Fractured proximal humerus, post op following open reduction internal fixation

You have just undergone fixation of your proximal humerus (shoulder bone) fracture with Kemble Wang. This was fixed with a combination of screws, plate, and often anchors and sutures to hold tendons down. 

In terms of fractures and broken bones, this is a pretty major injury and major surgery. There will be one main incision down the front of your shoulder. The following is an example of a proximal humerus fracture. 

Postoperatively your arm will be in a sling. You can start coming out of the sling under supervision of  the physiotherapist and for prescribed exercises. However, you should remain in the sling most of the time during the first 4 weeks. 

Wound and dressing: Your wound will have been closed with absorbable sutures. There will also be dermabond (skin glue) giving additional support. The wound would be covered with a waterproof dressing. You can shower with this wound dressing but do not let it overly soak. 

It is normal to have some tingling or numbness or weakness following your procedure. This is often due to a nerve block performed preoperatively to help with your pain, or due to local anaesthetic injected into the wound. This will wear off in the first day or two.

The following is your physiotherapy prescription:

General Information / Goals:

 

  • You need time to allow for healing. After 4 weeks postop the bone and tendon repair is at 40% of a normal shoulder which is sufficient to allow you to do assisted and active motion. This is the “active range of motion” period. We want you to normalize your motion and activities of daily living during this period.

  • After 8 weeks the bone and tendon will be about 60% as strong as a normal shoulder bone

  • After 12 weeks the bone and tendon is 80% as strong as a normal shoulder bone

Weeks 0-2:

  • Pendulars, elbow ROM, 

Weeks 2-4:

  • Passive elevation to 90, passive ER to 0 deg, scapular strengthening

  • Aquatic therapy ok after 2 weeks following wound check 

  • Passive horizontal flexion or IR for posterior capsule

  • Isometrics – arm by side

  • Scapular strengthening: arm does not have to be supported all the time.

    • side-lying supported scapular activation exercises - retraction, protraction, elevation, depression 

    • prone-lying with arms by side, progressively increasing abduction from 0 - 45 - 90 deg. ok

    • Followed by:

    • inferior glide: lower trap isometric exercise. Seated with arm resting in abduction at shoulder height or elbow bent depending on current comfortable elbow range. Draw shoulder blade down to back pocket and hold. (High EMG in serratus anterior and lower trap) ok

    • low row: Isometric shoulder extension in standing, arm by side, while retracting and depressing scapula.  Serratus ant and lower trap while bringing scapula into external rotation and post tilt

    • upper traps activation: Shrugs in standing with single red theraband around shoulder for scapular elevation activation – very light resistance, arm by side – 3 x 20 reps

 

Weeks 4-6: start active assisted ROM (elevate to 90, ER to 0)

  • Start weaning out of sling at week 4 

  • Scapular strengthening

  • Upper traps endurance:

    • Shrugs with isometric holds, 2 x 20 x 5 sec holds,

    • Begin with arm by side, progress to 30 deg abduction by week 6

  • Lawnmower: hip and trunk extension, trunk rotation, scapular retraction, upper and lower traps and serratus anterior. ‘Place elbow into back pocket’.

  • Robbery: upper and lower traps and serratus anterior. Begin in 40 – 50 deg forward flexion with palms facing thighs and elbows straight. Stand up and keep arms close to the body while moving into trunk and arm extension in a palms forward position, facing up and away from body. Hold a strong contraction for 5 sec while pinch both scapulae towards back pocket. 

  • Supine stick assisted flexion to 90 deg, rolled towel supporting under upper arm

Weeks 6-10: Start full active ROM aiming at regaining all range

  • AAROM ER @ 0 deg:

    • Increase ER range in 0 deg abduction.

    • Supine stick-assisted external rotation, arm by side

  • AAROM ER @ 30, 45, 60 and 90 deg:

  • ER in progressively greater abduction: Progress the above ER to greater Abduction: No limitation on ER range

  • Scapular stability:

    • Diamond press – lower and middle traps: supine with elbows and thumb forefinger in a diamond shape. Activate core, retract scapula, elevate elbows then palms.

    • Begin with reps, adding palms as tolerated.

    • Progress to pulses,

    • Supine overhead punches

 

Weeks 10+

  • Full strengthening, no restrictions

  • Diamond press - add weights after week 10

  • Overhead theraband pulls:

    • Elbows extended overhead,

    • Can begin with light resistance and sliding hands up wall. Pull hands apart and move slightly off the wall and hold for 2. Rest back against the wall and slide down again.

    • Begin with 20 reps, then increase hold for 5 sec x 20 reps,

    • Then moderate to heavy rubber between hands, 3 x 6, alternate days.

  • Upper traps strength:

    • Shrugs with scapular band:

    • Add 2 – 5 kg dumbbells, 3 x 8 - 12

  • Closed Kinetic chain exercises – ball on table, (compass, CW/CCW) ball against wall

  • Wall push up plus, progress to table, then on knees on floor, then on toes.

  • Can progress to hands ‘walking’ forward and back onto a low box, then sideways up and down off a box

  • Rotator cuff strength:

    • ER @ 0 deg in side lying: body weight progressing to dumbbells: ½ kg, 1 kg, 2 kg

    • Theraband resisted rows @ 0 deg abduction, progressing to 30, 45 60 and 90 deg abduction

    • Progressing to bent over rows in similar ranges

    • Supine punches with dumbbells – progress to circles CW/CCW

post op rehabilitation protocol developed in collaboration with Daniel Abrams, physiotherapist

©2020 Kemble Wang Orthopaedics

 

Disclaimer: All information provided on this webpage should be considered as general guidelines. Actual practice and (expected) outcomes may differ in your case. The contents has been created online for information purposes only. It is not intended to be a substitute for professional medical advice.