Occupational Therapy for Nonoperative Four-Part Proximal Humerus Fracture: A Case Report

Participant

The client was a 67-yr-old male retired accountant; he sustained a mechanical fall resulting in a four-part proximal humerus fracture to his dominant upper extremity. Because of a complex cardiovascular history, he decided to manage this fracture nonoperatively with occupational therapy. At evaluation he required moderate assistance with dressing and bathing and minimum assistance with grooming; he was also unable to use the computer efficiently or cook, which were his preferred occupations. We completed research using a descriptive and exploratory case study design (Portney & Watkins, 2008).

Outcome Measures

The client’s joint ROM measurements were taken for the shoulder and elbow and were recorded actively and passively. The client’s shoulder manual muscle score was recorded for all motions. We completed muscle grading using a numeric 5-point scale. Formal evaluation was completed at evaluation, at 3 mo, at 5 mo, and at a 12-mo follow-up with ongoing reassessment throughout treatment as is customary with this population.

The QuickDASH (Disability of the Arm Shoulder and Hand; Sorensen, Howard, Tan, Ketchersid, & Calfee, 2016) was used to assess the client’s self-reported functional status. It is scored as a percentage, with a clinically significant change being at least 14%. The Numeric Rating Scale for Pain (NRS; Farrar, Young, LaMoreaux, Werth, & Poole, 2001) was used to assess the client’s pain. A reduction in pain intensity of 2 points on the NRS was considered clinically significant.

Procedure and Intervention

A literature review was completed with the assistance of a biomedical librarian to identify studies with reference to rehabilitation after four-part proximal humerus fractures. More than 300 articles were reviewed, and 4 articles met the criteria. These articles provided an immobilization period and time frame dependent protocol for four-part proximal humerus fractures (Boons et al., 2012; Fjalestad & Hole, 2014; Launonen et al., 2012; Zyto et al., 1997). Trends in the literature regarding all types of proximal humerus fractures suggest that decreased immobilization time and decreased time between fracture and the start of rehabilitation correlate with positive results (Fu, Xia, Li, & Wu, 2014; Mafi, Khan, Mafi, & Hindocha, 2014).

The rehabilitation protocols in these studies were analyzed and used in conjunction with this case study to create an occupation-based rehabilitation protocol based on biomechanical principles and preparatory methods (Table 2). Precautions listed are to prevent displacement of the fracture. Treatment was broken up into four distinct phases based on precautions and recovery. In addition to therapeutic exercises, recommended functional activities are listed. In Phase 1, the client started performing: eating, brushing teeth, washing face, and assistance with lower extremity dressing. He was instructed to use one-hand compensation techniques for any activity involving shoulder motion. The sling was used at all other times during Phase 1.

In Phase 2, the client progressed from passive to active ROM and started isometrics exercises. Isometrics allow strengthening without changing the joint angle or muscle length. The clinician should manually assist the glide of the scapula with functional reaching activities such as removing and storing dishes from the dishwasher; this activity can be recreated in the clinic with light cones. The recommended functional activities added in this phase are all dressing and bathing, with the exception of hand behind back motions. The client in this case study was encouraged to return to the kitchen in a light capacity with no heavy lifting. To address scapular and glenohumeral mobility with computer use, we instructed the client to decrease mouse sensitivity to increase the need to incorporate shoulder ROM with mouse use. In Phase 2, the sling was used only during community mobility, and one-hand compensation techniques were discontinued.

In Phase 3, the motion restrictions were lifted, and use of weights was limited to 2–5 lb. The clinician addressed ROM limitations with end-range stretching. Diagonal movement patterns were initiated and incorporated into functional activity such as dressing, cooking, and cleaning. The client was encouraged to return to all daily and leisure activities, within weight limitations. Bathing and behind back hygiene will often be problematic when initiating these movements. Light gravity-assisted, internal-rotation stretching using the clinician’s leg for leverage (Figure 1A) and a towel behind the back for an internal rotation stretch (Figure 1B) as part of the home exercise plan were used in this phase.

OPEN IN VIEWER

Figure 1.

Passive internal rotation stretches (A) with clinician standing behind client using lower extremity and gravity assistance and (B) using a towel for leverage.

In Phase 4, the client had no strengthening precautions. In preparation for returning to overhead item retrieval for cooking, this client performed a combination of bicep curls and shoulder presses with eccentric lowering to simulate kitchen activity. Eccentric exercises allow the muscles to lengthen while producing force that simulates everyday activity. He also performed item retrieval and storage in diagonal movement patterns with progressive weights. Clients will be discharged without full ROM or strength because achieving a full return is unexpected; therefore, education on expectations should begin early in the rehabilitation process. Home exercises at discharge should continue to address stretching, particularly internal rotation (hand behind back), strengthening, and functional and diagonal movement patterns based on the client’s goals and prior level of function.