Background and Etiology
A fracture is defined as a partial or complete crack in a bone. Fractures can be minor with little or no displacement of the bone, or more severe with complete displacement of the two ends of the bone that requires surgery to realign. There are closed fractures that do not break the skin, and open fractures that do break the skin.
Fractures of the shoulder are usually caused by direct trauma or a fall on outstretched hand (FOOSH). In the event a person suspects a shoulder fracture, radiographic study (X-Ray) of the shoulder is essential.
The shoulder is comprised of three bones: the humerus, scapula (shoulder blade) and clavicle (collar bone). These bones form three joints: the glenohumeral joint, sternoclavicular joint, and acromioclavicular joint. Fractures in the shoulder area can involve any of the bones that form the shoulder, including the humerus or upper arm (humeral fracture.)
Proximal Humeral Fractures
Are common injuries in both the young and elderly. In the elderly and adult population osteopenic bone can fracture from minimal trauma or as the result of a shoulder dislocation or fall. In the young population a skeletally immature fracture, frequently occurs as an epiphyseal fracture of the proximal humeral growth plate (referred to as “Little League Shoulder”)
Of concern in proximal humeral fractures is neurovascular injury of the nearby axillary artery and brachial plexus, which provide blood and nerve innervation to the arm. Fracture to the surgical neck is the most common fracture in this region. Following a fracture, muscles in the region can cause a deformed appearance to the shoulder.
The most common cause of proximal humeral fractures is FOOSH (fall on an out stretched hand) or fall on the lateral aspect of the affected arm (most common in individuals 60 years of age or older.) In the young these fractures occur commonly in those who participate in throwing sports.
Symptoms of a proximal humeral fracture will vary depending on the severity of the fracture, but may include some or all of the following:
- Moderate to severe pain
- Decreased ability to move or lift arm, often results in holding the effected arm at ones’ side in a protective manner
- Redness, discoloration or bruising over the fractured area
- Deformity of the area due to misalignment of displaced bone or muscle
Medical treatment for a proximal humeral fracture most often includes a period of immobilization using a sling, with the arm slightly abducted. More severe shoulder fractures may require surgery to realign and stabilize the injury. How much movement should be restricted following the fracture will depend on the severity of the break.
Physical therapy interventions may be necessary because this injury tends to “stiffen” quickly over the first two to three weeks post-injury. Physical therapy will work first to restore good range of motion, and progress to active exercises and strengthening as the fracture heals.
Post shoulder fracture immobilization can have detrimental effects that can be improved through physical therapy including:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased mobility of the joint capsule and periarticular connective tissues
- Decreased circulation
- Loss of active and passive motion
Goals for physical therapy post fracture immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a physical therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the shoulder, rotator cuff and scapula muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: throwing) in use of the involved upper extremity in daily activities especially overhead activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the shoulder joint and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most fractures can be diagnosed with X-Ray studies and when necessary a CAT scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or those that affect the integrity of the shoulder joint.
When these fractures occur in young people they usually only require immobilization for a short period of time. More complicated humeral fractures that occur in the older population may require surgery to restore alignment, especially when they are displaced or affect the humeral head and shoulder joint. Surgical intervention may require the use of plates, screws and wires.
Rate of recovery and the prognosis from a shoulder fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and physical therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to recover. Patients may have residual motion and strength deficits, especially if the rotator cuff is involved.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.