Shoulder fracture

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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.


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Fig

3

Rad~ograph n day 16.

Fig

2

Patient in shoulder spica. Fig 4 Radiograph final results.




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JOSPT Summer 798 TRE TMENT OF HUMER L FR CTURE

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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.




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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




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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


shoulder extension.

Fig 22


shoulder internal rotation.




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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.




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OSPT Summer

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TREATMENT OF A HUMERAL FRACTURE

31

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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.




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OSPTVol

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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.




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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


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


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 " ~ %


0 ~ ' ~ ' ~ ' l > ' l k ' ~ 0 ' ~ 4 ' ~ 8 ' ~ 2 ~ %


Chart 5. Isometric strength-shoulder flexion and exten-

sion. Measurements taken supine. Arm flexed

903

KgCm

moment in kilograms centimeter. KgF kilograms of force.




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JOSPT Vol 2

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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 ' & '

' ?


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 '


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


356 14

305 12

Flexlon

Extension

- Flex~on Unlnvolved Side

Extension - Uninvolved Sbde

m .

-


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 ' & ~ %


Chart

10.

Circumferential measurements. Arm measure-

ments taken

12.7

centimeters from acromium. Forearm mea-

surements taken 7.6 centimeters from medial epicondyle.



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