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00/0
THE JOURNAL
OF ORTHOPAED~C
AND SPORTSPHYSICAL
THERAPY
Copyright O 1980 by The Orthopaedic and Sports Medicine Sections of the
American Physical Therapy Association

Serial Assessment and Treatment of a


Humeral Fracture

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

GARY L. SMIDT,* LPT, PhD

Clinical problems at the glenohumeral joint,


whether chronic or induced by trauma, tend to
manifest joint hypomobility with accompanying.
muscle weakness. Fractures at the proximal humerus tend to occur more frequently in older
patients, but in the presence of violent trauma
this injury may occur in the younger patient as
well.' The initial treatment often includes some
form of immobilization followed by remobilization
and muscle strengthening. There is a clinical
need to document the sequence and form of
physical therapy treatment and quantitatively reflect changes in joint motion and strength.
A case study of a patient with a proximal
humeral fracture is presented to (a) dezcribe the
clinical findings and treatment associated with a
shoulder injury, ( b ) describe and illustrate some
methods of assessment and treatment, and (c)
report results for joint motion and muscle
strength.
The hope of the author is that this paper might
provide an example of physical therapy evaluation and treatment for such a case and demonstrate a model for expected results. Further, this
paper might be used as a teaching model for
therapists who are unexperienced with this type
of patient.

angulation (Fig. 4). The spica cast was removed


on the 38th day post injury, at which time whirlpool and active exercise was initiated. Mild passive movements and resistive exercise were initiated on Day 6 following cast removal. On Day
1 3 post cast removal, radiographs showed the
fracture solidly healed, and more vigorous passive mobilization of joint (Grade IV' sustained
stretch and contract-relax) was administered
from this time. The mobilization techniques used
are illustrated in Figs. 5 to 11. On Day 56 following spica cast removal, glenohumeral and elbow
joint motion and strength were restored to normal. A more detailed account of events associated with the clinical course appears in the "Appendix." The patient received daily physical
therapy treatment for the first 44 days following
cast removal.
Some general guidelines to the treatment approaches were used. Following cast removal,
treatment emphasis was on reduction of pain
and discomfort. Until motion was approximately
80% of normal, the primary emphasis was
placed on mobilization of the joint, while incorporating resistive exercise as tolerated. As joint
motion approached normal, higher priority was
given 'to resistive exercise. Therefore, the application of physical therapy was to solve problems
in this order: pain, joint hypomobility, and muscle
weakness.

ONSET AND CLINICAL COURSE


A young man 13 years of age was struck by
opposing players while attempting to pass a
football. Radiological examination demonstrated
a fracture of the left proximal humerus (Fig. 1).
A closed reduction was performed under general
anesthetic, and a shoulder spica was applied
(Fig. 2). The patient's right upper extremity was
his dominant or preferred side. The patient was
discharged from the hospital on Day 5. On Day
16, radiographs showed that the alignment of
the bony fragments was being maintained (Fig.
3). The fracture healed without incident, and the
final result demonstrated a mild residual medial

ASSESSMENT-JOINT

MOTION

All motion measurements were obtained in the


supine position, except shoulder extension
which was accomplished sitting. Joint angle
measurements at the extremes of both active
and passive movements were obtained for the
shoulders and elbows bilaterally. The methods
of measurement for the shoulder are depicted in
Figs. 12 to 16.
At the outset, motion was extremely limited in
all directions of glenohumeral motion and elbow
flexion. Extension of the elbow was normal.
Shoulder
and
tion, and elbow flexion showed the most rapid

* Director and Professor, Programs in Physical Therapy. The University of Iowa. Iowa City. IA 52242.

25

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

26

Fig. 2. Patient in shoulder spica.

SMlDT

Fig. 4. Radiograph-final

JOSPT Vol. 2, No. 1

--

Fig. 3. Rad~ographon day 16.

results.

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

JOSPT Summer 7980

TREATMENT OF A HUMERAL FRACTURE

Fig. 5. Joint mobilization-horizontal

adduction.

Fig. 6. Joint mobilization-abduction.

Fig. 7. Joint mobilization-external

Fig. 8. Joint mobilization-internal

Fig. 9. Joint mobilization-dorsal

rotation.

Fig. 10. Joint mobilization-caudal

27

rotation.

glide.

glide.

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

28

SMlDT

JOSPT Vol. 2. No. 1

Fig. 1 1 . Joint mobilization-flexion.

Fig. 14. Method of joint motion measurement-internal

rotation.

Fig. 1 2. Method of joint motion measurement-flexion.

Fig. 1 5 . Method of joint motion measurement-external

rotation.

Fig. 13. Method of joint motion measurement-abduction.

Fig. 16. Method of joint motion measurement-extension

JOSPT Summer 1980

TREATMENT OF A HUMERAL FRACTURE

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 17. Method of strength measurement-shoulder

flexion.

Fig. 20. Method of strength measurementshoulder horizontal abduction.

Fig. 1 8. Method of strength measurementshoulder horizontal adduction.

Fig. 21. Method of strength measurementshoulder external rotation.

Fig. 19. Method of strength measurementshoulder extension.

Fig. 22. Method of strength measurementshoulder internal rotation.

29

AlDT

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Fig. 23. Method of strength measurement-elbow

flexion

JOSPT Vol. 2, No. 1

the shoulder and to the medial epicondyle for


the elbow. Measurements from three maximal
efforts were averaged, and the mean measurement served as the experimental unit.
The results are shown in Charts 5 to 9. Measurements of strength on the uninvolved and
involved sides consistently demonstrated moderately larger values for shoulder extension over
flexion, internal rotation over external rotation,
and horizontal adduction over horizontal abduction. Strength for elbow flexion was slightly
greater than for extension. Strength on the involved side tended to increase gradually and
was comparable to that of the uninvolved side by
45 to 56 days post cast removal.
Bilateral circumferential measurements at arm
and forearm revealed a difference between uninvolved and involved upper limbs. At 56 days,
the involved upper limb was considerably smaller
(Chart 10). This result tends to refute the validity
of using circumferential or girth measurements
as an index of muscle strength. For this patient
the strength at 56 days was normal, even though
a deficit in girth size for the involved side remained.

COMPARISON OF SHORT- AND LONG-TERM


MEASUREMENTS

Fig. 24. Method of strength rneasurernentelbow extension.

return to normal (Charts 1 to 4). Shoulder abduction, internal rotation, and external rotation
began to approach near-normal status at about
22 to 25 days post cast removal. Motion at the
injury shoulder was equivalent to the contralatera1 side on the 28th day for shoulder extension,
the 8th day for shoulder adduction, and the 56th
day for the remainder of the measurements.

Measurements for joint motion and muscle


strength were obtained from the patient 1 year
post injury to determine whether his status was
maintained. Joint motion of the injured shoulder
and elbow were retained at the same level as the
contralateral side (Table 1). Muscle strength increased dramatically between the 3rd and 12th
months, indicating that the patient was diligent
with his resistive exercise program and that the
intensity of his overall activity increased. Maturation may have contributed as well.

SUMMARY
ASSESSMENT-MUSCLE

STRENGTH

Measurements of strength were obtained with


the patient supine and the upper extremity oriented in the positions shown in Figs. 17 to 24.
Measurements of isometric strength were acquired from a manual dynomometer consistently
placed at locations on the distal arm (shoulder
measures) and forearm (elbow measures). Moment arms were measured from the point of
force application to the tip of the acromium for

A case study of a patient with a proximal


fracture of the humerus was used to demonstrate
an evaluation and treatment program. The methods and objective results were illustrated. The
patient's joint motion and muscle strength were
restored not later than 56 days after the spica
cast was removed and normal functional activities were resumed. At 12 months post injury, the
patient's joint motion was maintained and his
muscle strength continued to increase.

JOSPT Summer 7980

31

TREATMENT OF A HUMERAL FRACTURE


t w

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The author wishes to thank Dr. Webster Gelman for his role as an
orthopaedic surgeon in this case and for his cooperation and encouragement in support of this paper.

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REFERENCES
1. Maitland GD: Peripheral Manipulation. Ed 2. Boston: Butterworths, 1977
2. Neer CS, Welsh UP: The shoulder in sports. Orthop Clin North
Am 8:583-591. 1977

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APPENDIX

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Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Details of Clinical Course


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Day 1
4:00 PM: Patient struck by opposing players while attempting to
pass football.
5:00 PM: Patient waiting in hospital emergency room. Patient
examined and x-rays taken.
6:00 PM: Orthopaedist called in.
7:OO-8:00 PM: Closed reduction in operating room. Patient under
general anesthesia.
Diagnosis: Fracture of upper humeral shaft.
Operation: 1 ) Closed reduction. 2 ) Application of shoulder spica.
Procedure: By means of traction, abduction, external rotation, and
flexion, the arm was manipulated. X-rays showed almost anatomical
restoration of the bone. A shoulder spica cast was applied. The arm
was retained in the above-mentioned position.
8:30-10:OO PM: In recovery room.
10:OO PM: Taken to hospital room.

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The initial roentgenographic exam showed fracture deformity of


the proximal shaft of the humerus with foreshortening, anterior rotation, and anterior displacement of the major fragment. The humeral
head was not dislocated. Following the closed reduction, the X-ray
examination showed marked improvement in position and alignment
of fragments. There appeared to be no foreshortening. There was
some slight medial angulation of the distal fragment.

ln P-

Day 2

Day 5
Discharge from hospital. Adaptations for home care arranged.
Some walking each day. Appetite poor. X-rays showed alignment of
bony fragments was being retained. Progress examination of the
humerus taken in AP and axillary position shows no further change in
the position and alignment of the fragments compared to the post
casting film taken on October 5. 1976.
Day 1 6
X-rays show fracture to be maintaining good position. Patient has
no complaints of discomfort.
Day 38
M.D. report: Patient's shoulder spica case was removed, and after
45 minutes the patient was able to lower the arm to near normal
position. Father of patient will supervise and administer physical
therapy.
Physical therapy report: Physical therapy rendered on a daily
basis at University Hospitals. Diffuse tenderness at proximal arm
area. Pain on attempted voluntary movements. Atrophy, weakness.
deficit in glenohumeral and humeroulnar movement. Whirlpool. Codman's exercise (4 directions)-10 repetitions every 30 minutes.

JOSPT Vol. 2, No. 1


Post Cast Removal

Day 14

Day 2

Whirlpool discontinued. Moist heat initiated at scapulohumeral


complex. Contract-relax approach to passive stretch initiated for
angular movements. Caudal traction and dorsal glide continue. Left
hand behind back, passive stretch by patient using towel. Right thumb
to 9th thoracic vertebrae, left to left buttock. Bench press 20 pounds,
40 repetitions. Pushing punching bag 50 times. Straight arm shoulder
flexion and abduction (upright position) using 2 pounds.

Whirlpool, Codman's exercise, begin manual isometric exercise


and active elbow movement. Pain at shoulder during movement.
Day 3
Whirlpool. Codman's exercise, mild manual resistance to concentric contraction through 10-1 5' at 90" flexion. Resistive exercise (1
pound weight for elbow flexion).

Day 15
Same as Day 10. Exceptions: Bench press 22.5 pounds. 30 times;
bilateral elbow flexion 10 pounds, 30 times. 7.5 pounds bilateral
overhead flexion while supine. Shot basketball with two hands for first
time. Left thumb to sacrum today.

Day 4
Same as Day 3
Day 5

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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Day 16
Same as Day 3 plus active flexion, flexion and horizontal adduction
x 10. Passive movement in all directions of angular movement plus
caudal traction and dorsal glide. Training in upright sitting and standing posture. Gait training with emphasis on reciprocal armswing. Pain
diminishing some.

Moist heat stopped. 200 times pushing punching bag. Now facing
realities to simultaneously catching up with academic work at school,
attending services and youth group at church, and physical therapy
treatment program.

Day 6

Day 17

Same as Day 5. 2 pound weigh-elbow

flexion.

Day 7
Same as Day 6.

Day of rest.
Day 18
Same as Day 1 6

Day 8

Days 19 to 32

Same as Day 6. Codman's exercise with 2 and 5 pound weights.


Bilateral overhead wand exercise initiated. Soreness to palpation
continues at all areas of upper arm and scapula. Exquisite tenderness
at posterior glenohumeral joint. Patient is able to walk with appropriate
reciprocal shoulder movements. All movementscontinue to be slightly
guarded. Able to actively elevate arm above horizontal while upright.
Bilateral overhead wand with 5 pound weight.

Generalized soreness at proximal humerus has now subsided.


Some tenderness at anterior aspect of proximal humerus continues.
Began basketball practice in low-key fashion on Day 19. Rx same as
Day 18. Bench press 30 pounds, 30 times. Push punching bag 100
times. Left thumb behind back to T9. Straight arm shoulder flexion
and abduction with 2 pounds X 30.

Day 9
Day of rest. Whirlpool only. No exercise.
Day 10
Rx same as Day 8. Began passive dorsal glide. Elbow flexion in
upright position with 2 pound weight. Active external rotation encouraged at home. Returns to school. Rode bicycle for first time post
injury. Chief problems are decreased glenohumeral motion in direction of abduction and internal rotation, soreness on palpation, and
lack of strength in flexion.
Day 11
Same as Day 10.

Days 33 to 44
Joint motion near normal. Soreness to palpation at anterior humerus now minimal. Practicing basketball. 2.5 pounds bilateral shoulder flexion in upright position. Bench press 40 pounds. 30 times.
Bilateral elbow flexion in upright position, 30 times. Overhead shoulder flexion with 12.5 pounds, supine position. Begins squeezing small
rubber ball. Pushing punching bag 150 times per day. Continue
manual passive movements.
Days 45 to 55
During this period, physical therapy treatment takes place 2 of
every 3 days. Push punching bag 175 times; elbow flexion 20 pounds
x 30; overhead shoulder flexion (supine 10 pounds X 30), bench
press 55 pounds x 30; double straight arm shoulder flexion 10
pounds x 30; manual passive movements every third day. Some
discomfort on passive movement at extremes of motion. Use of left
hand in basketball for dribbling and shooting.

Day 12

Day 56

Progress is satisfactory. Codman's exercise discontinued. Other


Rx same as Day 10. Soreness on palpation at entire proximal arm.
Tenderness at posterior joint diminished. Obvious weakness in shoulder flexion.

Patient returns to playing competitive basketball. Patient will continue the following resistive exercises: 12.5 pounds X 30 shoulder
flexion overhead (supine); 12.5 pounds bilateral straight arm shoulder
flexion; 35, 65, 70 x 10 each on bench press; 30 pounds X 30
bilateral elbow flexion.
Two residuals are yet apparent:
1 ) Discomfort at proximal humerus on palpation with large amount of
force.
2) The size of the left upper limb is less than the right, particularly
the muscle mass about the proximal humerus.
Weight lifting advised for several months from this point.

Day 13
M.D. report: X-rays today reveal the fracture has healed solidly.
The patient has been utilizing physical therapy with excellent results.
He will continue mobilization exercises and return in three weeks.
Physical Therapy Report: Same as Day 10.

JOSPT Summer 1980

MOTION MEASUREMENTS - SHOULDER


INTERNAL AND EXTERNAL ROTATION

MOTION MEASUREMENTS - SHOULDER


FLEXION AND EXTENSION
120
Flexion - Uninvolved Side

,eO

33

TREATMENT OF A HUMERAL FRACTURE

--------

External Rotatlon
- Unlnvolved
Slde
- -

,*--**-"""-+-"--"-/
-- 140-,

--04--4----

---- Passive Movement

-Active Movement

60

40

20

-p

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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

0'6-'

Extension - Uninvolved Side

40

----.
Pass~veMovement
Act~veMovement

;'

'

'3; '=&

1
; ' 1 ' 6 ' ;0'2k1;8
Days Post Cast Removal

%%0 0 2

Chart 1 . Motion measurements-shoulder flexion and extension. Zero position: arm lateral and adjacent to trunk.
Flexion measurements taken supine. Extension measurements taken sitting.

Days Post Cast Removal

Chart 2. Motion measurements-shoulder internal and external rotation. Zero position: arm abducted, forearm vertical.
Measurements taken supine.

MOTION MEASUREMENTS - SHOULDER


ABDUCTION AND ADDUCTION

80
60

MOTION MEASUREMENTS -ELBOW FLEXION

---.Passlve Movement

--- Passive Movement

-Active Movement

- Act~veMovement
40

40

'6

'

1 1 ~ ' l k 1 ~ ~ 1 ~ 4 1 ~ 8 ' ; 2 " ~ %


Days Post Cast Removal

Days Post Cast Removal

Chart 3. Motion measurements-shoulder abduction and


adduction. Zero position: arm lateral and adjacent to trunk.
Measurements taken supine.

Chart 4. Motion measurements-elbow flexion. Zero position: straight line formed by arm and forearm. Measurements
taken supine.

ISOMETRIC STRENGTH - SHOULDER


FLEXION AND EXTENSION
508

20

457

18

406

16

Extens~on- Un!nvolved Slde

Flexton -

Unlnvolved Slde

0 ~ ' ~ ' ~ ' l > ' l k ' ~ 0 ' ~ 4 ' ~ 8 ' ~ 2 " ~ %

Days Post Cast Removal

Chart 5. Isometric strength-shoulder


flexion and extension. Measurements taken supine. Arm flexed 903 KgCm,
moment in kilograms centimeter. KgF, kilograms of force.

34

305

1n1

12 Internal Rotat~on- Uninvolved Slde

%,

ISOMETRIC STRENGTH - SHOULDER


HORIZONTAL ABDUCTION, ADDUCTION

ISOMETRIC STRENGTH - SHOULDER


INTERNAL. EXTERNAL ROTATION

::I

406
356

JOSPT Vol. 2, No. 1

SMlDT

External
Rotatlon
-Uninvolved S~de
---.
-

____-~

-- -

406

16-

356

14-

305

12

152

Horfzontal Adductlon - Unlnvolved Slde

6-

-Horizontal Adductlon

,___--4-

Internal Rotatlon
External Rotatlon

--.
Horizontal

Abduction

eod

%
' ?%

1;'16'2b12b1;8'&'

'

Journal of Orthopaedic & Sports Physical Therapy


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Copyright 1980 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Chart 6. Isometric strength-shoulder internal and external


rotation. KgCm, moment in kilograms/centimeter. KgF, kilograms of force.

203

"1

'

'

'

'

'

"

Abduction - Uninvolve_dSide_-

Chart 7. Isometric strength-shoulder horizontal abduction


and adduction. KgCm, moment in kilograrns/centimeter.
KgF, kilograms of force.

ISOMETRIC STRENGTH - ELBOW


FLEXION. EXTENSION

ISOMETRIC STRENGTH - SHOULDER


ABDUCTION

"'

Days Post Cast Removal

Days Post Cast Removal

406

16r

356

14 Flex~on- UnlnvolvedSide
Extension
Uninvolved
bde- - - - - - - - - - - - - --- - -S
- m .- - - - - - - - - . 12

305

Flexlon
Extension

'0

12 16 20 24 28 32
Days Post Cast Removal

Days Post Cast Removal

Chart 8. Isometric strength-shoulder abduction. Measurement taken supine, arm abducted 45'. KgCm, moment in
kilograms/centimeter. KgF, kilograms of force.

Chart 9. Isometric strength-elbow flexion and extension.


Measurements taken supine, forearm flexed 80'. KgCm,
moment in kilograms/centimeter. KgF, kilograms of force.

CIRCUMFERENTIAL MEASUREMENTS

25

6Uninvolved Arm

-Arm
---.
Forearm

';I ' A '

'1;'16'2b'2b12'8'&"~%
Days Post Cast Removal

Chart 10. Circumferential measurements. Arm measurements taken 12.7 centimeters from acromium. Forearm measurements taken 7.6 centimeters from medial epicondyle.