Rehabilitation of Proximal & Clavicular Fractures

19th Annual Primary Care Orthopaedic & Sports Medicine Symposium January 25, 2019

Jeremy Sherman, PT, MPT

 Disclosures

 No financial disclosures to note. Jeremy Sherman, PT

 Sport & Spine Clinic – Edgar  Director/Physical Therapist  Sports Medicine coverage Edgar High School

 PT  University of Wisconsin – Madison Objectives

 Identify evidence-based exercise programs for patients with humerus or clavicular fractures to increase ADL independence.

 Develop progressions of exercises for return of upper extremity functional independence.

 Identify benefits of evidence based exercise to improve funcitonal outcomes following upper extremity fracture. Functional Limitations seen Following Upper Extremity Fractures

 Limited AROM for ADLs:  Overhead and behind the back

 Weakness for lifting, carrying, push/pull

 Difficulty sleeping in bed

 Limitations with household activities

 Compensatory movement patterns Proximal Humerus Fractures

 6% of fractures

 MOI: usually Trauma  Fall directly on shoulder  Forceful collision  Car accident

 Osteoporosis factor

 Female > Male

 Displaced vs. Non-displaced Symptoms

 Swelling

 Bruising

 Severe shoulder motion restriction

 Numbness/Tingling in , , or

 Deformity Post-operative vs. Non-operative Treatment

 Sling for 6 weeks  and wrist ROM immediately after injury

 Koval et al. – Improved outcomes if initiated within 14 days of injury  Decreased rates of stiffness and improved ability to perform ADLs

 Pendulum exercises at 3 weeks

 Active ROM at 6 weeks

 Full ROM and strength restrictions lifted after full healing seen on films. Interventions for Proximal Humerus Fractures

 Range of Motion:  Pendulums  Pulleys  Cane Exercises  Wall slides  Table slides Interventions for Proximal Humerus Fractures

 Strengthening Exercise: started once fracture union is seen  Deltoid and Isometrics  Scapular stabilization exercises  Scapular retraction, low trap setting, rhythmic stabilization, rows  Active exercises starting supine and then moving to seated/standing  Active Resistive = Deltoid and RTC as AROM improves  Daily Home Exercise Program Strengthening Exercises Interventions for Proximal Humerus Fractures

 Manual Therapy: to improve functional movement  Shoulder mobilizations – when indicated  Glenohumeral and scapular  Soft tissue mobilizations  Scar mobilizations for post-operative  PROM  Dry needling of trigger points Interventions for Proximal Humerus Fractures

 Functional Training:  Reaching into an overhead cupboard  Push/pull a cart to mimic household chores  Functional lifting from different heights  Opening/closing door  Transfers  Return to work activities  Compensatory techniques if needed Interventions for Proximal Humerus Fractures

 When to return to Daily Activity:  Diagnostic testing reveals closure of fracture and physician approves full return  Can be 6 months to full year for full return  Expect some limitations  Ease into activity to avoid overuse and remember to ice if needed Outcomes following Proximal Humerus Fracture

 Most patients have functional pain-free shoulder  May take up to 2 years for full recovery  Rapid improvements within first 6 months, near full recovery in 1 year

 Counsel patient there will be some strength and motion deficits Patient Screening

 Check for:  Falls Risk Reduction Strategies  For Contact Sports => proper protective equipment  Low Density  Possible supplementation of Calcium and Vitamin D Rehabilitation and Interventions for Clavicular Fractures

Fracture  35% of all shoulder injuries  Most common cause = trauma  Direct blow or fall  Most often diagnosed = <20 y.o.  Sports injuries  Age increases = result of fall  Midshaft = 75-80% of clavicle fractures Clavicular Fractures

:  Pain over injury site  Arm pain or changes in sensation in severe cases  Bruising  Swelling  Inability to lift arm  Grinding sensation with movement  Bump or step-off at injury site Rehabilitation and Interventions for Clavicular Fractures

 Sling

 6-8 weeks

 Figure 8 Brace Rehabilitation and Interventions for Clavicular Fractures

 Early Range of Motion Exercises:  Distal extremity motion  Pendulums  Cane exercises  Table slides  Early intervention  Prevent weakness and stiffness  After 4 weeks if physician sees good position and stability, Physical Therapist will guide to achieve full shoulder ROM Rehabilitation and Interventions for Clavicular Fracture

 When to start strenuous exercise:  Both non-operative and operative usually begins around 6-8 weeks after injury/surgery  Appropriate healing needed  Age, health, complexity of injury/surgery factors  Active ROM progression  Strengthening exercise  Work on shoulder complex as a whole for good stabilization  Scapular stabilizers, RTC, , rhythmic stabilization Rehabilitation and Interventions for Clavicular Fractures

 Strengthening Exercise:  Phase I (0-6 weeks): isometric exercises at neutral, elbow/forearm exercises, scapular retraction  Phase II (7-12 weeks): theraband ER/IR, Row, side lying ER, prone Y/T/I, standing scaption, isotonic biceps curl  Phase III (13-18 weeks): standing forward flexion, rhythmic stabilization and proprioceptive training drills, push up progression, add progressive resistance 1-5#, limited weight training near week 13  Phase IV – closed kinetic chain exercises, plyometrics for throwing and overhead athletes, interval sport programs, return to weight training based on physician’s advice. Rehabilitation and Interventions for Clavicular Fractures

 When to Return to Daily Activity:  Nonstrenuous activity after about 6 weeks  Strenuous job duties = 9-12 weeks

 Return to Sport:  Non-operative 9-11 weeks following trauma (Faldini et al)  Operative:  ~12 weeks gradual return to activity  ~16-18 weeks – full sports based on healing and physician approval  Functional Testing Functional Testing

 Seated Medicine Ball Test (Harris et al)  Sit on the floor with back against the wall, legs extended and apart for balance  Bring ball to chest and throw while keeping the back against the wall  Best of 3 trials  Males use 6 lb. ball, Females 4 lb. ball Upper Limb Functional Testing

 Seated Medicine Ball Toss

Rating Distance (meters) Excellent 5.76+ Good 5.00-5.75 Average 4.25-4.99 Below Average 3.50-4.24 Poor 0-3.49  Highly reliable test of upper body power in older adults Upper Limb Functional Testing

 Single Arm Seated Shot Put Test (Negrete et al.)  Seated in a chair without armrests  Feet and legs placed on chair in front  Nonthrowing arm placed across the chest and a strap placed across the chest to secure the subject to the chair  6 lb. medicine ball  4 warm up puts and then 3 trials  At least 90% symmetry in distance side to side Upper Limb Functional Testing

 Timed Push Up Test (Negrete et al)  Widely used in lots of settings to test upper body strength  Significant reliability  90% confidence in minimal detectable change represents true improvement (2 reps)  How many you can do in 1 minute  Male: > 18 reps, Female: > 12 reps  Also can do to exhaustion12  Male: >39, Female: >27  Safe, inexpensive, repeatable, practical Upper Limb Functional Testing

 Modified Pull-up Test ( Ervin et al)  Used in schools age 5-15  Test of strength focused on the back, shoulder, forearm, and arm strength  Complete as many as possible until break form or pause for more than 2 seconds  Adjustable bar positioned to allow participant to grab bar with back flat on surface. Strap hangs down 8 inches and chest has to touch strap. Upper Limb Functional Testing

 Modified Pull-Up Test

Boys Girls 5-6 ≥ 2 5-6 ≥ 2 7 ≥ 3 8 ≥ 4 7 ≥ 3 9-10 ≥ 5 11 ≥ 6 8-15 > 4 12 ≥ 7 13 ≥ 8 14 ≥ 9 15 ≥ 10 Upper Limb Functional Testing

 Upper Quarter Y Balance Test (Gorman, Westrick, Butler)  Weight bearing on the contralateral limb  Test medial reach, inferolateral reach, superolateral reach  Start with right and do in that order, repeat on left  Best of 3 trails, allowed 1 practice trail  Reach as far as possible without loss of balance  Challenges balance, proprioception, strength and ROM  Normalize reach distance  Measure arm length from C7 to the most distal tip of the right middle finger  Must have good form  Cannot touch down with reach hand, fall off platform, shoved the sliding platform, used sliding platform for support, failed to come back to starting position, and lifted feet off floor Upper Limb Functional Testing

 Upper Quarter Y Balance Test  Reliable test for measuring UE reach in a closed chain position13  No difference in baseball and softball players  No difference in throwing and non-throwing in un-injured athletes  Not at good measure of strength Upper Limb Functional Testing

 Closed Kinetic Chain Upper Extremity Stability Test (Tucci, Roush, Butler)  Push up position, or modified push up position  36 inches apart  Count how many times one hand can touch the other hand in 15 secs  Hand must come back to the starting position each time  3 trials with rest up to 45 secs between sets Upper Limb Functional Testing

 Closed Kinetic Chain Upper Extremity Stability Test  Improvement of 3-4 touches is considered significant  Reliable tool for healthy, subacrominal impingement, and different levels of physical activity  Collegiate-level baseball players no differences existed in scores by position  Clinically relevant for use in upper extremity function Effect of Exercise

 Bruder et al. - Exercise reduces impairment and improves activity in people after upper limb fractures  Early commencement of exercise beneficial for conservatively managed proximal humerus fractures  Supervised exercise and home exercise program leads to reduction in impairment, particulary ROM. References

 Bruder et al. Exercise reduces impairment and improves activity in people after some upper limb fractures: a systematic review. Journal of Physiotherapy. 2011; 57(2):71-82.

 Herzog MM, Whitesell RC, Mac LM, Jackson ML, Culotta BA, Axelrod JR, Busch MT, Willimon SC. Functional outcomes following non-operative versus operative treatment of clavicle fractures in adolescents. J Child Orthop. 2017; 11:310-317.

 MacIntyre NJ, Kwan LL, Johal H, Lefaivre KA, Guy P, Sprauge S, et al. Rehabilitation of Proximal Humerus Fractures-A Scoping Review. SM J Trauma Care. 2017; 1(1):1001

 Canbora MK, Kose O, Polat A, Konukoglu L, Gorgec M. Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study. Int J Shoulder Surg. 2013 Jul-Sep; 7(3):105-109.

 Hauschild et al. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg. 2013 Oct; 133(10):1385-1393.

 Faldini et al. Nonoperative treatment of closed displaced midshaft clavicle fractures. J Orthopaed Traumatol. 2010; 11: 229-236.

 Harris C, Wattles AP, DeBeliso M, Sevene-Adams, PG, Berning JM, Adams KJ. The Seated Medicine Ball Throw as a Test of Upper Body Power in Older Adults. Journal of Strength and Conditition Research. 2011; 25(8): 2344-2348. References

 Negrete RJ, Hanney WJ, Kolber MD, Davies GJ, Ansley MK, McBride AB, Overstreet AL. Reliability, Minimal detectable change, and normative values for testes of upper extremity function and power. J Strength Cond Res. 2010;24: 3318-3325.

 Ervin RB, Fryar CD, Wang CY, Miller IM, Ogden CL. Strength and body weight in US children and adolescents. Pediatrics. 2014 Sep 1;134(3):782-9.

 Gorman PP, Butler RJ, Plisky PJ, Kiesel KB. Upper quarter Y balance test: reliability and performance comparison between genders in active adults. J Strength Cond Res. 2012;26 (11): 3043-3048.

 Westrick RB, Miller JM, Carow SD, Gerber JP. Exploration of the Y-balance test for assessment of upper quarter closed kinetic chain performance. International Journal of Sports Physical Therapy. 2012;7(2):1139-147.

 Butler RJ, Myers HS, Black D, Kiesel KB, Plisky PJ, Moorman CT, Queen RM. Bilateral Differences in the Upper Quarter Function of High School Aged Baseball and Softball Players. The International Journal of Sports Physical Therapy. 2014; 9(4): 518-524.

 Tucci HT, Martins J, Sposito G, Camarini P, Oliveira A. Closed kinetic chain upper extremity stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC Musculoskeletal Disorders. 2014;15: 1474- 2474.

 Roush JR, Kitamura J, Chad Waits M. Reference values for the closed kinetic chain upper extremity stability test (CKCUEST) for college baseball players. North American Journal of Sports Physical Therapy. 2007;2(3):159-163.

 Butler R, J, Reiman M, Plisky P, Kiesel K, Taylor D, Queen R. Sex differences in dynamic closed kinetic chain upper quarter function in college swimmers. Journal of Athletic Training. 2014;49(4):442-446.