Wk 4: Fractures of the UL

Proximal humeral fractures

  • Often older women, associated osteoporosis, after a fall

  • Often extensive bruising

Proximal humeral fracture classification

Neer classification

Is a system used to classify proximal humerus fractures by the number of displaced segments

One part fracture: no segments displaced

Two part fracture: one segment displaced

Three part fracture: two segments displaced, including one tuberosity and the surgical neck

Four part fracture: All four segments are displaced

Proximal humeral fracture conservative treatment

Impacted fractures

  • Broken bone jammed into each other

  • Active and active assisted movement as soon as possible

  • In a sling in between for pain relief

Unimpacted fractures

  • Broken bones aligned and still in original position

  • Support in sling for about 1 week

  • Assisted shoulder exercises

  • Pendular exercises

Conservative management

Look:

  • X-ray

  • Bruising

  • Slings

  • Willingness to move

Feel:

  • No advantage in palpating the fracture

Move

  • Active movements

  • Active assisted movements

  • Avoid rotations, avoid resistance

Role of physiotherapy in proximal humeral fracture

  1. Advice and education

  2. Move even if uncomfortable or painful

  3. Early active movement exercises

  4. Active assisted, pendular

  5. Pain control → using ice and sling

Surgical treatment

3 or 4 part fracture

  • Surgery (ORIF)

  • Hemiarthroplasty (half replacement of shoulder)

Younger patients with severely comminuted, displaced, intra-articular fracture

  • External fixation for 6 weeks

Physiotherapy protocol post shoulder hemiarthroplasty

Phase 1

  • Active and assisted exercise

  • Pendular

  • Avoid lifting or overhead work

    2-4 weeks in

  • Start horizontal flexion and shoulder extension

  • Start isometric strengthening of exercise

Phase 2 (6 weeks to 3 months)

  • Start rotations (HBB, external rotation exercises)

  • Wall push ups

Phase 3 (3-6 months)

  • Theraband strengthening

Wrist fracture

  • Distal radius fracture

  • Colles’ fracture → most common fracture in older people

  • Associted with osteoporosis

Mechanism

  • Fall on outstretched hand

  • Pulls distal fragment back, radius shortened

  • Dinner fork deformity

Wrist fracture: treatment

Reduce

  • Manipulate under anaesthetic

Hold

  • Cast 5-6 weeks

Move

  • Unsplinted joints from day 1

  • Wrist after removal of cast

Physiotherapy after removal of cast (union)

Assess: Look, feel, move

Exercises

  • Supervised and home exercise program ROM and grip strength

  • Typical dosage: initially on/off 2 × 5 min daily

Exercise prescription after wrist fracture

  • Pronation/supination

  • Flexion/extension

  • Prayer exercise

Wrist fracture complications

  • Stiffness

  • Mal-union

  • Compression of median nerve

  • Complex regional pain syndrome: pain out of proportion or desensitisation

Passive modalities

  • Passive joint mobilisation

  • Ultrasound

  • Other electrotherapy modalities