Humeral fractures occur commonly with up to five percent of all fractures falling into this category, eighty percent of humeral fractures being minimally displaced or undisplaced. Osteoporosis is a contributing factor in many of these fractures and a fracture of the forearm on the same side is a typical presentation. Nerve or arterial damage from the fracture is an important consideration but not common. Typical sites of fractures are the top of the arm (neck of humerus - "shoulder fracture") and the middle of the shaft of the humerus.

A fall onto the outstretched hand, onto the elbow or onto the shoulder itself is the most common cause of a fractured arm. Since many of the arm muscles insert onto the humeral head, when the injury occurs the muscular action involved can displace the fragments and complicate the management. 65 years old is the peak incidence for this kind of fractured humerus and if younger patients suffer this fracture the likely cause will involve high forces such as traffic accidents or sports injury.

Humeral fractures usually occur with great force and if this has not happened then a serious condition such as cancer must be considered. When the physio examines the arm they may find very limited shoulder movement, severe swelling and bruising, some shortening in shaft fractures and pain on movement of the elbow or shoulder. The radial nerve, which supplies the extensors of the wrist and fingers and thumb extensors and abductors, can be damaged but this is more common in shaft fractures and less so in fractures of the humeral neck.

Management of Humeral Fractures

Acutely the patient is kept still and given adequate analgesia to relieve the initial pain. Fractures of the upper part of the arm bone can mostly be managed without operation if there is little or no displacement but rotator cuff injury could occur if the greater tuberosity is fractured, especially if it is displaced any distance, great force was involved or the patient is older. A collar and cuff sling allows upper humeral fractures to traction themselves straight and in line, while shaft fractures can be braced but are difficult to control.

Open reduction internal fixation (ORIF) is often performed for displaced fractures with three or four fragments and more commonly in younger patients, while older patients have humeral head replacement to prevent pain and stiffness in the shoulder. Nailing or plating is used in shaft fractures if necessary but these usually heal without surgery. Humeral fractures can have complications including injury to the radial nerve in shaft fractures, frozen shoulder and death of the humeral head due to loss of blood supply. Although normal healing time is 6-8 weeks, older sufferers may never re-establish normal range of shoulder movement.

Physiotherapy for Shoulder Fractures

Initial physiotherapy assessment consists of assessing the patient's pain levels as these can vary hugely, the joint ranges of motion of the elbow, hand and wrist and the tissue swelling and bruising in the arm. Muscle strength is tested in the forearm as this may indicate an injury to the radial nerve, as may loss of sensory discrimination. The patient may stay in the sling for 2-3 weeks with the physio exercises beginning early if pain is reasonable and the fracture stable. The aim is to maintain the range of motion of the shoulder joint while the fracture heals, by performing bent over pendular exercises to counteract gravity.

Once the three week stage is reached the fracture will have begun to heal and auto-assisted exercises can be started, where the patient helps the affected arm with the uninjured one. This is progressed to unassisted exercises, moving the arm up above the head, behind the back and behind the neck. As the six week point approaches, when the bone has effectively healed, the physiotherapist will start the patient doing more forceful exercises involving gentle stretches at the end of range to improve mobility. Mobilisation techniques to the shoulder joint and strengthening exercises using Theraband are progressed to increase muscle power and joint range.