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骨折康复系列讲座-肩一-肱骨近端骨折处理及康复
时间:2010/12/1 21:58:34
Proximal humeral fractures Treatment and Rehabilitation
 
Introduction
Fractures of the proximal humerus are not uncommon, especially in older age groups. They have been reported to account for 4% to 5% of all fractures
 
Definition:
Proximal humeral fractures:
The humeral head, atomic neck
Surgical neck of the humeral
 
Classification
The Neer’s classification system is currently the most widely used system. It is based upon accurate identification of each of four potential fracture fragments: the articular head, lesser tuberosity, greater tuberosity, and shaft
 
Mechanism of injury
Caused by a fall on an elbow or outstretched hand, especially in an elderly patient, or by trauma to the lateral aspects of the shoulder. Seizures can occasionally result in fracture/dislocation of the shoulder
 
Treatment Goals
Orthopaedic objectives
Alignment:
Maintain a normal relationship between the humeral head and the glenoid
Reduce the greater and lesser tuberosities to maintain rotator cuff function
Obtain a neck shaft angle of 130 to 150 degrees and a retroversion angle of 30 degrees
Stability
External immobilization: for nondisplaced stable fractures
Internal fixation: displaced two-part or three-part fractures
Endoprosthesis: four-part fractures
 
Range of Motion:
Restore the full range of motion of the shoulder in all planes
Frequently, there may be residual loss of range of motion secondary to the fractures
Muscle Strength:
Improve the strength of the following muscles and attempt to regain full strength against maximum resistance
Functional Goals:
Improve and restore the function of the shoulder in self-care, dressing and grooming           In addition, shoulder movement and strength are vital in almost all sports activities
 
Expected Time of Bone Healing
Six to 8 weeks
Expected Duration of Rehabilitation
Twelve weeks to 1 year
 
Sling
Biomechanics: Stress-sharing device
Mode of bone healing: secondary.
Indications: nondisplaced, impacted or minimally displaced for 2-3 weeks
 
Open reduction and internal fixation
Biomechanics: Stress shielding with plate fixation
Mode of bone healing: primary when rigid fixation secondary when rigid fixation not
Indications: two-part, three-part or those that may also require repair of the rotator cuff
 
Closed reduction and percutaneous
Fixation/Cannulated screw Tension Banding
Biomechanics: Stress-sharing device
Mode of bone healing: secondary, with callus formation
Indications: for two-part with no significant rotator cuff tears for displaced surgical neck fracture
 
Prosthetic Arthroplasty
Biomechanics: Stress-sharing device
Mode of bone healing: Tuberosities secondary
Indications: with significant risk of avascular necrosis
 
Closed reduction and immobilization?
Biomechanics: Stress-sharing device
Mode of bone healing: secondary
Indications: used if satisfactory reduction is achieved
 
External fixator
Biomechanics: Stress-sharing device
Mode of bone healing: secondary, with callus formation
Indications: Used for open and severely comminuted fractures
 
Methods of Treatment
 
Special considerations of the fracture
Age
Articular involvement
Avascular necrosis
Malunion/nonunion
 
Associated injury
Rotator cuff tears
Neurovascular injuries
Four-part fractures
Posterior dislocation
 
Weight bearing
The involved extremity should be non-weight bearing
Avoid supporting the body’s weight until clinically and radiographically united
Gait
Arm swing is initially absent and may be reduced on a long-term basis
 
Treatment: early (day of injury to one week)
Stability at fracture site: none
Stage of bone healing: Inflammatory phase, the fracture hematoma is colonized by inflammatory cells, and debridement of the fracture begins
X-ray: No callus, the fractures line is visible
 
Orthopedic and Rehabilitation
Considerations
Physical examination
Dangers
Radiography
Weight bearing
Rom
Muscle strength
Functional activities
Methods of treatment: specific aspects
Sling
Open reduction and internal fixation
Closed reduction,
Percutaneous fixation and
Cannulated screws
Hemiarthroplasty
 
Prescription
Day one to one week
Precautions: Avoid shoulder motion
Rom: None at the shoulder and elbow, Gentle pendulum exercises with elimination of gravity are allowed for nondisplaced fractures and hemiarthroplasty
Muscle strength: No strengthening exercises to the elbow/shoulder
Functional Activities: with uninvolved extremity, needed assistance
Weight bearing: None on affected extremity
 
Treatment: two to four weeks
Stability at fracture site: none to minimal
Stage of bone healing: beginning of reparative phase: Osteoprogenitor cells differentiate into osteoblasts. Which lay down woven bone.
X-ray: No Callus: fracture line is still visible
Prescription
 
Two to four weeks
Precautions: Avoid internal/external rotation of the shoulder
Rom: Patients treated conservatively with a sling can continue with pendulum
         Active to gentle passive-assistive exercise to the shoulder
         Patients treated surgically should start passive-assistive ROM in supine position,
         No AROM to the shoulder
Muscle strength: isometric with sling only, No strengthening for surgical intervention
         Ball-squeezing
Functional activities: with uninvolved extremity, needed assistance
Weight bearing: None
 
Treatment: four to six weeks
Stability at fracture site: With bridging callus. the fracture is usually stable confirm with physical examination
Stage of bone healing: reparative phase. Further organization of the callus and formation of lamellar bone begins. Once callus is observed bridging the fracture site. the fracture is usually stable ,however, the strength of this callus especially with tensional load, is significantly lower than  that of normal bone further protection (if not further immobilization) is required to avoid refracture
X-ray: Bridging callus is visible .with increased rigidity of the fixation ,less bridging callus is noted ,and healing with endosteal callus predominates expect less callus in end-of –bone fractures than in midshaft fracturers 
Prescription
Four to six weeks
Precautions: Do not apply force in attempting to regain the full range of motion
Rom: Shoulder –limited range
         Flexion/abduction up 100 to 110 degrees
         Internal/external rotation-limited
         Pendulum exercise against gravity
         Elbow –full ROM in flexion, extension, supination, and pronation
         Surgically treated patients may continue with passive-assistive ROM exercises
Muscle strength: Shoulder-avoid exercises to the deltoid if it is incised during surgery Eblow-isometic and isotonic
Functional activities: used for dressing and grooming as tolerated need assistance in house cleaning and preparing meals
Weight bearing: None on affected extremity
 
Treatment: six to eight weeks
Stability at fracture site: with bridging callus, the fractures is usually stable; confirm with physical examination
Stage of bone healing: reparative phase. Further protection of bone avoiding refracture, the strength with torsional load is significantly lower than that of normal lamellar bone
X-ray: bridging callus is visible. With increased rigidity, less bridging callus Is noted ,and healing with endosteal callus predominates. The fracture line is less distinct   
Prescription
Six to eight weeks
Precautions: avoid forced ROM
Rom: AROM, gentle PROM and active-assistive ROM to the shoulder and elbow in all planes, to tolerance
Muscle strength: isometric to the shoulder, isometric and isotonic to the elbow, start PRE for patient with a sling
Functional activities: the involved extremity is for self-care and feeding some self-care activities used the uninvolved
Weight bearing: As tolerated
 
Treatment: eight to twelve weeks
Stability at fracture site: stable
Stage of bone healing: remodeling phase. Woven bone is replace with lamellar bone .the process of remodeling takes months to years for completion
X-ray: Abundant callus, fracture line begins to disappear .with time, there will be reconstitution of the modularly canal
Prescription
Eight to twelve weeks
Precautions: None
Rom: Active, active-assistive ROM to the shoulder, Abduction is encouraged
Muscle strength: resistive exercises to the shoulder with gradual increases in weights. isokinetic exercises using appropriate equipment to improve strength and endurance 
Functional activities: prescribed self-care and functional activities
Weight bearing: FWB
Long-term considerations
反射性交感神经营养不良综合症
Reflex sympathetic dystrophy may lead to a decrease ROM and strength and to severe pain. Loss of motion may be permanent, especially
Malunion can cause significant functional limitations
Nonunion is not uncommon
Interposition
Excessive soft-tissue dissection
Inadequate immobilization
Poor patient compliance
Overaggressive physical therapy
 

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Lore [2017-1-17]
 
Imserpsive brain power at work! Great answer!
 
Joan [2017-1-18]
 
Frankly I think that's abollutesy good stuff.
 
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