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Humeral Shaft Fracture

The medical definition of a Humeral shaft fracture, specifically mid-shaft is when the

middle third of the humerus is fractured.1 Within a mid-shaft humeral fracture there are multiple

categories that the fracture line can fall under meaning the type of break that was placed on the

bone. Such as the oblique, spiral, comminuted, segmental and transverse this is the type my

patient experienced. Many times other tissues can be damaged with a humeral fracture such as

muscles, tendons and even damage to the brachial plexus. There are many different ways to

fracture the humerus either by direct force or indirect force. Direct force is by direct impact, or

by car accidents with a crushing force. Indirect forces, such as a fall on the elbow or extended

arm or strong muscular contractions, can result in a fractured humerus.2 My patient experienced

an indirect force by falling off of a ladder, fracturing his humerus with a transverse fracture line

that pierced his triceps.

According to the American Physical Therapy Association, humeral fractures are

classified under the Clinical Pattern 4G: Impaired Joint Mobility, Muscle Performance, and

ROM associated with Fracture.3 Risk factors or consequences of this pathology include bone

demineralization, medications, nutritional deficiency and prolonged non-weight-bearing state.

Humeral fractures account for about 3 % of all fractures and about 30% of these injuries need to

be treated surgically.2 If the site of injury is not obvious of a fracture, the next step is to have an

X-ray done to see the severity of the fracture and to proceed with the proper care. Individuals

with humeral fractures can be treated conservatively or surgically. Humeral shaft fractures have

tremendous healing potential due to the excellent blood supply of the bony fragments provided

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by the surrounding soft tissue and muscles envelopes.4 This healing process depends on the

location of the fracture and how severe the morphology of the fracture is presented.

The bases of anatomy within the given specific area and or fracture is as follows: The

glenoid cavity of which in houses and accepts the humeral head of the humerus to the scapula.

Within this area are also the supraglenoid tubercle, infraglenoid tubercle, and the acromion of the

scapula, coracoid process of the scapula, along with the Superior, inferior, medial, and lateral

borders of the scapula. Also, within this area we can find the humeral head, neck, greater/lesser

tuberosities, surgical neck, anatomical neck, deltoid tuberosity, medial epicondyle, lateral

epicondyle, trochlea, and capitulum. All of these bony structures are of the humerus from the

proximal end to distal end. Now, exiting down further on the arm medially to the elbow area of

which we can find the ulna which includes the coronoid process of the ulna, radial notch of ulna,

ulnar tuberosity, the head of the ulna, and the ulnar styloid process. Also we have the radius of

which is constant on the lateral aspect of the arm of which includes the head/neck of the radius,

radial tuberosity, shaft of the radius, ulnar notch of the radius, radial styloid process of which all

make-up the radius. The muscles and soft tissues that make-up this area of the humerus, radius,

and ulna are Gross anatomy of muscles of arm including deltoid, supraspinatus, infraspinatus,

subscapularis, teres minor (rotator cuff), labrum, capsule, coracobrachialis, biceps brachii,

brachialis, triceps brachii, brachioradialis. The ulnar collateral ligament consists of an anterior,

posterior, transverse ligament space of which protect against valgus force. The radial collateral

ligament aids in protecting against Varus forces-uncommon injury. The Annular ligament

(stabilizer of the head/neck of radius) flexor carpi ulnaris, flexor carpi radialis, extensor carpi

radialis/ulnar longus & brevis, extensor digitrum, extensor digitorum minimi, anconeus,

supinator, abductor pollicus longus, extensor pollicus longus, extensor indicis, and opponis

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pollicis all aid in making up the “elbow” area down to the wrist. All of the muscles, soft tissues,

and or ligaments listed aid in assisting with the overall strength, stability, flexibility, range of

motion, and overall anatomy of the arm.

The identified patient is a 64-year-old Caucasian male. The patient is 6’0 ft. and weighs

approximately 220 lbs. The patient’s occupation is a semi-retired dentist, but is still very active

in everyday life. The patient's chief complaint is weakness in the right arm. Patient underwent an

open reduction internal fixation of the right humerus following a transverse mid-shaft humeral

fracture in 2010. In this particular surgery they removed the long head of his bicep. His worst

pain level is a 6 out of 10 (on the visual analogue scale) and his lowest pain level is no pain. The

patient's past medical history consists of hypertension, reflux, kidney stones, a ganglionic cyst

removed from right hand, and lipoma removal from right forearm. A neurilemmal was

surgically removed from the left leg (no positive results concluded 1972). In March of 1975,

motor vehicular accident on a Harley Davidson, fractured head of right tibia and partial traumatic

reflection of the right patella (medial to lateral). In December of 1975, open surgical repair on

right knee to remove road debridement and repair ligaments. The patient underwent arthroscopy

on right knee in 2004. Rooster comb injections (Supratz) were prescribed for the right knee

numerous times. In 2008, paresthesia of the finger tips on the right arm (pre-op), which led to the

diagnosis of an intramedullary spinal meningioma on his spinal cord (C3-C4). The tumor was

multi-lobed, with surgical removal expected to be an hour. The surgery ended up being eight

hours, (post-op) damage to C5, lost neural function of right deltoid and partial bicep and in

addition, quadriplegia paralysis. The patient lost 40% function to the right arm, also losing all

sensory perception of left lateral lower extremity (side of hip, side of leg, sole of foot, toes).

Patient complains of chronic headaches, crepitus of C3-C4 vertebrae. The patient suffers from a

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closed external pool of cerebral spinal fluid adjacent to C3-C4. The patient had total knee

replacement in 2009. In 2011, fractured left clavicle proximal to the acromion, fractured right

hand 4th and 5th metacarpals, 3rd degree abrasions of left lateral side of knee and entire left

scapular area, required 7 cadaver allografts and 3 autogenous grafts taken from lateral border of

left thigh. In 2015, patient underwent prostatic cancer with laparoscopic, robotic-assisted radical

prostatectomy. The patient's medication list consists of Lotrel 5/10 mg, Maxide 37.5/25 mg,

Flomax .4 mg, OTC medication, CoQ-10, prn Ranitidine 150 mg, Claritin, Fish Oil all once a

day. The patient has pain while trying to push, pull, tighten and lift objects. Patient expresses

concern of limited range of motion on right shoulder. The patient's main goals are to increase his

strength and range of motion. Also, the patient would like to work on his overall posture.

Within the review of systems, other history information that was received (other than

what was stated above) consisted of the patient’s blood pressure 130/80 and his heart rate 70

bpm. Observations that were substantial were the patient’s posture presenting with a forward

head, rounded shoulders anteriorly and a severe kyphotic curve to his thoracic spine. The patient

does tend to compensate with his right shoulder, engaging his traps and scapula. His right

shoulder is depressed more than his left shoulder. During palpations the patient presented with

moderate tenderness over the humerus plate and fixation screws in his right arm. He can feel the

most pain at the proximal and distal ends of the fixation. The patient’s active range of motion

was within normal limits on the left shoulder extension, abduction, internal rotation, and elbow

flexion and extension. The active range of motion on the right shoulder was limited in some

planes, but within normal limits on shoulder abduction, and elbow flexion/ extension. Shoulder

range of motion decreases very quickly in these cases, so the quicker to intervene the better.5 If I

would have encountered this patient, a specific special test I would have done is the tap test or

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percussion test (Sensitivity-Specificity. Looking at the X-rays and taking into consideration the

description of the fracture from the patient, it was very obvious the humerus was fractured.

Patient completed The Upper Extremity Functional Index, scoring a 51/80. The patient

confirmed his difficulty with functional activities that involves pushing, pulling, and lifting as

stated earlier with this Index.

Below is an evaluation of the patient consisting of data gathered from goniometry and

manual muscles testing. This data is composed in a table format to easily indicate areas of which

are normal or areas of which need to be assessed. To see proper progression while implementing

rehabilitation program the patient would be tested every few weeks or when proper short/long-

term goals are achieved.

Goniometry-Passive Range Left Shoulder/Elbow Right Shoulder/Elbow

Shoulder Flexion 165˚ 150˚ w/pain at neck at end

range

Shoulder Extension 65˚ 48˚ w/ slight pain

Shoulder Abduction 175˚ 170˚

Shoulder Internal Rotation 87˚ 75˚

Shoulder External Rotation 65˚ 65˚

Elbow Flexion 146˚ 146˚

Elbow Extension 5˚ hyperextension 3˚ hyperextension

Manual Muscle Testing Left Shoulder Right Shoulder

Shoulder Flexion 5/5 4/5

Shoulder Extension 5/5 4/5

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Shoulder Abduction 5/5 5/5

Shoulder Internal Rotation 5/5 5/5

Shoulder External Rotation 5/5 5/5

Elbow Flexion-Biceps

Brachii

5/5 4/5

Elbow Flexion-Brachialis 5/5 5/5

Elbow Flexion-

Brachioradialis

5/5 5/5 slight compensations

w/shoulder

Elbow Extension 5/5 5/5

Upper Traps 5/5 5/5

Rhomboids and middle traps 2/5 1/5

Infraspinatus/ teres min &

maj

4/5 5/5

Deltoid 5/5 5/5

Pectoralis Major 5/5 5/5

Acknowledged within my evaluation, the patient presents with moderate tenderness over

the fixation of the right humerus and expresses concern of right arm weakness. These complaints

are limiting the patient in lifting, pulling, pushing and tightening objects that have to do with his

active daily living as a farmer. The patient’s primary diagnosis from the primary care provider

was right mid-shaft humeral fracture. He then underwent a right open reduction internal fixation,

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which left him with a plate, screws, and a reduction of the long head of the biceps. Humeral

plating has been accepted as the standard technique for fixation of humeral shaft fractures.6

Considering the type of fracture, which was a mid-shaft humeral fracture with a

transverse fracture line that pierced the patient’s triceps into consideration, leads us to the review

of literature that will focus on his surgery and post op interventions. According to the patient’s

X-ray the transverse fracture line had a lateral displacement. With a second opinion it was clear

that this fracture would not heal on its own with the arm in a sling or cast. The healing process

of bone determines if the patient needs a closed or open reduction. To help the healing process of

the bone is why the internal fixation is placed to stabilize and maintain alignment of the fracture

site. The patient’s open reduction internal fixation procedure was an anterolateral approach

which resulted in extraction of the long head of the biceps because of specific desired location of

the plate. After surgery, they closed with 20 staples to ensure proper healing of the incision. At

this time, my very pleased patient has not had to go back for a second surgery to remove any of

the fixation devices that may have migrated overtime. During postoperative management, not

only must the fracture site be protected as it heals, soft tissues injured at the time of the fracture

occurred and further damaged when exposing the field during surgery must also be managed

appropriately as they heal.7

The patient shows determination and motivation for therapy. The prognosis is good.

Exercise often in conjunction with other interventions is one of the most common physiotherapy

interventions used to reduce impairment and increase activity in the rehabilitation of people with

upper limb fractures.8 The patient stated many anticipated goals in the history. The physical

therapy goals consist of long and short term goals. The primary long term goal for this patient is

to be able to complete simple active daily living activities with increased strength in eight weeks.

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A second-long term goal for the patient is to be able to increase to full range of motion in right

shoulder without compensation of the traps and scapula in 7 weeks. The third long term goal is to

be able to increase proper posture, shoulders back, head up and neutral and stand up straight in 6

weeks. Short term goal number one for the patient is to increase range of motion in shoulder

flexion on right arm to reach for items overhead without getting fatigued in 2 weeks. Short term

goal number two for the patient is to decrease pain level at the end range of shoulder flexion on

right arm in 1.5 weeks. Short term goal number three is to be able to complete task involved with

lifting at waist level with increased strength in 2 weeks.

The patient attended outpatient therapy twice a week for six to eight weeks. Taking into

consideration the patient is in senior adulthood and post-op open reduction internal fixation, we

will focus on his main chief of complaint stated in the history. First, beginning with myofascial

manipulation of the superficial skin to the right shoulder to aid in mobility and breaking of

lesions, etc. Moving to passive range of motion, I will show the patient all the planes to move in

without compensation (keeping proper form in mind), because I will be stabilizing him

throughout the ranges of motion. Leading to active assisted range of motion, the patient can

engage himself, and I will still have a stabilizing hand on him to help remind those compensating

muscles to not engage (use D1/D2 motion as well). After achieving active range of motion

without compensations we will work on joint mobilizations for any limitations. Starting with

distraction of the right shoulder and beginning with a grade 1 to 2. Anterior and posterior glides

to increase right shoulder flexion and extension beginning with a grade 1 to 2. Moving to

therapeutic exercises for stretching include the corner stretch to work on retraction and posture,

as well as the wall stretch, reaching out to different points on the wall and holding for 10

seconds. Supine stretches with the T-bar. Light strengthening exercises that also aid in stretching

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will consist of Thera bands in all planes, beginning in the supine position. Each session will

conclude with modalities such as rest and ice. The patient will be sent home with a home

exercise program to help maintain the improvement made here in the clinic. The patient will

continue the corner stretch, wall stretch and T-bar stretch at home with 10 repetitions, holding

for 10 seconds each, twice a day. Patient will be given a Thera band to work on shoulder flexion

in supine and shoulder extension in side lying doing this 15 times, twice a day working in a non-

painful range. However, if either of the exercises causes pain he is instructed to stop all

exercises.

The patient will benefit and progress from myofascial manipulation of the superficial

skin to more of an ironing or stroking motion with the heel of the hand and a chisel grip which is

slightly deeper in the soft tissue to target the deltoid. As well as working on the scapular platform

with scapular framing of each border. Both of these motions will serve to loosen up the shoulder

complex to ensure increased range of motion. The joint mobilizations will move to grade 3 to

improve range of motion as well. We will continue with stretching exercises, to work on proper

posture. Including more strengthening exercises, working more against gravity with the different

levels of Thera bands, as well as incorporating light hand weights. Thus, we are always working

towards therapeutic activities to make each exercise more functional to reach the end goal. We

always end the sessions with modalities such as ice. I will monitor his pain level and he will

continue with the appropriate therapy. The home exercise program will be continued with each

session in more challenging exercises.

Another area of focus will be on the patient’s core, gait, and overall endurance. Being

that the patient is 220lbs and within long adult I will keep into consideration and modify

exercises to properly aid within his manner. Some of the exercises that can be implemented to

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the patient for core are just simply contracting the core muscles and then relaxing. During this

exercise we can also focus on the patients breathing and educate them if needed. Another

exercise would be simply having the patient raise their heels off a table and holding for a brief

amount of time before lowering back to the table. This will aid with the lower abdominal

muscles that tend to be very weak within patients. We can progress from one leg to both legs,

different heights off the table, or time. Also, having the patient complete simple or modified

crunches will work on core, but also flexibility as well. Within this rehabilitation program the

patient will also be instructed to walk at home, join a walking club or gym. Within the time of

the patient being in rehab the exercises that will be introduced/ completed for endurance are the

arm bike (aid in ROM) leg bike, treadmill or elliptical. All of these can be progressed, but first

starting out slow and building properly to progress.

Thus, instructing and educating the patient on proper ergonomics, form, and technique

are essentially vital for this patient’s well-being. Properly educating the patient on these will only

aid in more fulfillment of a healthier lifestyle, with also reducing the possibility or chance of

future injuries. Some of the areas that will be demonstrated and then implemented to the patient

is how to properly lift objects from the ground while utilizing your leg muscles, not essentially

your back muscles. Proper form of this will be demonstrated and then instructed to the patient to

complete as well. Another form will be lifting an object, but not rotating before you’ve changed

your lower extremity first before walking. This will aid to the patient to hopefully decrease the

chances of any rotational injury, slipping or falling due to the change in load, decreases the

chances of a hernia, and or aid in proper building of technique.

With the patient being a dentist and also a board member (many conferences, meetings,

flights) another area that we will look at is the patient’s overall posture when practicing in their

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line of profession. Possibly providing or finding a new chair or educating on posture within this

area will aid in the patient’s chances of decreasing pain while practicing with their profession.

Thus, with the patient flying a lot and attending board meetings the patient will be instructed on

proper posture when sitting in a chair and or during long period of sitting/flying. By assessing,

educating, and properly instructing these issues to the patient we only hope to see an increase in

the quality of their life.

Lastly, a focus that will be educated to the patient is within their diet/nutritional regiment

program. With the patient being an elder we want to educate the patient on how important their

diet and nutritional daily values are. Keeping in mind or seeing if they supplement with any

foods and or vitamins. If needed, a proper diet program will be implemented to the patient for

ease of use to aid in their nutritional values and hopefully increase their quality of life.

In conclusion, the patient will be released with a take-home-packet of exercises, goals,

and guidelines on the bases of keeping their range of motion, strength, core, endurance, and

nutrition up-to-date and within the correct guidelines of their life. In this, hopefully the patient

will live a substantially healthier and reduced risk of injury way of life.

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Possible Rehabilitation Protocol-Humeral Shaft Fracture (Transverse-Mid. Shaft)

Humeral Shaft Fracture (Transverse-Mid Shaft)Pre-op 1-2wk: Patient is within sling for protection-instructed on post-op Rehab goals

10-12 wks. Goal of Treatment Physio TreatmentPhase 11 wk.

2-3 wks.

1wk:-Reduce swelling, pain, increase healing process, decrease pain-Arm immobilizer: protection of arm, aids in stabilizing arm, reducing potential injury from ROM-All shoulder movements are avoided-only wrist, hand, fingers. Assist with ADL’S2-3wks :- Continue to reduce pain, swelling, atrophy of muscles, keep cardiovascular under control, and increase ROM/exercises.

1wk:-TENS and ice, for pain control -Splint/Sling, Monitor use and weight bearing instructions via physician-Cardiovascular conditioning-Gentle range of motion exercises of the neck, wrist, and hand-Passive supine external rotation to 40° -Passive supine forward elevation.2-3wk;-Pendulum swings with brace, isometric exercises, NO weight bearing

Phase 23-6 wks.

3wk:-Control pain/Edema as needed, Regain full ROM, Minimize deconditioning, decrease atrophy, increase strength/ROM

6wk:-Control pain as needed, Keep increasing strength/ROMIncrease cardiovascular training

3wk:-Pendulum swings-Passive external rotation with stick or pulleys - Passive forward elevation with assist from non- involved arm or pulleys-Passive internal rotation and hyperextension with stick- Isometrics: Internal rotation, external rotation, flexion, extension, abduction in a neutral position-6wk:-Active forward elevation in supine, Active forward elevation with weights in supine -Forward elevation in standing with stick -Pulleys with eccentric lowering of involved arm

Phase 36-9 wks.

6wk-9wk:-Increase strength, work within new ROM (work on increasing) Increase rotator Stability/scapular stability, Keep up Cardiovascular.

6wk-9wk :- Active forward elevation with weights increased, Forward elevation with stick work increase (weighted) ,Pulleys-Rows (work-weighted)

Phase 49-12+

9wk-11wk:-Increase strength (end range)Gain equal strength in the rotator cuffs (decrease impingement) Strengthen scapular rotators, equal strength bilaterally/ROM. Keep up Cardiovascular.

12wk:-Continue increase weight/progression exercises.Introduce take-home exercise program.

9wk:-Resistive exercises: Standing forward press, Thera-band resisted (flexion, internal rotation, external rotation and abduction) exercises, and rowing -Self stretching: flexion/abduction combined, internal rotation, flexion, abduction/external rotation combined, bilateral hanging stretches -Advanced internal rotation, shoulder flexion, external rotation and horizontal abduction stretching

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References

1. Dutton M., Dutton’s Orthopedic: Examination, Evaluation and Intervention. 3rd ed. McGraw-Hill Professional; July 2,2012

2. Boschi V, Pogorelic Z, Grandic L, et al. Subbrachial approach to humeral shaft fractures: new surgical technique and retrospective case series study. Canadian Journal of Surgery. February 2013; 56(1):27-34 8p. Accessed April 15, 2016.

3. Adapted Practice Patterns. Musculoskeletal (patterns 4A-4J). American Physical Therapy Association. http://www.apta.org/Guide/PracticePatterns/. Last published October 11.2015.

4. Rosenbaum A, M.D., Uhl R, M.D. Nonunion of humeral shaft fractures following flexible nailing fixation. Orthopedics (Online). 2012;35(6):512-5.

5. Esmailiejah AA, Abbasian MR, Safdari F, Ashoori K. Treatment of Humeral Shaft Fractures: Minimally Invasive Plate Osteosynthesis Versus Open Reduction and Internal Fixation. Trauma Monthly. 2015; 20(3):e26271. doi:10.5812/traumamon.26271v2.

6. Bruder, Andrea et al., Exercise reduces impairment and improves activity in people after some upper limb fractures: a systematic review; Journal of Physiotherapy, Volume 57, Issue 2, 71-82

7. Gui Do M, Jin Yong L, Da Yeon K, Tae Ho K. Comparison of Maitland and Kaltenborn mobilization techniques for improving shoulder pain and range of motion in frozen shoulders. Ind J Physioth OT. May 2015; 27(5):1391-1395 5p.

8. Harsimran K, Ranganath G, Ravi S. Comparing effectiveness of antero-posterior and postero-anterior glides on shoulder range of motion in adhesive capsulitis - a pilot study. Ind J Physioth OT.October 2011; 5(4):69-72 4p.

9. Hiscock N, Bell S, Coghlan J. Pain, depression and the postoperative stiff shoulder. BMC. Musculoskelet Disord. December 4, 2015; 16:1-6.