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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.

A forceful incident is normally required to fracture the humerus and if there is no history of this the physician will suspect a cause such as cancer. The physio examination will show significant pain on attempted movement of the shoulder or elbow, reduced movement of the shoulder, widespread bruising or swelling in the whole arm and in shaft fractures some arm shortening is possible. Checking for nerve damage is important as the radial nerve can be injured especially in shaft fractures, impairing control of wrist and thumb muscles.

Management of Arm Fractures

Acutely the patient is kept still and given adequate analgesia to relieve the initial pain. Fractures of the upper part of the arm bone can mostly be managed without operation if there is little or no displacement but rotator cuff injury could occur if the greater tuberosity is fractured, especially if it is displaced any distance, great force was involved or the patient is older. A collar and cuff sling allows upper humeral fractures to traction themselves straight and in line, while shaft fractures can be braced but are difficult to control.

Displaced three or four part fractures typically require surgery, referred to as ORIF (open reduction internal fixation) and this is more likely in younger people. Older people may have a poorer result in terms of pain and movement so may have surgical replacement of the head of the arm bone. Plating and nailing is usually unnecessary for shaft fractures as they heal well normally. The side effects of humeral fractures include nerve injury in shaft fractures, adhesive capsulitis and avascular necrosis of the head of the humerus. Healing occurs in six or eight weeks and older people may never regain full movement of the shoulder.

Shoulder Fracture Treatment by Physiotherapy

Initial physiotherapy assessment consists of assessing the patient’s pain levels as these can vary hugely, the joint ranges of motion of the elbow, hand and wrist and the tissue swelling and bruising in the arm. Muscle strength is tested in the forearm as this may indicate an injury to the radial nerve, as may loss of sensory discrimination. The patient may stay in the sling for 2-3 weeks with the physio exercises beginning early if pain is reasonable and the fracture stable. The aim is to maintain the range of motion of the shoulder joint while the fracture heals, by performing bent over pendular exercises to counteract gravity.

Once the three week stage is reached the fracture will have begun to heal and auto-assisted exercises can be started, where the patient helps the affected arm with the uninjured one. This is progressed to unassisted exercises, moving the arm up above the head, behind the back and behind the neck. As the six week point approaches, when the bone has effectively healed, the physiotherapist will start the patient doing more forceful exercises involving gentle stretches at the end of range to improve mobility. Mobilisation techniques to the shoulder joint and strengthening exercises using Theraband are progressed to increase muscle power and joint range.