(Also known as Fractured Humerus, Humerus Fracture, Broken Arm)
What is a humeral fracture?
A humeral fracture is a condition characterized by a break in the upper arm bone (humerus) (figure 1).
The long bone of the upper arm is known as the humerus. The humerus joins with the shoulder blade to form the shoulder joint and the bones of the forearm (radius and ulna) to form the elbow (figure 1).
Following a fall onto the shoulder or outstretched arm, or, due to a direct impact to the upper arm, stress is placed on the humerus. If these forces are beyond what the humerus can withstand, a break in the bone may occur. When this occurs the condition is known as a humeral fracture and can vary from a small undisplaced fracture to a severe displaced (and/or comminuted) fracture with obvious deformity.
There are generally three different regions where humeral fractures may occur:
- Near the shoulder (fracture of the neck of the humerus, fracture of the greater tuberosity)
- The shaft of the humerus
- Near the elbow (supracondylar fracture, fractures of the condyles, fractures of the epicondyles)
Causes of a humeral fracture
A humeral fracture usually occurs following a fall onto an outstretched hand, the elbow, or the point of the shoulder (e.g. a fall from a height, in horse riding, or whilst cycling), occasionally they may occur due to a direct blow such as a motor vehicle accident or collision with another player during contact sports such as rugby or football (e.g. a 'hip & shoulder' bump).
Signs and symptoms of a humeral fracture
Patients with a humeral fracture typically experience a sudden onset of sharp, intense pain at the time of injury. Pain is usually located somewhere between the elbow and shoulder. Pain may increase when attempting to perform movements of the upper limb such as arm elevation, overhead activities, taking the arm across the chest or during pushing, pulling or lifting activities. Pain may also increase when lying on the affect side, applying pressure to the shoulder, or on firmly touching the humerus at the site of injury. An ache in the upper arm may also be present that is particularly prominent at night or first thing in the morning (especially during the first few days following injury).
Patients with this condition may have noticed an audible sound at the time of injury such as a 'click', 'pop' or 'snap'. There is usually localized tenderness and swelling at the site of injury, and, depending on the severity, a bony deformity may be evident. After a day or two following injury, extensive bruising may be evident in the upper arm, or sometimes down into the elbow and/or forearm.
Diagnosis of a humeral fracture
A thorough subjective and objective examination from a physiotherapist is important to assist with diagnosis of a humeral fracture. An X-ray is required to confirm diagnosis and should always be taken if a fracture is suspected.
Treatment for a humeral fracture
For those humeral fractures that are displaced, treatment typically involves anatomical reduction (i.e. re-alignment of the fracture by careful manipulation under anaesthetic) followed by surgical internal fixation to stabilize the fracture (using plates and screws). This may be followed by the use of a plaster cast and/or sling for a number of weeks.
For those fractures that are not displaced, treatment may involve the use of a sling, or, plaster cast immobilization and the use of a sling for a number of weeks. The orthopaedic specialist will advise the patient as to which management is most appropriate based on a number of factors, including the location, severity and type of humeral fracture.
Evaluation of the fracture with follow up X-rays is important to ensure the fracture is healing in an ideal position. Once healing is confirmed, rehabilitation can progress as guided by the treating physiotherapist and orthopaedic specialist.
One of the most important components of rehabilitation following a humeral fracture is that the patient rests sufficiently from any activity that increases their pain (a sling is often required). Activities which place large amounts of stress through the humerus should also be avoided, particularly lifting, pushing or pulling, lying on the affected side and arm elevation activities. Rest from aggravating activities allows the healing process to take place in the absence of further damage. Once the patient can perform these activities pain free, and the fracture has healed, a gradual return to these activities is indicated provided there is no increase in symptoms. This should take place over a period of weeks to months with direction from the treating physiotherapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause further damage and may slow healing or prevent healing of the humeral fracture altogether.
Manual "hands-on" therapy from the physiotherapist such as massage, trigger point release techniques, dry needling, joint mobilisation, stretches, and electrotherapy can assist with hastening healing and improving range of movement, pain and function. This can generally commence once the orthopaedic specialist and physiotherapist have indicated it is safe to do so.
Patients with a fractured humerus should perform pain free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. This is particularly important as soft tissue flexibility and strength are quickly lost with inactivity. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
In the final stages of rehabilitation for a humeral fracture, a gradual return to activity or sport can occur as guided by the treating physiotherapist provided there is no increase in symptoms.
Prognosis of a humeral fracture
Patients with a humeral fracture usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in a number of weeks to many months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. In patients with only very minor fractures that are un-displaced (such as an avulsion fracture) return to sport can sometimes occur in as little as 6 – 8 weeks as guided by the treating physiotherapist.
Physiotherapy for a humeral fracture
Physiotherapy treatment for patients with this condition is important to ensure an optimal outcome and allow a safe return to activity. Treatment may comprise:
- the use of a sling or figure-of-8 bandage
- electrotherapy (e.g. ultrasound)
- postural taping
- exercises to improve posture, flexibility and strength
- activity modification advice
- a graduated return to activity plan
- soft tissue massage
- joint mobilization (following completion of fracture healing)
Other intervention for a humeral fracture
Despite appropriate physiotherapy management, some patients with a humeral fracture do not improve adequately and may require other intervention. The treating physiotherapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, CT scan, MRI or bone scan, periods of plaster cast immobilization or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the fractured humerus. Occasionally, patients with fractures that are initially managed without surgical intervention may require surgery to stabilize the fracture and a bone graft to aid fracture healing.
Exercises for a humeral fracture
The following exercises are commonly prescribed to patients with a humeral fracture. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 3 times daily and only provided they do not cause or increase symptoms.
Shoulder Blade Squeezes
Begin sitting or standing tall with your back straight (figure 2). Squeeze your shoulder blades together as far as possible pain-free. Hold for 3 seconds and repeat 10 times provided there is no increase in symptoms.
Figure 2 – Shoulder Blade Squeezes
Begin this exercise by leaning forwards with your 'good' forearm supported on a table or bench (figure 3). Keeping your back straight and your shoulder relaxed, gently swing your affected arm forwards and backwards as far as possible pain-free. Repeat the exercise swinging your arm side to side as far as possible pain-free. Repeat 10 times in each direction provided there is no increase in symptoms.
Figure 3 – Pendular Exercises (right side)
Begin this exercise by leaning forwards with your 'good' forearm supported on a table or bench (figure 4). Keeping your back straight and your shoulder relaxed, gently swing your affected arm in circles clockwise as far as possible pain-free. Repeat the exercise swinging your arm counter clockwise. Repeat 10 times in each direction provided there is no increase in symptoms.
Figure 4 – Pendular Circles (right side)
Physiotherapy products for a humeral fracture
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a humeral fracture include:
- Shoulder Supports
- Ice Packs or Heat Packs
- Sports Tape (for protective taping)
- Posture Supports
- Resistance Band (for strengthening exercises)
- TENS Machines (for pain relief)
To purchase physiotherapy products for a humeral fracture click on one of the above links or visit the PhysioAdvisor Shop.
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