Action With the origin fixed, the pectoralis major adducts, internally rotates arm Clavicular head – originates from the medial half of clavicle . Sternocostal head –originates from : the   manubrium and body of sternum and 6 costal cartilages. Insertion : The upper and lower fibers of pectoralis major insert to crest greater tubercle of the humerus .

5. 3)axillary nerve The axillary nerve (c5-6) originates off the posterior cord of the brachialplexus the brachial plexus ( C5-T1 nerve roots ) (a web of nerves from the neck that supplies the arm ). The trunks are the source for the lateral , posterior , and medial cords of the plexus

6. axillary nerve It divides into: Motor branch to (deltoid & teres minor ms ) Sensory branch to ( the skin over the inferior 2/3 of the deltoid muscle)

7. 4) axillary artery The blood supply to the humeral head is supplied predominantly by the anterior and posterior humeral circumflex arteries from axillary artery .

8. Neer classification The most common classification for PHF. It is focused around the PHF being composed of 4 major segments (parts ) including ( the greater tuberosity , , lesser tuberosity , articular surface “head”, and humeral shaft) .

9. (# no displaced ) (or Minimally) regardless of the number of fracture lines # of one segment & displacement according to the criteria. Neer set criteria of displacement as ( ≥ 1-cm separation) or ( ≥ 45 ° angulation) # & displacement of the surgical neck + (greater or lesser tuberosity displacement) all four segments are # & displaced causing loss of articulation nerve injury & avascular necrosis

10. F alling on the outstretched hand Direct trauma to the shoulder more common in old age with O.P R oad traffic accidents . Sports injury ( Stress fractures can occur with repetitive overhead throwing ) Seizures (with violent muscle contractions ). M echanism of injury

11. Signs and symptoms Sever pain of the shoulder. Bruising and swelling that can extend below the fractured area, entire extremity and chest Inability to move the arm . Deformity (rarely ): of the upper arm in internally rotated position. (Due to pulling force of the pectoralis major to the shaft fragment anteriorly and medially )

12. Associated injuries In fracture dislocation of the proximal humerus can be associated with neural and vascular injury especially when located near the head. Axillary nerve injury : may result in temporary paralysis of deltoid & teres minor (cause weakness of arm abduction ), sensory affection along the upper lateral arm and (rarely) permanent damage . A xillary artery injury : a large expanding haematoma , if neglected can lead to avascular necrosis of head of humerus Muscular injury : rotator cuff injuries Signs and symptoms

13. I maging X -rays: Plain radiographic imaging is the primary baseline investigation for diagnosis, classification, and management planning. X-rays should include : AP & lateral view Doppler ultrasound : May be used to assess the associated vascular injury and concomitant rotator cuff tears. Computerised tomography (CT ) : to give more details about bone status, it can be used to evaluate tuberosity displacement and degree of comminution , articular surface involvement and for fracture union follow up . CT angiography : Can be used for accurate diagnosis and guiding management of co-existing arterial injury. MRI : Can detect avascular necrosis

14. M anagement Conservative treatment It is successful in most of stable fractures and is not displaced . Some disblaced fractures with whom operation is contraindicated ( Significant bone O.P or serious medical state of patient ) . It consists in the use of a sling to achieve shoulder immobilization with a physical therapy progrom .

15. Surgical treatment plate and screw Intramedullary nail Arthroplasty (hemi or total) With major displacement of the fractured bone parts.

16. Conservative treatment for non disblaced PHF

17. < 1-2 weeks after PHF > Pain and swelling control Immobilization in a sling ( remove for hygiene & exc . Only) Administration of anti-inflammatory medications (NSAID) assists in reducing inflammation and swelling while analgesics are given to reduce pain . Cold backs on the site of swelling

18. < 1-2 weeks after PHF > Pendulum exercises. AROM exercises to joints away from shoulder: Scapular retraction Neck , elbow, wrist, and hand AROM

19. After 2 week Ext rot should be limited to 30°-40 ° begin to add forward elevation exercises with pulley (within limit of pain). After 3 week B egin supine external rotation with a stick with slight amount of abduction , approximately 15 -20°ext rot to restrict rotational stress to the fracture.

20. < 4 weeks > • Begin Submaximal isometric exercises for the rotator cuff & shoulder ( int , ext rot , abduction ). int rot ext rot abduction

21. < 3 to 6 weeks > AAROM ( supine shoulder flexion until 90 ° ) with a stick

22. < 6 to 8 weeks > After radiological union (assumed to be 6-8 wks ) remove sling Gradual Progression to PROM Gradual AAROM in erect position using stick Wall slides

23. < 6 to 8 weeks > AROM of sh. in all directions (supine then erect position)

24. < 8 to 10 weeks > Isotonic exercises for RTC , scapular muscles . using t herabands for progressive strengthening in all directions Extension & retraction ext rot Int rot abduction flexion

25. ( 10-12 Weeks) T he patient should achieve full ROM in all directions . Posterior capsule stretching stretching of sh. rotators

26. (10-12 Weeks) Concentrate on scapular strengthening . Prone scapular strengthening ( I ,T, Y shapes )

27. Concentrate on rotator cuff and shoulder muscles strengthening Progress isotonic exercises using weights for strengthening. • Weights can start at 1 lb and move forward in 1-lb increments until 5 lbs. If any pain persists after exercises with weights, then discontinue the exercises. Int & ext rot (10-12 Weeks)

28. Overhead ball exercises to increase ROM & improve sh. proprioception bouncing overhead ball exercises (10-12 Weeks)

29. >12 wks Functional exercises ( according to the patients’ sports or physical work demands ) Aiming to return to previous activities kettle bell