Bryan Houseman, D.O., ATC Orthopaedic Trauma and Fracture Surgeon New Hampshire Orthopaedic Center September 10, 2016 I have no relevant disclosures pertaining to this talk. From Rockwood & Green, 8 th ed 1
From Rockwood & Green, 8 th ed Anterior humeral circumflex Ascending branch Gerber et al., JBJS 1990 PHCA Posteromedial plexus Hettrich et al, JBJS 2010 From Rockwood & Green, 8 th ed Vessel injury Fragment devascularization Nonunion Osteonecrosis From Rockwood & Green, 8 th ed 2
Neer (1970): 1 cm, 45 based on parts From Rockwood & Green, 8 th ed Maximize function Stable fixation if unstable fracture Early rehab Whenever possible Minimize pain Who and What is your patient? Age physiologic not always chronologic Cognitive status Activity level Injury mechanism Associated injuries 3
Proximal humerus fractures have been described by many as a soft tissue injury with a bony dysfunction! The forces placed on the fragments at the time of injury are the same that post operatively must be respected. 4
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The understanding of the repair is the 1 st step to recovery. The parts of the fracture that are repaired will dictate how, when, and why the recovery can be advanced. Don t ever be afraid to ask for more specifics about the surgery, repair, and/or case specific limitations. The goal initially is pain management and LIMITED immobilization. Goal: Maintain ROM without displacing the fracture. What can be done right away? Elbow, Wrist and Hand motion (E/W/H)! Koval et. al., JBJS 1997;79A:203 6
Pain management Pendulum exercises Limited immobilization to decrease pain and not create an unstable fracture 15 20 Supine ER with a cane. Fifteen to 20 degrees of abduction are permitted if the patient is more comfortable. Establish a home exercise program so patient is performing exercises 3 5 times per day for 30 min. Each session. New X rays Stable continue changes or loss of reduction surgery/acceptable position? OR 7
Begin assisted forward elevation (FE). Perform pulley exercises and teach for home program. Perform isometric exercises for IR, ER, extension, and abduction. Begin supine active FE. Progressively increase patient s position from supine to erect during FE exercises. Use therabands of progressive strengths for IR, ER, flexion, abduction, and extension. Goal is progressive strengthening of deltoid and rotator cuff. Begin flexibility and stretching exercises to progressively increase ROM in all directions. Progressive return to unrestricted ROM/activity based on fracture healing, pain, and progress with rehab program At any point the patient may need a step back to eventually more a step forward. Communication of progress/concerns are paramount! 8
The goal initially is pain management and acute immobilization. Short Term Goal: Maintain ROM without destroying the fixation. What can be done right away? Elbow, Wrist and Hand motion! Begin elbow, wrist and hand (E/W/H) active ROM Ashoulder immobilizer is typically utilized for soft tissue rest, pain management, and control of swelling. After 14 days, begin pendulum exercises. Want fracture to begin to heal and surgical incisions to close. Establish a home exercise program so patient is performing pendulum and E/W/H exercises 3 5 times per day for 10 minutes each session. 9
The fracture is observed radiographically Signs of hardware failure, AVN, loss of reduction, and or infection closely monitored. Pain management can be achieved by a multimodal approach with medication, thermal therapies, and/or TENS units Begin supine AAROM ER with a cane. Limit range to ~15 20 degrees. The goal is gentle motion not gross gains. Remember early fracture healing is occurring. Begin active assisted forward elevation (FE), supine or with a pulley/stick. Perform pulley exercises and teach for home program. Perform isometric exercises for IR, ER, extension, and abduction. Introduction of gravity as a stressor is the goal Begin supine active FE. Progressively increase patients position from supine to erect during FE exercises. Use Therabands of progressive strengths for IR, ER, anterior, middle and posterior deltoid. Begin flexibility and stretching exercises to progressively increase ROM in all positions (i.e. towel behind back, finger walking up the wall, etc.). Communication is KEY. Problems stop, back up, call. 10
Patients are placed in a shoulder immobilizer with an abduction pillow post operatively. Pendulum, elbow, wrist, hand ROM is started immediately. F/U at 7 10 days to remove sutures, check x rays and start passive ROM in physical therapy. Therapy typically can be more aggressive with this method as there is less bony union needed. Active ROM and strengthening are started after x ray evidence of fracture healing. Most important signs of healing are the tuberosities! The rehab protocol would then follow that of the stable ORIF. Abduction sling. Elbow, wrist, hand and Pendulum ROM exercises. 7 10 days: continue sling/immobilizer until 3 6 weeks post op. Start early passive shoulder ROM( limited to 90 degrees elevation, 0 degrees ER), active elbow, wrist, hand ROM Avoid ER for 6weeks to allow subscapularis or lesser tuberosity to heal. Avoid combined abduction and external rotation (risks dislocation). 6 Weeks: Active supine ROM started. Generally may use arm for daily activities and driving. Resistive exercises started at 10 12 weeks 3 Months: activity as tolerated. Adjust home exercise program to any patient deficits. Patient expected outcomes after RTSA for fracture and low Want to be able to perform ADL s 11
Initially the goal of post surgical management is pain control, soft tissue quiescence, and putting out fires Initially the determination of whether the fracture is operative or non operative If surgery is selected what type is the next hurdle. Restoration of function in this patient population is the ultimate goal. A balance of fracture healing, patient pain, and prevention of loss of range of motion is the foundation of patient outcomes. If the timing of the foundation principals are out of sync failure can and commonly will be the result. 12
bhousemando@nhoc.com www.nhoc.com Questions? 13