Humeral fractures occur commonly with up to five percent of all
fractures falling into this category, eighty percent of humeral
fractures being minimally displaced or undisplaced. Osteoporosis is a
contributing factor in many of these fractures and a fracture of the
forearm on the same side is a typical presentation. Nerve or arterial
damage from the fracture is an important consideration but not common.
Typical sites of fractures are the top of the arm (neck of humerus -
"shoulder fracture") and the middle of the shaft of the humerus.
The
usual cause of a humeral fracture is a direct fall on the arm, either
on the hand, elbow or directly onto the shoulder itself. Due to all the
muscles that attach to the upper humerus, there can be a lot of muscular
force at the time, dictating how much the bones are pulled into a
displaced position. Humeral fractures are more common in the elderly
with an average age of fracture of around 65 years and younger people
usually have a history of forceful trauma such as motor accidents or
sport.
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 Humeral Fractures
After the
fracture the patient's movements are kept restricted and sufficient
analgesia provided to keep them comfortable. With little or no
displacement the management is non-operative but if the greater
tuberosity is fractured then it is important to suspect rotator cuff
injury. This is more common in injuries with high forces, when the
patient is older or the tuberosity is displaced significantly. Humeral
neck fractures can be kept in line with a collar and cuff, allowing the
elbow to hang free, while shaft fractures are difficult to manage but
can be braced.
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.
Shoulder Fracture Treatment by Physiotherapy
Initially
the physio assesses the arm, asking the patient about their pain level
as this varies greatly, examining the swelling and bruising of the arm.
The physiotherapist then checks the available range of movement of the
shoulder, elbow, forearm and hand. Any muscle weakness and sensory loss
is noted as this may denote nerve damage. If not operated on, a sling is
continued with and if the fracture is not too painful or severe, early
exercises are started by the physiotherapist. Pendular exercises, with
the patient bending over at the waist, are important in the early stages
as they allow movement of the shoulder joint without much force.
Three
weeks after the fracture bone healing will be well under way so the
physiotherapist will instruct the patient in auto-assisted exercises,
using the other arm, to help reduce stress on the injury. Unassisted
exercises are the next step as the arm becomes stronger, to practice
lateral and medial rotation and flexion. At six weeks the bone will be
clinically sound so the physio can progress to more vigorous movements
with resistance and gentle end-range stretching. Joint mobilisations can
be useful to free up the sliding and gliding movements of the joint and
strengthening and joint range work continued with Theraband.