Shoulder fracture
-
Upload
dimitris698 -
Category
Documents
-
view
215 -
download
0
Transcript of Shoulder fracture
-
7/25/2019 Shoulder fracture
1/10
01 96-601 1 80/0201-02 5 02.00/0
THE JOURNAL
F
ORTHOPAED~CND SPORTS HYSICALHERAPY
Copyright O 1980 by The Orthopaedic and Sports Medicine Sections of the
American Physical Therapy Association
Serial Assessment and Treatment of a
Humeral Fracture
GARY
L
SMIDT,* LPT, PhD
Clinical problems at the glenohumeral joint,
whether chronic or induced by trauma, tend to
manifest joint hypomobility with accompanying.
muscle weakness. Fractures at the proximal hu-
merus tend to occur more frequently in older
patients, but in the presence of violent trauma
this injury may occur in the younger patient as
well.' The initial treatment often includes some
form of immobilization followed by remobilization
and muscle strengthening. There is a clinical
need to document the sequence and form of
physical therapy treatment and quantitatively re-
flect changes in joint motion and strength.
A case study of a patient with a proximal
humeral fracture is presented to (a) dezcribe the
clinical findings and treatment associated with a
shoulder injury, b ) describe and illustrate some
methods of assessment and treatment, and
c)
report results for joint motion and muscle
strength.
The hope of the author is that this paper might
provide an example of physical therapy evalua-
tion and treatment for such a case and demon-
strate a model for expected results. Further, this
paper might be used as a teaching model for
therapists who are unexperienced with this type
of patient.
ONSET AND CLINICAL COURSE
A young man 1 3 years of age was struck by
opposing players while attempting to pass a
football. Radiological examination demonstrated
a fracture of the left proximal humerus (Fig. 1).
A closed reduction was performed under general
anesthetic, and a shoulder spica was applied
(Fig.
2).
The patient's right upper extremity was
his dominant or preferred side. The patient was
discharged from the hospital on Day
5.
On Day
16, radiographs showed that the alignment of
the bony fragments was being maintained (Fig.
3). The fracture healed without incident, and the
final result demonstrated a mild residual medial
angulation (Fig. 4). The spica cast was removed
on the 38th day post injury, at which time whirl-
pool and active exercise was initiated. Mild pas-
sive movements and resistive exercise were ini-
tiated on Day 6 following cast removal. On Day
13 post cast removal, radiographs showed the
fracture solidly healed, and more vigorous pas-
sive mobilization of joint (Grade IV' sustained
stretch and contract-relax) was administered
from this time. The mobilization techniques used
are illustrated in Figs. 5 to 11. On Day 56 follow-
ing spica cast removal, glenohumeral and elbow
joint motion and strength were restored to nor-
mal. A more detailed account of events associ-
ated with the clinical course appears in the Ap-
pendix. The patient received daily physical
therapy treatment for the first 44 days following
cast removal.
Some general guidelines to the treatment ap-
proaches were used. Following cast removal,
treatment emphasis was on reduction of pain
and discomfort. Until motion was approximately
80%
of normal, the primary emphasis was
placed on mobilization of the joint, while incor-
porating resistive exercise as tolerated. As joint
motion approached normal, higher priority was
given 'to resistive exercise. Therefore, the appli-
cation of physical therapy was to solve problems
in this order: pain, joint hypomobility, and muscle
weakness.
ASSESSMENT-JOINT MOTION
All motion measurements were obtained in the
supine position, except shoulder extension
which was accomplished sitting. Joint angle
measurements at the extremes of both active
and passive movements were obtained for the
shoulders and elbows bilaterally. The methods
of measurement for the shoulder are depicted in
Figs. 1 2 to 16.
At the outset, motion was extremely limited in
all directions of glenohumeral motion and elbow
flexion. Extension of the elbow was normal.
Director and Professor, Programs in Physical Therapy. The Univer-
Shoulder
and
sity of Iowa. Iowa City. IA
52242.
tion, and elbow flexion showed the most rapid
25
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
2/10
2
6
SMlDT JOSPT Vol. 2
No.
Fig
3
Rad~ograph n day 16.
Fig
2
Patient in shoulder spica. Fig 4 Radiograph final results.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
3/10
JOSPT Summer 798 TRE TMENT OF HUMER L FR CTURE
7
Fig
5 Joint mobilization horizontal adduction.
Fig 8 Joint mobilization internal rotation.
Fig
6 Joint mobilization abduction.
Fig 9.
Joint mobilization dorsal glide.
Fig
7 Joint mobilization external rotation.
Fig
10 Joint mobilization caudal glide.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
4/10
8
SMl T
OSPT Vol 2
No.
Fig Joint mobilization flexion. Fig
14
Method of joint motion measurement internal rotation.
Fig 2 Method of joint motion measurement flexion.
Fig
5 .
Method of joint motion measurement external rotation.
Fig
13 Method of joint motion measurement abduction.
Fig
16 . Method of joint motion measurement extension
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
5/10
JOSPT Summer 1980 TRE TMENT
O
HUMER L FR CTURE 29
Fig 17
Method of strength measurement shoulder flexion.
Fig
20 Method o f strength measurement
shoulder horizontal abduction.
Fig
8 Method of strength measurement
shoulder horizontal adduction.
Fig 21
Method of strength measurement
shoulder external rotation.
Fig 19
Method of strength measurement
shoulder extension.
Fig 22
Method of strength measurement
shoulder internal rotation.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
6/10
lDT
JOSPT Vol 2, No
Fig
23 . Method of strength measurement elbow flexion
Fig.
24. Method of strength rneasurernent
elbow extension.
return to normal (Charts 1 to 4). Shoulder ab-
duction, internal rotation, and external rotation
began to approach near-normal status at about
22 to 25 days post cast removal. Motion at the
injury shoulder was equivalent to the contralat-
era1 side on the 28th day for shoulder extension,
the 8th day for shoulder adduction, and the 56th
day for the remainder of the measurements.
ASSESSMENT MUSCLE STRENGTH
Measurements of strength were obtained with
the patient supine and the upper extremity ori-
ented in the positions shown in Figs. 17 to 24.
Measurements of isometric strength were ac-
quired from a manual dynomometer consistently
placed at locations on the distal arm (shoulder
measures) and forearm (elbow measures). Mo-
ment arms were measured from the point of
force application to the tip of the acromium for
the shoulder and to the medial epicondyle for
the elbow. Measurements from three maximal
efforts were averaged, and the mean measure-
ment served as the experimental unit.
The results are shown in Charts 5 to 9. Mea-
surements of strength on the uninvolved and
involved sides consistently demonstrated mod-
erately larger values for shoulder extension over
flexion, internal rotation over external rotation,
and horizontal adduction over horizontal abduc-
tion. Strength for elbow flexion was slightly
greater than for extension. Strength on the in-
volved side tended to increase gradually and
was comparable to that of the uninvolved side by
45 to 56 days post cast removal.
Bilateral circumferential measurements at arm
and forearm revealed a difference between un-
involved and involved upper limbs. At 56 days,
the involved upper limb was considerably smaller
(Chart 10). This result tends to refute the validity
of using circumferential or girth measurements
as an index of muscle strength. For this patient
the strength at 56 days was normal, even though
a deficit in girth size for the involved side re-
mained.
COMPARISON OF SHORT AND LONG TERM
MEASUREMENTS
Measurements for joint motion and muscle
strength were obtained from the patient 1 year
post injury to determine whether his status was
maintained. Joint motion of the injured shoulder
and elbow were retained at the same level as the
contralateral side (Table 1 . Muscle strength in-
creased dramatically between the 3rd and
1
2th
months, indicating that the patient was diligent
with his resistive exercise program and that the
intensity of his overall activity increased. Matu-
ration may have contributed as well.
SUMMARY
A case study of a patient with a proximal
fracture of the humerus was used to demonstrate
an evaluation and treatment program. The meth-
ods and objective results were illustrated. The
patient s joint motion and muscle strength were
restored not later than 56 days after the spica
cast was removed and normal functional activi-
ties were resumed. At 12 months post injury, the
pat ient s joint motion was maintained and his
muscle strength continued to increase.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
7/10
OSPT Summer
7980
TREATMENT OF A HUMERAL FRACTURE
31
t w
D N
N t
0
D N
N
I-
w 0
N
t
0
CON
N
ln
w
N
m
ol
P- w
N m
LI) N
o m
m
ln
N
o m
m
m m
0 m
N
ln
ol m
N w
N
ln
t
N
N
m
t
0
a
N
N m
m
o
0 7
N
m
r
N m
0
0
-
n P
0
0 P
ln
P-
D ol
N LD
m n
-
m
o m
m n
>
2
.=
.-
C
.
p +
$ a
.,-
m
m d o
0
czE:
o m -
E
The author wishes to thank Dr. Webster Gelman for his role as an
orthopaedic surgeon in this case and for his cooperation and en-
couragement in support of this paper.
REFERENCES
1. Maitland GD: Peripheral Manipulation. Ed
2.
Boston: Butter-
worths, 1977
2.
Neer CS, Welsh UP: The shoulder in sports. Orthop Clin North
Am 8:583-591. 1977
APPENDIX
Details of Clinical Course
Day 1
4:00 PM: Patient struck by opposing players while attempting to
pass football.
5:00 PM: Patient waiting in hospital emergency room. Patient
examined and x-rays taken.
6:00 PM: Orthopaedist called in.
7:OO-8:00 PM: Closed reduction in operating room. Patient under
general anesthesia.
Diagnosis: Fracture of upper humeral shaft.
Operation: 1 Closed reduction. 2 Application of shoulder spica.
Procedure: By means of traction, abduction, external rotation, and
flexion, the arm was manipulated. X-rays showed almost anatomical
restoration of the bone. A shoulder spica cast was applied. The arm
was retained in the above-mentioned position.
8:30-10:OO PM: In recovery room.
10:OO PM: Taken to hospital room.
Day 2
The initial roentgenographic exam showed fracture deformity of
the proximal shaft of the humerus with foreshortening, anterior rota-
tion, and anterior displacement of the major fragment. The humeral
head was not dislocated. Following the closed reduction, the X-ray
examination showed marked improvement in position and alignment
of fragments. There appeared to be no foreshortening. There was
some slight medial angulation of the distal fragment.
Day 5
Discharge from hospital. Adaptations for home care arranged.
Some walking each day. Appetite poor. X-rays showed alignment of
bony fragments was being retained. Progress examination of the
humerus taken in AP and
axillary position shows no further change in
the position and alignment of the fragments compared to the post
casting film taken on October 5. 1976.
Day 16
X-rays show fracture to be maintaining good position. Patient has
no complaints of discomfort.
Day 38
M.D. report: Patien t's shoulder spica case was removed, and after
45 minutes the patient was able to lower the arm to near normal
position. Father of patient will supervise and administer physical
therapy.
Physical therapy report: Physical therapy rendered on a daily
basis at University Hospitals. Diffuse tenderness at proximal arm
area. Pain on attempted voluntary movements. Atrophy, weakness.
deficit in glenohumeral and humeroulnar movement. Whirlpool. Cod-
man's exercise (4 directions)-10 repetitions every 30 minutes.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
8/10
OSPTVol
2 No
Day 14
ost Cast Removal
Day 2
Whirlpool, Codman's exercise, begin manual isometric exercise
and active elbow movement. Pain at shoulder during movement.
Day 3
Whirlpool. Codman's exercise, mild manual resistance to concen-
tric contraction through 10-1 5' at 90 flexion. Res istive exercise (1
pound weight for elbow flexion).
Day 4
Same as Day 3
Day 5
Same as Day 3 plus active flexion, flexion and horizontal adduction
x
10. Passive movement in all directions of angular movement plus
caudal traction and dorsal glide. Training in upright sitting and stand-
ing posture. Gait training with emphasis on rec iproca l armswing. Pain
diminishing some.
Day 6
Same as Day 5. 2 pound weigh-elbow flexion.
Day 7
Same as Day 6.
Day
8
Same as Day 6. Codman's exercise with 2 and 5 pound weights.
Bilateral overhead wand exercise initiated. Soreness to palpation
continues at all areas of upper arm and scapula. Exquisite tenderness
at posterior glenohumeral oint. Patient is able to walk with appropriate
reciprocal shoulder movements. All movements continue to be slightly
guarded. Able to actively elevate arm above horizontal while upright.
Bilateral overhead wand with 5 pound weight.
Day 9
Day of rest. Whirlpool only. No exercise.
Day 10
Rx same as Day 8. Began passive dorsal glide. Elbow flexion in
upright position with 2 pound weight. Active external rotation encour-
aged at home. Returns to school. Rode bicycle for first time post
injury. Chief problems are decreased glenohumeral motion in direc-
tion of abduction and internal rotation, soreness on palpation, and
lack of strength in flexion.
Day 11
Same as Day 10.
Day 12
Progress is satisfactory. Codman's exercise discontinued. Other
Rx same as Day 10. Soreness on palpation at entire proximal arm.
Tenderness at posterior oint diminished. Obvious weakness in shoul-
der flexion.
Day 13
M.D. report: X-rays today reveal the fracture has healed solidly.
The patient has been utilizing physical therapy with excellent results.
He will continue mobilization exercises and return in three weeks.
Physical Therapy Report: Same as Day 10.
Whirlpool discontinued. Moist heat initiated at scapulohumeral
complex. Contract-relax approach to passive stretch initiated for
angular movements. Caudal traction and dorsal glide continue. Left
hand behind back, passive stretch by patient using towel. Right thumb
to 9th thoracic vertebrae, left to left buttock. Bench press 20 pounds,
40 repetitions. Pushing punching bag 50 times. Straight arm shoulder
flexion and abduction (upright position) using 2 pounds.
Day 15
Same as Day 10. Exceptions: Bench press 22.5 pounds. 30 imes;
bilateral elbow flexion 1 0 pounds, 30 times. 7.5 pounds bilateral
overhead flexion while supine. Shot basketball with two hands for first
time. Left thumb to sacrum today.
Day 16
Moist heat stopped. 200 times pushing punching bag. Now facing
realities to simultaneously catching up with academic work at school,
attending services and youth group at church, and physical therapy
treatment program.
Day 17
Day of rest.
Day 18
Same as Day 16
Days 19 to 32
Generalized soreness at proximal humerus has now subsided.
Some tenderness at anterior aspect of proximal humerus continues.
Began basketball practice in low-key fashion on Day 19. Rx same as
Day 18. Bench press 30 pounds, 30 times. Push punching bag 100
times. Left thumb behind back to T9. Straight arm shoulder flexion
and abduction with 2 pounds
X
30.
Days 33 to 44
Joint motion near normal. Soreness to palpation at anterior hu-
merus now minimal. Practi cing basketball. 2.5 pounds bilateral shoul-
der flexion in upright position. Bench press 40 pounds. 30 times.
Bilateral elbow flexion in upr ight position, 30 times. Overhead shoul-
der flexion with 12.5 pounds, supine position. Begins squeezing small
rubber ball. Pushing punching bag 15 0 times per day. Continue
manual passive movements.
Days 45 to 55
During this period, physical therapy treatment takes place 2 of
every 3 days. Push punching bag 175 imes; elbow flexion 20 pounds
x
30; overhead shoulder flexion (supine 1 0 pounds
X
30), bench
press 55 pounds x 30; double straight arm shoulder flexion 10
pounds
x
30; manual passive movements every third day. Some
discomfort on passive movement at extremes of motion. Use of left
hand in basketball for dribbling and shooting.
Day 56
Patient returns to playing competitive basketball. Patient will con-
tinue the following resistive exercises: 12.5 pounds
X
30 shoulder
flexion overhead (supine); 12.5 pounds bilateral straight arm shoulder
flexion; 35, 65, 70
x
10 each on bench press; 30 pounds
X
30
bilateral elbow flexion.
Two residuals are yet apparent:
1 Discomfort at proximal humerus on palpation with large amount of
force.
2)
The size of the left upper limb is less than the right, particularly
the muscle mass about the proximal humerus.
Weight lifting advised for several months from this point.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
9/10
JOSPT ummer 1980 TREATMENT OF A HUMERAL FRACTURE 33
MOTION MEASUREMENTS
-
SHOULDER
FLEXION AND EXTENSION
Passive Movement
ctive Movement
,eO
1 4 0 - ,
Flexion
-
Uninvolved Side
,*--**-"""-+-"--"--
0 4 4
/ -
0 ' 6 - '
'
1 ' 1 ' 6 ' ;0'2k1;8 3 ;
=
Days Post Cast Removal
60
40
20
Chart
1
. Motion measurements-shoulder flexion and ex-
tension. Zero position: arm lateral and adjacent to trunk.
Flexion measurements taken supine. Extension measure-
ments taken sitting.
:
Extension
-
Uninvolved Side
-
p
MOTION MEASUREMENTS SHOULDER
ABDUCTION AND ADDUCTION
$
80 ---
Passive
Movement
60
ct~veMovement
40
Days Post Cast Removal
Chart
3.
Motion measurements-shoulder abduction and
adduction. Zero position: arm lateral and adjacent to trunk.
Measurements taken supine.
MOTION MEASUREMENTS - SHOULDER
INTERNAL AND EXTERNAL ROTATION
120
External Rotatlon
-
Unlnvolved Slde
--------
Q
40
.
ass~veMovement
Act~veMovement
0
2
Days Post Cast Removal
Chart 2. Motion measurements-shoulder internal and ex-
ternal rotation. Zero position: arm abducted forearm vertical.
Measurements taken supine.
MOTIO N MEASUREMENTS -ELBOW FLEXION
.
Passlve Movement
ctive Movement
Chart 4. Motion measurements-elbow flexion. Zero posi-
tion: straight line formed by arm and forearm. Measurements
taken supine.
40
ISOMETRIC STRENGTH
-
SHOULDER
FLEXION AND EXTENSION
-
508 2
Extens~on Un nvolved Slde
457 8
406
16
Flexton
-
Unlnvolved
Slde
6 4
1 1 ~ ' l k 1 ~ ~ 1 ~ 4 1 ~ 8 ' ; 2 " ~ %
Days Post Cast Removal
0 ~ ' ~ ' ~ ' l > ' l k ' ~ 0 ' ~ 4 ' ~ 8 ' ~ 2 ~ %
Days Post Cast Removal
Chart 5. Isometric strength-shoulder flexion and exten-
sion. Measurements taken supine. Arm flexed
903
KgCm
moment in kilograms centimeter. KgF kilograms of force.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.
-
7/25/2019 Shoulder fracture
10/10
4
SMlDT
JOSPT Vol 2
No.
ISOMETRIC STRENGTH - SHOULDER
INTERNAL. EXTERNAL ROTATION
406
356
::I
305 12
Internal Rotat~on Uninvolved Slde ____ ~
External Rotatlon - Uninvolved S~de
--.
-
n
.
___ - - 4 -
Internal Rotatlon
External Rotatlon
1 ; ' 1 6 ' 2 b 1 2 b 1 ; 8 ' & '
' ?
Days Post Cast Removal
Chart
6.
Isometric strength-shoulder internal and external
rotation. KgCm moment in kilograms/centimeter. KgF kil-
ograms of force.
ISOMETRIC STRENGTH - SHOULDER
ABDUCTION
203
Abduction - Uninvolve_dSide_-
'
1 - -
ISOMETRIC STRENGTH
-
SHOULDER
HORIZONTAL ABDUCTION ADDUCTION
406 16 -
356 14-
305
12
Horfzontal Adductlon - Unlnvolved Slde
1 52 6 -
orizontal Adductlon
.
orizontal Abduction
e o d
0 ~ 1 ~ ' ~ ' 1 ~ ' 1 ~ ' ~ 0 ' ~ 4 1 ~ 8 '
Days Post Cast Removal
Chart 7. Isometric strength-shoulder horizontal abduction
and adduction. KgCm moment in kilograrns/centimeter.
KgF kilograms of force.
ISOMETRIC STRENGTH - ELBOW
FLEXION. EXTENSION
406 16r
' 0 4 8 12 16 20 24 28 32
Days Post Cast Removal
356 14
305 12
Flexlon
Extension
- Flex~on Unlnvolved Side
Extension - Uninvolved Sbde
m .
-
Days Post Cast Removal
Chart
8. Isometric strength-shoulder abduction. Measure-
ment taken supine arm abducted 45 . KgCm moment in
kilograms/centimete r. KgF kilograms of force.
Chart
9 sometric strength-elbow flexion and extension.
Measurements taken supine forearm flexed
80 .
KgCm
moment in kilograms/centime ter. KgF kilograms of force.
CIRCUMFERENTIAL MEASUREMENTS
5
Uninvolved Arm
6
-Arm
---.
Forearm
';I ' ' 1 ; ' 1 6 ' 2 b ' 2 b 1 2 ' 8 ' & ~ %
Days Post Cast Removal
Chart
10.
Circumferential measurements. Arm measure-
ments taken
12.7
centimeters from acromium. Forearm mea-
surements taken 7.6 centimeters from medial epicondyle.
Copyright1980JournalofOrthopaedic&Sports
PhysicalTherapy.Allrightsreserved.