Shoulder and Elbow Rehabilitation Quiz

Fractures & Dislocations of the Upper Limb

• Clavicle fractures, also known as broken collarbones, are common in adults (2-5%) and children (10-15%).
• They account for 44-66% of all shoulder fractures and are the most common fracture in childhood.
• Treatment choice is debated, with options including conservative and surgical management.
• Treatment selection depends on factors including biologic age, functional demands, and the type of fracture.

Clavicle Fracture Classification

• Allman classified clavicle fractures into three groups based on location:
  • Group I: Middle third (midshaft) fractures (80%)
  • Group II: Distal third fractures (12-15%), a common site for non-union. Neer further categorized Group II based on the coracoclavicular ligament position.
  • Group III: Proximal third fractures (5-6%)

Clavicle Fracture Mechanism of Injury

• Clavicle fractures are often caused by a direct blow to the shoulder (e.g., falling onto shoulder or car collision).
• Can also occur due to a fall onto an outstretched arm, or during childbirth.

Clavicle Fracture Complications

• Malunion: Although common, it rarely causes functional impairment.
• Non-union: Rare.
• Neurovascular involvement: Subclavian vessels and brachial plexus can be at risk, especially with high-velocity trauma.
• Degenerative arthritis of acromioclavicular or sternoclavicular joints.

Clavicle Fracture Union Time

• Early union occurs in 1-2 weeks in children.
• In adults early union occurs in 3-6 weeks and consolidation in 12 weeks.
• Callus formation is visible and palpable.
• Immobilization duration is not consistent, with recommendations ranging from two to six weeks.

Clavicle Fracture Conservative Management

• Undisplaced fractures are typically treated conservatively.
• Immobilization with a sling is often used for 2-4 weeks.
• A figure-of-eight brace is sometimes used to prevent secondary fracture shortening.
• Treatment continues until clinical union is confirmed (no pain, tenderness or movement at fracture site) in appropriate timeframe (6–8 weeks).
• Radiographic union can be checked with follow-up x-rays.

Clavicle Fracture Surgical Management

• Surgical management is indicated for fractures with significant displacement (>2cm), severe skin tenting (open fractures requiring debridement), associated neurovascular injury, or non-union (failure of conservative treatment).
• Surgical methods include open reduction and internal fixation using plates and screws, or intramedullary fixation.

Clavicle Fracture Rehabilitation

• Physical therapy programs typically start with gentle motion exercises like pendular exercises.
• Gentle range-of-motion (ROM) exercises begin 2-4 weeks post-injury and strengthening exercises are initiated 6-10 weeks post-injury.
• Full activity, including sports, is typically permitted 3 months post-injury when pain-free motion and radiographic union are achieved.
• Patients should be aware of their body mechanics to maintain proper posture and avoid problems associated with using a sling (e.g., slouching, shrugging, etc.)
• Important to take note of situations like coughing and sneezing which can cause clavicle movement. Avoidance of these movements as much as possible or learning active-assisted coughing techniques is helpful.

Shoulder Dislocation

• Anterior dislocations comprise the majority (>95%).
• Posterior dislocations are less common (<5%).
• True inferior dislocations are rare (<1%).
• Multidirectional dislocations are due to ligament laxity and are typically painless.

Anterior Shoulder Dislocation Mechanism of Injury

• Usually an indirect fall. It may be direct when there is a blow to the shoulder from behind.
• Caused by an excessive amount of abduction and external rotation of the arm.
• The glenohumeral joint is most susceptible to dislocation in the 90° abduction and 90° external rotation.

Anterior Shoulder Dislocation Complications

• Bony: Bankart lesion, Hill-Sachs lesion, neck of humerus, greater or lesser tuberosity fractures
• Soft tissue: Soft tissue Bankart lesion, subscapularis tear and rotator cuff tear
• Vascular: Axillary artery injury, avascular necrosis of humeral head
• Nerve: Axillary nerve neuropraxia
• Recurrent dislocation
• Shoulder stiffness with prolonged immobilization

Anterior Shoulder Dislocation Tests

• Dugas test: Inability to touch the opposite shoulder with the affected hand

Anterior Shoulder Dislocation Clinical Picture

• Arm held in an abducted and externally rotated position; internal rotation and adduction may be limited.
• Loss of normal contour of the deltoid and acromion is noted, posterior fullness.
• Humeral head is palpable anteriorly.
• All movements are limited and painful.
• Palpable fullness below the coracoid process and towards the axilla.

Posterior Shoulder Dislocation

• Rare and often missed.
• More common in epileptics and those with electrocution.
• Caused by overpull of the subscapularis and latissimus dorsi muscles.
• Involves an indirect force applying flexion, adduction, and internal rotation to the humerus.
• Often a result of a fall on an outstretched hand.
• Imaging is challenging, and a lateral view is essential; an axillary view is preferred.

Posterior Shoulder Dislocation Clinical Picture

• Arm is adducted and internally rotated.
• Clinically locked in internal rotation, unable to externally rotate the shoulder.
• May or may not lose deltoid contour.
• May note posterior prominence of the humeral head.
• Tear of subscapularis muscle (weakness in internal rotation).

Luxatio Erecta (Inferior Shoulder Dislocation)

• Also known as an inferior dislocation.
• Cause: Severe hyper-abduction forces.
• Arm is in an abducted position.
• Reduction is done by in-line traction and gentle adduction.

Shoulder Dislocation Management

• Emergency—usually needs to be reduced within 24 hours to avoid avascular necrosis of the humerus head.
• Reduction techniques (e.g., closed reduction or open reduction).
  • Hippocratic method
  • Stimson’s gravity method
  • Kocher’s method.
• Post-reduction immobilization methods

Operative Indications for Shoulder Dislocation

• Irreducible shoulder
• Displaced greater tuberosity fractures.
• Glenoid rim fractures bigger than 5 mm.
• Multiple recurrent dislocations

Non-operative Shoulder Dislocation Treatment

• Pain and edema reduction
• Protecting static stabilizer and strengthening dynamics
• Improve shoulder stability.
• Exercises designed to enhance joint proprioception and address kinetic chain deficits.

Surgical Shoulder Dislocation Treatment Post-Procedure Precautions

• If subscapularis is cut, no resisted internal rotation for 4-6 weeks.
• External rotation is usually limited to 30 degrees initially then 45 degrees at 6 weeks.
• Avoid provocative postures (external rotation, abduction, distraction, extension).

Humerus Fracture

• Proximal humerus, including surgical and anatomical neck, greater and lesser tubercles.
• Humeral shaft.
• Distal humerus. Includes fractures of the condyle, epicondyles, and supracondylar fractures.

Proximal Humerus Fracture—Neer Classification

• Anatomical neck
• Surgical neck
• Lesser tuberosity
• Greater tuberosity

Proximal Humerus Fracture Complications

• Adhesive capsulitis (Frozen shoulder)
• Multi-part fractures lead to avascular necrosis
• Neurovascular injuries.

Proximal Humerus Fracture Treatment

• Stable and minimally displaced—sling immobilization and early motion.
• Significant displacement—ORIF in younger adults, hemiarthroplasty for elderly or comminuted fractures.
• Bony healing usually takes 6-8 weeks in adults.

Humeral Shaft Fracture Treatment

• Closed reduction and immobilisation in upright position by POP or cylinder cast and/or functional brace.
• Operative treatment indications include: inadequate reduction, nonunion, open fractures, segmental fractures, or associated vascular/nerve injuries.
• Most common—plates and screws; sometimes intramedullary nails.

Humeral Shaft Fracture Rehabilitation

• Phase 1 (0-6 weeks):
  • Active ROM of neck, shoulder, elbow, wrist, and hand.
  • Pendulum exercises.
  • Passive self-assistive exercises.
• Phase II (6-12 weeks):
  • Early active, resistive, and stretching exercises.
  • Therabands for internal rotators, external rotators, flexion, extension, & abduction.
• Phase III (>12 weeks):
  • Begin isotonic exercises (rubber tubing to weights).
  • Focus on rotator cuff and scapular strengthening, progressing to weights.
  • Increase ROM and flexibility, progress to overhead exercises.

Supracondylar Fracture

• Most common fracture type in children, usually due to falling.
• Two types: Extension type (posterior displacement) and flexion type (anterior displacement).

Supracondylar Fracture Complications

• Brachial artery injury (Volkmann's ischemia)
• Nerve injury (median, ulnar, or radial nerves).
• Stiffness
• Heterotopic calcification (Myositis ossificans)
• Mal-union (cubitus varus or valgus)

Supracondylar Fracture Treatment

• Non-displaced: Immobilization with a long-arm cast or splint.
• Displaced: Closed reduction with percutaneous pinning; open reduction and internal fixation are sometimes required.

Supracondylar Fracture Rehabilitation

• Phase 1 (0 to 6 weeks): Gradual return to ROM of the elbow, wrist, fingers, active elbow exercises.
• Phase II (6 to 12 weeks): Passive ROM, active elbow exercises with resistance.
• Phase III (> 12 weeks): Isotonic exercises for strengthening, progress to more challenging exercises, full ROM.

Volkmann's Contracture

• Deformity of the hand, fingers, and wrist caused by a brachial artery injury after supracondylar fracture.
• Characterized by decreased blood flow leading to muscle damage and shortening.
• Pain, pallor, pulselessness, paresthesias, and paralysis (5Ps).

Volkmann's Contracture Treatment

• Prevention is key.
• Intra-compartmental pressure over 30 mmHg necessitates an urgent fasciotomy
• Post-surgery, aggressive therapy and tendon slide, neurolysis, and extensor transfer.
• Aggressive passive stretching, ROM exercises, and muscle strengthening are needed.

Post-Traumatic Ossification

• Usually results from impact causing damage to the periosteum and surrounding muscle
• Bone grows within the muscle forming a painful calcification.
• Treatment focuses on RICE principle, stretching, and strengthening.

Mal-union Supracondylar Fracture Management

• Most commonly results in cubitus varus deformity.
• Management involves corrective supracondylar osteotomy.

Test your knowledge on non-operative and surgical treatment options for shoulder instability and elbow fractures. This quiz covers rehabilitation protocols, surgical indications, and specific intervention techniques. Enhance your understanding of effective management strategies in orthopedic care.