PROXIMAL HUMERUS FRACTURES:

THE GOALS AND THE ROLES FOR THERAPY

DAVID KLEIN, MD

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 2

KENNEDY-WHITEORTHOPAEDIC CENTER

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 3

WHY DO SHOULDER FRACTURE PATIENTS NEED THERAPY?

• Teach them to be functional while injured

• Prevent them from making things worse

• Prevent them from getting stiff

• Motion and strengthening to restore premorbid functioning

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 4

DOES EVERY SHOULDER FRACTURE PATIENT NEED THERAPY?

No

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 5

CAN EVERY SHOULDER FRACTURE PATIENT BENEFIT FROM THERAPY?

Yes

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 6

CAN THERAPY HURT SOME SHOULDER FRACTURES?

Absolutely

7

XWHAT THIS TALK WILL NOT BE:

Not a cookbook of protocols (neither mine nor anybody else’s)

Not a recitation of Brotzman

Not a whole bunch of pictures

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 8

WHAT THIS TALK WILL BE:

Concept driven, not protocol driven

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 9

THIS THERAPY TALK ISMAINLY GEARED TO NON-OP FX

Most of these timings for non-op treatment

Stable fixation or arthroplasty may allow faster progression

(defer to operative surgeon)

Soft tissue or bone quality may slow progression

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 10

FOR POST-OP FRACTURE REPAIR THERAPY

Rely on the surgeon’s guidelines

Tuberosity repair is similar to cuff repair

ORIF for humeral neck fx in a 20 yr old

is different than

ORIF for 4-pt humeral neck fx in a 70 yo

Stiffness is an easier problem to treat than Nonunion

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 11

HOW THIS TALK IS STRUCTURED: Fracture personality – pattern, stability, and other factors

Patient personality

Fracture healing timeline

Fracture care – things that can go bad

Addressing immobilization – GRAVITY is your friend

Addressing function – modified activities temporarily

Addressing motion – eliminating stiffness and paving the way for function

Addressing muscle control – more important in a composite joint

Special topics – dystrophy, arthritis, associated conditions

Summary and recap

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 12

“UNIVERSAL PUBLISHED GUIDELINES”

“Just a” Sling for Week 1

Start Pendulums and Passive Week 2-3

Start Active Motion Week 6

Start Strengthening Week 12

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 13

WHY NOT COOKBOOK?SEVERAL FACTORS:

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 14

FRACTURE PERSONALITY

Displacement

Stability

Pattern type

Host type

Surrounding tissues

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 15

FRACTURE PERSONALITY – DISPLACEMENT AND ANGULATION

Nondisplaced fractures

– “Crack in the teacup”(frequently it will still hold the tea and keep you dry)

Displacement and/or angulation may block motion

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 16

FRACTURE PERSONALITY – STABILITY

Stable fractures can be moved earlier

• Less risk of nonunion• Patient hurts less (usually)

Most nondisplaced fractures are stable

Stability usually declares itself by two or three weeks

• Comparison with new x-rays:If it shifts, usually inherent to the fracture

• Not to the patient’s activity• Not to the therapist’s activity• Resorption occurs before new bone is laid down

• Stability usually accompanied by decreased pain

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 17

FRACTURE PERSONALITY – PATTERN TYPE

Energy of injury

Neer’s definition of “parts”

“One part” (nondisplaced) fractures are the best of all!

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 18

FRACTURE PERSONALITY – PATTERN TYPE

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 19

FRACTURE PERSONALITY – PATTERN TYPE

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 20

FRACTURE PERSONALITY – PATTERN – DEFORMING FORCES

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 21

FRACTURE PERSONALITY – BONE (AND REPAIR) QUALITY

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 22

FRACTURE PERSONALITY – BONE (AND REPAIR) QUALITY

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 23

FRACTURE PERSONALITY – HOST TYPE

Both Physical and Psychological factors

Physical is similar to Cierny’s “host type” : 

       - type A: normal immune status        - type B: some degree of compromise       - type C: significant compromise 

Personality impediments – you’ve seen these before

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 24

FRACTURE PERSONALITY – HOST DISEASE PROCESSES

Parkinson’s and other increased muscle tone disorders

Obesity

Dementia

“Fibromyalgia”

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 25

FRACTURE PERSONALITY – SURROUNDING TISSUES

Degree of associated injury

• Swelling• Wounds• Skin sensitivity• Ipsilateral fractures and sprains

Inherent skin condition

• History of bruises and skin tears• “Waxy-ness”

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 26

PATIENT-PERSONALITY

Do too much

Do too little

Very interested

Not interested

Analogy: “Driving the patient” -- a Racecar is different from a Economy car – you as the driver have to apply and release the throttle quite differently for each vehicle.

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 27

FRACTURE HEALING TIMELINE

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 28

FRACTURE HEALING TIMELINE

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 29

FRACTURE HEALING TIMELINE

Fractures tend to get “Sticky” by 3-4 weeks

Fractures tend to be - Solid - by 6-8 weeks

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 30

FRACTURE FUNCTION PLATEAU TIME

Eight months…

Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment

Ehud Rath, MDa, , , Nassim Alkrinawi, MDb, Ofer Levy, MD, MCh(Orth), FRCSc,Ronen Debbi, MDd, Eyal Amar, MDa, Ehud Atoun, MDd

doi:10.1016/j.jse.2013.01.033

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 31

FRACTURE CARE – THINGS THAT CAN GO WRONG

Shift/collapse/lost reduction

Delayed union

Nonunion

Pseudoarthrosis

(as compared to ‘just’ a Fibrous Union)

Nerve palsy

Severe stiffness

Dystrophy

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 32

SO, HOW TO TREAT THEM?

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 33

ADDRESSING IMMOBILIZATION – GRAVITY IS YOUR FRIEND

Productive: allow gravity to provide traction

• Counteracts resting muscle tone, with the exception of Pec Major

• “Cuff and Collar” might be best• Sleep upright in a chair (without pillows under elbow)

Counterproductive: true Velpeau, strapping arm to chest

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 34

ADDRESSING FUNCTION – MODIFIED TEMPORARY ACTIVITIES

The “OT” Part of Shoulder Therapy

Allowable range of motion and limb useELBOW, wrist, and hand…

Walker alternatives (hemi-walker, better cane)

Pendulums for hygiene

Bathing

Dressing

Learning to eat

Sleeping position modifications (near-upright)

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 35

ADDRESSING MOTION – PAVING THE WAY FOR FUNCTION

Immediate – Elbow, Wrist, and Hand

• Uninjured elbows quickly stiffen in face of shoulder fracture

• Uninjured hands rarely stiffen despite massive swelling

Delay until healing – Glenohumeral joint

• Passive range of motion easiest supine• Delay aggressive stretching until fairly solid

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 36

ADDRESSING MUSCLE CONTROL – IMPORTANT FOR THE COMPOSITE SHOULDER JOINT

The shoulder as a balancing act

Ye Olde “Seal and Ball” analogy:

The shoulder as a muscle coordination act

• Similar to composite finger flexion, but without mechanical tethers

• Need to re-teach scapulothoracic and glenohumeral joint• The classic 2:1 ratio

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 37

ADDRESSING STRENGTH

Generally wait at least 6-8 weeks post-fracture

Soft tissue (rotator cuff) takes about 12 weeks

Probably no contraindication to isometrics earlier

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 38

GOING BEYOND FUNCTION?

Rehab to MAX or rehab to needed?

Most state they want it ALL

Most settle for LESS

When is enough enough?

• Age-based• Sport-based• Sex-based

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 39

MISCELLANEOUS

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 40

NON-UNION VS. STIFFNESS

Stiffness is easier to treat than Non-union

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 41

NON-UNION VS. STIFFNESS

Stiffness is easier to treat than Non-union

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 42

PROBLEMS WITH PENDULUMS

Patients don’t do them correctly

They need the stability and mobility to bend at waist

…but pendulums are great for dressing, washing, etc.

?

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 43

STIFF JOINTS – ADHESIVE CAPSULITIS

Start therapy while still anesthetized

Allows the treating therapist to experience an unguarded “feel” of the limb

Allows the awake and pain-free patient to see what’s possible

Both a practical and psychological benefit for the weeks to come

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 44

PAINFUL JOINTS – DYSTROPHY

When an approach stalls, change your path

Remember Watson’s principle of LOADING rather than motion

One of the few times to recommend strengthening before motion

(more like endurance rather than strengthening)

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 45

CREPITANT JOINTS – ARTHRITIS

So it’s bone on bone? …So what?!

Remember the Ronco rock tumblers:

Better to have Polished IVORY than PUMICE

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 46

CREPITANT JOINTS – ARTHRITIS, TAKE TWO

Arthritic joints lose motion for two reasons:

• DEFORMITY of the articulating surface• Loss of sphericity• Encroachment of osteophytes

• CONTRACTURE of the thickened joint capsule

With therapy,

• While the articular surface may NOT be readily changeable,

• The CAPSULE definitely IS s t r e t c h a b l e !

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 47

CHANNEL THE BOXER IN THE PATIENT

Scapular elevation is hard to eliminate

Teach them to ‘box’ in front of a mirror

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 48

ELEVATION IS PART PERCEPTION

“It’s Great – It goes as high as the other one.”

Increased external rotation frequently makes up for lost elevation

Corollary – If they don’t get back external rotation,

“It’s NOT that great…”

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 49

RE-CAP AND SUMMARY

Fractures and Patients differ

What you do (or don’t do) may not be benign

Keep the elbow moving

Most fractures get “sticky” around 3-4 weeks

Stiffness is easier to treat than Non-union(But best to have neither)

External rotation often makes up for elevation

Fluid crepitant motion beats no motion any day

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 50

… IT’S ALL ABOUT

FUNCTION

THERAPY for PROXIMAL HUMERUS Fractures -- David Klein, MD 51

P.S.