PT Considerations for the Nonoperatively Treated Proximal Humerus - PowerPoint PPT Presentation

PT Considerations for the Nonoperatively Treated Proximal Humerus Fractures John Cavanaugh PT MEd ATC SCS

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Proximal Humerus Fractures - Intro  Incidence: 4-6% of all fractures  3rd most common fx pattern seen in elderly  Injury ratio: 2:1 female to male  ↑’ ed age correlates with increasing fracture risk in women  Mechanism of injury:  Low-energy falls elderly with osteoporotic bone  High-energy trauma young individuals  Concomitant soft tissue and neurovascular injuries (axillary nerve) 4

Non-Operative Management  85% PHF are minimally displaed & managed non-operatively  1, 2, 3 part surgical neck fractures  Greater tuberosity fractures displaced < 5mm  Good to Excellent outcomes ~85% – Koval KJ J Bone Joint Surg Am. 1997 – Gaebler C, Acta Orthop Scand. 2003 – Kruithof RN J Orthop Traumatol 2017 5

Non-Operative Management Fracture healing : Rehabilitation: 3 distinct but overlapping 3 distinct but overlapping stages phases  Inflammatory stage  Maximum Protection Phase  Repair stage  Moderate Protection Phase  Late remodeling stage  Return to Function Phase 6

Proximal Humerus Fracture Non-Operative Rehabilitation Guielines  General Principles  Phyisician directed  Radiograph evidence of healing  Realistic Goals  Early Mobilization – Hodgson J Shld Elbow Surg 2007 – Lefevre-Colau JBJS 2007 7

 Randomized, prospective/controlled trial of minimally displaced PHF  Group A: (N 44) Immediate ROM  Group B: (N 42) 3 weeks of immobilization  Craft Shoulder Disability Questionnaire  Group A 42.8% (1 year) 43.2% (2 year)  Group B 72.5% (1 year) 59.5% (2 year ) – Reported 3x more pain on movement, 2x night disturbance 8

 RCT: 74 patients with an impacted PHF (1,2,3 part)  Group A: 37 passive mobilization within 3 days of frx  Group B: 37 sling immobilization x 3 weeks  Constant Global Score (3 months f/u)  (A) 71 vs (B) 61.1  Mean change in pain (6 weeks →3 mo) (A) 34.9 vs (B) 19.2  Fracture-healing rate 100% (A & B)  Compliance to PT sessions = 70% (A & B) 9

Proximal Humerus Fracture Non-Operative Rehabilitation Guielines  General Principles  Physical Therapist guided – MD directed clinical guideline  Individualized  Criteria based progression  Communication w/MD 10

Maximum Protection Phase (0-6 weeks) Goals : Control pain and swelling Protect fracture site / Allow for healing Maintain ROM/Function distal extremity Improve AAROM: Elevation to 110 ° and ER to 30 ° Independent with home exercise program 11

Maximum Protection Phase (0-6 weeks)  Treatment Interventions:  Modalities (Ice / TENS ) (Moist Heat after 10 days)  Sling immobilization (duration / schedule per MD)  Cervical & distal extremity AROM  Postural correction (as indicated)  Codman’s / Pendulum execises (when tolerated) 12

Maximum Protection Phase (0-6 weeks)  Treatment Interventions:  PROM: Elevation / ER  AAROM (when tolerated): – Elevation / ER  Aquatic therapy 13

 Re-education for dyssynergic shoulders  Adjunct to traditional therapeutic exercise  Proprioceptive input 14

Maximum Protection Phase (0-6 weeks)  Treatment Interventions  Scapular and Deltoid strengthening (when tolerated)  Soft Tissue Massage  Home exercise program – consider insurance situation 15

Maximum Protection Phase (0-6 weeks)  Criteria for Advancement  Tolerating sling discontinuation with self-care, ADL’s  AAROM: Elevation to 110° ER to 30° 16

Moderate Protection Phase (4-12 weeks)  AAROM: Wand FF/ER  Pulleys (when appropriate)  120 degrees FF  Humeral Head Control  Active IR ROM (Towel pass) 17

Moderate Protection Phase (4-12 weeks)  Glenohumeral mobilization  Scapular stabilization exercises 18

Moderate Protection Phase (4-12 weeks)  Airdyne Bike Upper Body Ergometer  Scapular and Deltoid PRE’s 19

Moderate Protection Phase (4-12 weeks)  Rototor cuff Isometrics  Dictated by gains in ER ROM  Scaption (PRE) 20

Moderate Protection Phase (4-12 weeks)  Criteria for Advancement / Goals  AAROM : Elevation to 150° ER to 65°, IR to 70°  Improve scapulohumeral rhythm to WNL < 90° elevation (scapular plane)  Improve muscle strength to > 4/5  Independent with home exercise program as instructed 21

Strengthening / Function Phase (10-? Weeks)  Goals:  Improve scapulohumeral rhythm to WNL < 120°elevation (scapular plane)  Improve muscle strength to 5/5  Maximize ROM, strength, flexibility so to meet the demands of ADL and/or sports participation where indicated  Independent with home exercise program as instructed 22

Strengthening / Function Phase (10-? Weeks)  Treatment Interventions  Towel Stretch (IR)  Posterior capsule stretching  Pect Minor Streching  Rototor cuff Isotonics 23

Strengthening / Function Phase (10-? Weeks)  Treatment Interventions  PNF (Manual resistance → theraband)  Sport Specific Activites (if and when indicated) – e.g. golf, tennis, etc) 24

Summary  Rehabilitation Guidelines: PHF  Directed by MD, Guided by PT  Radiological evidence of healing  Early Mobilization  Criteria for advancement  Succesful Outcome 25