Fractures.pptx

FRACTURES & SOFT TISSUE
INJURIES OF UPPER LIMB
DHEERAJ LAMBA (PHD)
HEAD & ASSOCIATE PROFESSOR
DEPARTMENT OF PHYSIOTHERAPY, JIMMA UNIVERSITY, JIMMA

FRACTURE CLAVICLE
INCIDENCE: THIS IS COMMON IN INFANTS
AND YOUNG CHILDREN. THIS IS ALSO ONE
OF THE COMMON BIRTH FRACTURES.
MOI: IT IS CAUSED BY A FALL ON THE
OUTSTRETCHED (FOOSH) HAND OR ON
THE POINT OF THE SHOULDER. IT MAY
OCCUR DURING EXTRACTION OF THE
HAND IN BREECH DELIVERY.
CLINICAL FEATURES: THE COMMON
SITE IS THE JUNCTION OF THE OUTER AND
MIDDLE THIRD OF THE BONE.

Treatment:
Infants and children: In children below 3 years, simple
strapping across the clavicle from the front backwards and a
cuff and collar
will be quite sufficient. The fracture unites in two or three weeks.
Older children and adults: There are numerous methods
described, but the simplest is the best. The principle is to lift the
outer fragment upwards and maintain its alignment with the
inner fragment by a firm figure of 8 bandage with paddings in
the axilla. The arm is supported in a sling. The fracture unites in
about 4 weeks.

Complications: Gross displacement can occasionally
endanger the brachial plexus and vessels and may need
surgical intervention and internal fixation. Stiff shoulder is
the commonest complication in older adults and is overcome
by early mobilisation by active exercises.

PHYSIOTHERAPY
OVERALL GOALS OF THE SURGICAL PROCEDURE AND
REHABILITATION ARE TO:
• CONTROL PAIN AND INFLAMMATION
• REGAIN NORMAL UPPER EXTREMITY STRENGTH AND ENDURANCE
• REGAIN NORMAL SHOULDER RANGE OF MOTION
• ACHIEVE THE LEVEL OF FUNCTION BASED ON THE ORTHOPEDIC
AND PATIENT GOALS
THE PHYSICAL THERAPY SHOULD BE INITIATED WITHIN THE FIRST
WEEK AND ONE HALF TO TWO FULL WEEKS POST-OP.

Goals:
Maintain elbow and wrist ROM, prevent shoulder stiffness, control pain and
swelling. Protect the repair.
Week 1
Sling.
May remove sling to do Pendulum exercises. No active shoulder motion.
Elbow and wrist ROM exercises, but no resisted exercises.
Goals:
Initiate shoulder ROM. Prevent pain. Protect the repair.
Weeks 2-3
Continue sling
Sling may be removed for exercises. May begin active-assisted motion. Continue
pendulum exercises. Rope/pulley exercises.
No lifting anything heavier than a glass in operative hand.
Weeks 4-5
May begin to wean from sling. If X-rays show no change in hardware, may begin
full active and passive motion.
No lifting anything heavier than a pencil.

GOALS OF PHASE:
• Full ROM
• Maximize upper extremity strength and endurance
• Maximize neuromuscular control
• Initiate sports specific training/functional training
Weeks 6- 8
If radiographs are showing signs of union, may begin to slowly incorporate resistance and
strengthening exercises. May now use arm to lift nothing heavier than a carton of milk.
Weeks 8-12
Once radiographs show union and 2 weeks of resistance exercises have been performed,
then may work on aggressive shoulder rehab to return to sports. Once painless shoulder
function has been achieved and strength has returned, and an athlete has completed the
return to play rehab, then an athlete may return to play.
STRENGTH
Progress strengthening program with increase in resistance and high speed repetition
Progress with eccentric strengthening of posterior cuff and scapular musculature
Progress rhythmic stabilization activities to include standing PNF patterns with tubing
for strength and endurance
Initiate military press, bench press, and lateral pull-downs
Initiate sport specific drills and functional activities
Initiate interval throwing program
Initiate light plyometric program

DISLOCATION OF THE
ACROMIO-CLAVICULAR JOINT:
THE ACROMIO-CLAVICULAR JOINT SUSTAINS SUBLUXATION OR
DISLOCATION DUE TO A FALL ON THE OUTER ASPECT OF THE
SHOULDER. PARTIAL RUPTURE OF THE CORACO-CLAVICULAR
LIGAMENTS RESULTS IN SUBLUXATION AND COMPLETE RUPTURE
RESULTS IN DISLOCATION .
CLINICALLY, THE PATIENT PRESENTS WITH ACUTE PAIN ON THE
TOP OF THE SHOULDER. THERE IS AN ELEVATION OF THE OUTER
END OF CLAVICLE AND TENDERNESS AT THAT SITE.
RADIOLOGY REVEALS THE DEGREE OF DISPLACEMENT AT THE
JOINT.

Mild and moderate
displacements are treated by
strapping. This goes around the
outer 1/3 of clavicle above and
the point of the elbow below with
the elbow kept at 90 degree
flexion. In cases of gross
displacements, open reduction
may be required. Repair of the
ruptured coraco clavicular
ligaments and internal fixation
with a vertical screw or
intramedullary pin gives good
results functionally and
cosmetically.

Acute Stage:
Type I Injury
Days 1-7
Ice
NSAID’s
Shoulder sling for 5-7 days– rest as needed
AROM fingers, wrist and elbow
Begin Pendulum Exercises – day 2 or 3
Shoulder isometrics trapezius and deltoid muscles
Days 7-10
Expect symptoms to subside
Discontinue sling
AROM and strengthening as symptoms allow
Type II Injury
Day 1
Ice for 24-48 hours
NSAID’s
Sling for comfort 1-2 weeks
Day 7 :Gentle ROM of shoulder
Allow use of arm for ADL
Discontinue sling at 7-14 days
Type III Injury – Non-operative
Ice for 24 hours
Sling – discontinue as symptoms
subside (1-4 weeks)
Leukotape - may increase
comfort and facilitate weaning
from sling and allow progression
of ROM and strengthening
exercises.
Begin ADL with arm at 3-4 days
Slowly progress functional
ROM, gentle PROM at 7 days
Type IV, V and VI injuries are
diagnosed by radiographs and
will need surgical consult.
Return to athletics and play
depends on healing and
restoration of near normal
strength and ROM.

After Acute Stage:
Type I and Type II injuries can progress to ROM and strength training as symptoms
permit. Type I can return to sport when nearly normal ROM and strength. No heavy
lifting, stresses, or contact sports until full painless ROM, and no point tenderness over
AC joint (usually by 2-3 weeks)
Type II injuries should avoid heavy lifting, pushing, pulling or contact sports for at least 6
weeks.
Type III injuries typically have full ROM at 2-3 weeks with gentle ROM exercises and return
to activity in 6-12 weeks with protection of AC joint.
Continue patient education
PROM, AAROM, AROM progression
Posture training
Strengthening of trapezius, deltoid, rotator cuff and scapular musculature
– may include isometrics, exercise bands, active progressing to resistive
forward flexion, side-lying external rotation, seated press-ups, push-ups plus Weight bearing
scapular stabilization using physio ball. Joint mobilization if glenohumeral joint limitations;
contraindicated at AC joint if hypermobility.
Modalities as needed– ice, electrical stimulation
Frequency & Duration
1-2 times per week for 2-4 weeks if Type I or II
1-2 times per week for 4-12 weeks if Type III, non-operative

FRACTURE SCAPULA
THIS IS NOT VERY COMMON. IT IS MOSTLY DUE TO DIRECT INJURY FROM
THE BACK.
THE FRACTURE SCAPULA MAY BE
A)FRACTURE NECK OF SCAPULA (25%)
B) FRACTURE BODY OF SCAPULA (50-60%)
C) FRACTURE ACROMION,
D) FRACTURE CORACOID.
DISPLACEMENT IS MINIMAL AS THE BONE IS WELL PADDED BY MUSCLES.
A CUFF AND COLLAR IS GIVEN FOR 2-3 WEEKS TILL THE SOFT TISSUE
INJURIES HEAL. ACTIVE MOVEMENTS ARE THEN ENCOURAGED TO OBTAIN
GOOD A FUNCTIONAL RECOVERY.

DISLOCATION OF THE SHOULDER
JOINT
CLASSIFICATIONS:
THE FOLLOWING CLINICAL TYPES SHOULD BE
RECOGNIZED.
1. ACUTE DISLOCATION.
A) ANTERIOR DISLOCATION -- COMMONEST TYPE.
B) POSTERIOR DISLOCATION -- THIS IS RARE.
C) INFERIOR DISLOCATION-- LUXATIO ERECTA.
2. OLD UNREDUCED DISLOCATION.
3. RECURRENT DISLOCATION.

DISLOCATIONS
ANTERIOR
DISLOCATION
POSTERIOR
DISLOCATION
INFERIOR
DISLOCATION

ANTERIOR DISLOCATION
MECHANISM OF INJURY:
THE SHOULDER IS ONE OF THE JOINTS WHICH EASILY GETS
DISLOCATED BY TRAUMA. A FALL ON THE OUTSTRETCHED
HAND WITH THE ARM IN THE ABDUCTED AND EXTERNALLY
ROTATED POSITIONS CAUSES THE HEAD OF THE HUMERUS
TO SLIP ANTERIORLY.
Clinical features:
a. The absence of the head in its normal position leaving the
glenoid vacant.
b. The presence of the head in an abnormal position.
c. Positive (Dugas sign)

FIRST TIME DISLOCATORS:
MAY BE IMMOBILIZED FOR 4-6 WEEKS BEFORE
STARTING PHYSICAL THERAPY.
RECURRENT DISLOCATORS:
PHYSICAL THERAPY CAN BEGIN IMMEDIATELY
• PHASE I: 0-4 WEEKS
• GOALS:
• REST
• ESTABLISH FULL MOTION
• RETARD MUSCULAR ATROPHY
• DECREASE PAIN AND
INFLAMMATION
• ALLOW CAPSULAR HEALING
AAROM with wand to tolerance
Begin IR/ER at side, progress to 30degrees, 60 degrees then
90 degrees AB as pain subsides
Submax isometrics for all shoulder musculature
Gentle joint mobs & PROM
Modalities (ice) to decrease inflammation and pain

CONT…
PHASE II: 4-8 WEEKS
• GOALS:
• INCREASE DYNAMIC
STABILITY
• INCREASE STRENGTH
• MAINTAIN FULL MOTION
Isotonic Strengthening
Rotator Cuff
Scapular Stabilizers
Deltoid, Biceps, Triceps
Rhythmic Stabilization
Basic
Intermediate
Advanced
Phase III: 8-12
Goals:
Increase neuromuscular control
(especially in apprehension
position)
Progress dynamic stability
Increase overall strength
Continue to progress previous isotonic exercises
Begin dynamic stabilization
Basic
Intermediate
Advanced
Introduce basic plyometrics
*In Athletes begin to work ER/IR in 90 degrees AB

CONT…..
• PHASE IV: RETURN TO ACTIVITY
• GOALS:
• PROGRESSIVELY INCREASE
ACTIVITIES TO PATIENT FOR
FULL FUNCTIONAL RETURN
Continue previous isotonic
strengthening program
Advance plyometrics
Instruct in maintenance program prior
to discharge

POSTERIOR DISLOCATION:
THIS IS A RARE TYPE WHICH OCCURS DURING ATTACKS OF FITS OR ELECTRO CONVULSIVE
THERAPY. HERE THE HEAD IS DISPLACED POSTERIORLY AND THE ARM IS IN INTERNAL
ROTATION. THIS IS OFTEN MISSED AND NEEDS A SUPERO-INFERIOR VIEW RADIOGRAPH
ALSO.
OLD UNREDUCED DISLOCATION:
THE PATIENTS OFTEN PRESENT WITH A DISLOCATION UNREDUCED FOR SOME WEEKS.
MANIPULATION UNDER ANESTHESIA CAN BE TRIED FOR DISLOCATION UP TO 4 OR 6
WEEKS OLD. IT BECOMES IMPOSSIBLE TO REDUCE, IF IT IS OF LONGER DURATION DUE
TO SOFT TISSUE CONTRACTURE.
RECURRENT DISLOCATION SHOULDER:
THIS IS A CONDITION CHARACTERIZED BY REPEATED DISLOCATION OF THE SHOULDER
JOINT IN A PERSON, FOLLOWING ONE EPISODE OF ACUTE DISLOCATION. SUBSEQUENT
DISLOCATIONS REQUIRE LESS AND LESS VIOLENCE.

FRACTURE HUMERUS & ITS TYPE :
• EPIDEMIOLOGY
• MOST COMMON FRACTURE OF THE HUMERUS
• HIGHER INCIDENCE IN THE ELDERLY, THOUGHT TO BE RELATED TO
OSTEOPOROSIS
• FEMALES 2:1 GREATER INCIDENCE THAN MALES
• MECHANISM OF INJURY
• MOST COMMONLY A FALL ONTO AN OUTSTRETCHED ARM FROM
STANDING HEIGHT
• YOUNGER PATIENT TYPICALLY PRESENT AFTER HIGH ENERGY TRAUMA
SUCH AS MVA
Proximal Humerus Fractures

PROXIMAL HUMERUS FRACTURES
• NEER
CLASSIFICATION
:
• FOUR PARTS
• GREATER AND
LESSER
TUBEROSITIES
• HUMERAL
SHAFT
• HUMERAL
HEAD
• A PART IS
DISPLACED IF
>1 CM
DISPLACEMENT

REHABILITATION PROTOCOL FOR PROXIMAL
HUMERUS FRACTURES
Time Frame:0-6 weeks Phase-1
Immobilization: Sling / Immobilizer / Brace with 15 degrees abduction
x 6 weeks. Wear continuously except for therapy and hygiene /
bathing.
Restrictions: Avoid A/AA/PROM and strengthening with exception of
small, slow shoulder pendulums as pain allows.
Exercises:
Gripping exercises, elbow, wrist and finger ROM. Shoulder pendulums
(slow, small circles).

Time Frame: 6-10 weeks Phase-2
Immobilization: None
Restrictions: Add AROM, AAROM and PROM at 6 weeks unless advised otherwise
by surgeon.
Stretching should be gradual and in slow increments while avoiding pain. Do not
push past end point. If patient develops pain, drop back to early phase of
rehabilitation until pain free.
No strengthening.
Exercises: Gradually increase ROM exercises in line with restrictions.
Continue with modalities used as needed.
Time Frame: 10-14 weeks Phase-3
Restrictions:
Exercise advancement should be gradual and in slow increments while avoiding
pain. If patient develops pain, drop back to early phase of rehabilitation, until pain
free.

Exercises:
Continue with shoulder PROM, AAROM and AROM (Goal is 75% or greater of
normal PROM by 12 weeks). At 10 weeks begin shoulder isometric
strengthening with arms at side (IR, ER, scapular stabilization). At 12 weeks
add shoulder resistance strengthening exercises. Progression should be
gradual and in slow increments while avoiding pain.
Time Frame: 14+ weeks
Restrictions:
No specific restrictions. Patients ROM, strength and endurance should be
advanced progressively while avoiding pain.
Exercises:
ROM should be returning to normal; if not, continue to address with stretching.
Progressive upper body strengthening may be more aggressive after 16
weeks. Add exercises simulating work requirements or sport at 18 weeks as
part of return to work/ sport program.
Consider work conditioning program based on patients job requirements and
patient motivation at 6 months.

Return to work:
Cognitive work: 1-2 weeks
Light manual (retail/ light personal service): 8 weeks
Manual labor: 12-14 weeks
Overhead lifting intensive manual work: 4-6 months

FRACTURE OF THE SHAFT OF THE
HUMERUS:

HUMERAL SHAFT FRACTURES
• DIRECT TRAUMA IS THE MOST COMMON ESPECIALLY MVA
• INDIRECT TRAUMA SUCH AS FALL ON AN OUTSTRETCHED HAND
• FRACTURE PATTERN DEPENDS ON STRESS APPLIED
• COMPRESSIVE- PROXIMAL OR DISTAL HUMERUS
• BENDING- TRANSVERSE FRACTURE OF THE SHAFT
• TORSIONAL- SPIRAL FRACTURE OF THE SHAFT
• TORSION AND BENDING- OBLIQUE FRACTURE USUALLY ASSOCIATED
WITH A BUTTERFLY FRAGMENT

• CLINICAL EVALUATION
• THOROUGH HISTORY AND PHYSICAL
• PATIENTS TYPICALLY PRESENT WITH
PAIN, SWELLING, AND DEFORMITY OF
THE UPPER ARM
• CAREFUL NV EXAM IMPORTANT AS THE
RADIAL NERVE IS IN CLOSE PROXIMITY
TO THE HUMERUS AND CAN BE
INJURED

Goal of treatment is to establish union with acceptable
alignment >90% of humeral shaft fractures heal with nonsurgical
management

REHABILITATION PROTOCOL
TIME FRAME: 0-4 WEEKS PHASE-1
• IMMOBILIZATION: SLING IMMOBILIZER / BRACE WITH 15 DEGREES
ABDUCTION X 4 WEEKS.
• WEAR CONTINUOUSLY EXCEPT FOR THERAPY AND HYGIENE /
BATHING.
• RESTRICTIONS: NO STRENGTHENING. AVOID AGGRESSIVE
STRETCHING AND ROTATIONAL STRESS. LIMIT ER TO NEUTRAL
AND IR TO CHEST.
• EXERCISES: GRIPPING EXERCISES, ELBOW, WRIST AND FINGER
ROM, SHOULDER PENDULUMS, PROM/AAROM/AROM FOR
SHOULDER SHOULD BE SLOW AND TO TOLERANCE.
• MODALITIES USED AS NEEDED.

Time Frame: 4-8weeks Phase-2
Restrictions: No strengthening until fracture healing. Avoid pain, stretch
to tolerable discomfort only.
Exercises: Gradually increases ROM exercises.
Stretching should continue to be slow and to tolerance while avoiding
pain.
Modalities used as needed.
Time Frame: 8-12weeks Phase-3
Restrictions: Exercise advancement should be gradual and in slow
increments
while avoiding pain. If patient develops pain, drop back to early phase of
rehabilitation, until pain free.
ROM restrictions: FF-none, ABD‐none, IR‐ 20°, ER 20°.
Exercises: Continue with shoulder PROM, AAROM and AROM. At
8weeks begin shoulder isometric strengthening with arms at side (IR,
ER, scapular stabilization). At 10weeks add shoulder resistance

Time Frame: 12-‐26 weeks Phase-4
Restrictions: No specific restrictions. Patients ROM, strength and endurance
should be advanced progressively while avoiding pain.
Exercises: ROM should be 85%normal or greater; if not, continue to address
with stretching Progressive upper-‐body strengthening may be more aggressive
after 16 weeks. Add plyometric training for athletes at 18 weeks.
Add exercises simulating work requirements at 18 weeks as part of return to
work program.
Time Frame: 26+weeks phase-5
Goal: Restore normal shoulder function and progress to return to sport or return
to work.
Restrictions: No specific restrictions. Advance progressively while avoiding
pain. If the patient develops pain they are to return to earlier stage of
rehabilitation.
Exercises: Aggressive upper‐body strengthening and with initiation of
plyometric training and sports or work specific training. Consider work

DISTAL HUMERUS FRACTURES
SUPRACONDYLAR FRACTURES, INTERCONDYLAR,
CONDYLAR AND EPICONDYLAR
SUPRACONDYLAR
FRACTURE
• MOST COMMON ELBOW FRACTURE IN
CHILDREN (60%)
• FRACTURE LINE EXTENDS
TRANSVERSELY OR OBLIQUELY
THROUGH DISTAL HUMERUS ABOVE
THE CONDYLES.
• DISTAL FRAGMENT USUALLY
DISPLACES
POSTERIORLY(EXTENSION TYPE)
COMMONEST TYPE.

INTERCONDYLAR FRACTURE
• FRACTURE LINE EXTENDS BETWEEN
MEDIAL AND LATERAL CONDYLES AND
EXTENDS TO SUPRACONDYLAR
REGION
• RESULTS AND T OR Y SHAPED
CONFIGURATION FOR FRACTURE
• CALLED TRANS-CONDYLAR IF IT
EXTENDS THROUGH BOTH CONDYLES

EPICONDYLAR FRACTURE
• USUALLY AVULSION FROM TRACTION
OF RESPECTIVE COMMON FLEXOR
(MEDIAL) OR EXTENSOR (LATERAL)
TENDONS
• MEDIAL EPICONDYLE AVULSION
COMMON IN SPORTS &
ADOLOCENTS WITH STRONG
THROWING MOTION. (FOOSH WITH
VALGUS INJURY) CHECK MEDIAN
NERVE
• FRACTURE LATERAL EPICONDYLE
COMMON IN CHILDERN CHECK

OLECRANON FRACTURE
• DIRECT TRAUMA : FALL ON POINT OF ELBOW
• INDIRECT TRAUMA : CONTRACTION OF TRICEPS PRODUCE
AVULSION FRACTURE

TREATMENT
TYPE I:
• ABOVE ELBOW PLASTER CAST WITH 30 OF ELBOW FLEXION
• MAINTAIN FOR 3 WEEKS
TYPE II:
• CLEAN BREAK FRACTURE WITH SEPARATION
• ORIF USING TENSION BAND WIRING (TBW)
TYPE III:
• COMMINUTED FRACTURE
• EXCISION OF OLECRANON &
• REATTACH THE TRICEPS TO PROXIMAL ULNA

REHABILITATION PROTOCOL
• AFTER REDUCTION, THE EXTENSION TYPE OF FRACTURE IS
IMMOBILIZED IN AN ABOVE ELBOW PLASTER SLAB WITH THE
ELBOW IN FLEXION. WHEREAS, THE FLEXION TYPE (LESS COMMON)
OF FRACTURE IS IMMOBILISED WITH THE ELBOW IN EXTENSION. IN
EITHER CASE THE PLASTER IS REMOVED AFTER 4 WEEKS.
• THE FRACTURE FRAGMENTS ARE FIXED INTERNALLY WITH THE
KIRSCHNER WIRES. POSTOPERATIVELY THE LIMB IS IMMOBILISED
IN A POSTERIOR SLAB WITH ELBOW IN FLEXION FOR 3 WEEKS. THE
K-WIRES ARE ALSO REMOVED AFTER 3 WEEKS AND THE ELBOW IS
MOBILISED.
• AFTER 3 WEEKS (MOBILIZATION) PHASE
• WAX THERAPY, ROLLER SKATES, NO PASSIVE

ELBOW DISLOCATIONS
• EPIDEMIOLOGY
• ACCOUNTS FOR 11-28% OF INJURIES TO THE ELBOW
• POSTERIOR DISLOCATIONS MOST COMMON
• HIGHEST INCIDENCE IN THE YOUNG 10-20 YEARS AND USUALLY
SPORTS INJURIES
• MOST COMMONLY DUE TO FALL ON OUTSTRETCHED HAND OR
ELBOW RESULTING IN FORCE TO UNLOCK THE OLECRANON FROM
THE TROCHLEA
• POSTERIOR DISLOCATION FOLLOWING HYPEREXTENSION, VALGUS
STRESS, ARM ABDUCTION, AND FOREARM SUPINATION (MORE
COMMON TYPE) 90%
• ANTERIOR DISLOCATION ENSUING FROM DIRECT FORCE TO THE
POSTERIOR FOREARM WITH ELBOW FLEXED (LESS COMMON) 10%

ELBOW FRACTURE/DISLOCATIONS
SURGICAL TREATMENT
• POSTERIOR DISLOCATION
• CLOSED REDUCTION UNDER SEDATION
• REDUCTION SHOULD BE PERFORMED WITH THE ELBOW FLEXED
WHILE PROVIDING DISTAL TRACTION
• POST REDUCTION MANAGEMENT INCLUDES A POSTERIOR
SPLINT WITH THE ELBOW AT 90 DEGREES
• OPEN REDUCITON FOR SEVERE SOFT TISSUE INJURIES OR
BONY ENTRAPMENT
• ANTERIOR DISLOCATION
• CLOSED REDUCTION UNDER SEDATION
• DISTAL TRACTION TO THE FLEXED FOREARM FOLLOWED BY
DORSALLY DIRECT PRESSURE ON THE VOLAR FOREARM WITH
ANTERIOR PRESSURE ON THE HUMERUS

Phase I: Weeks 1-4
Goals: Control edema and pain
Early full ROM
Protect injured tissues
Minimize deconditioning
Intervention:
• Continue to assess for neurovascular compromise
• Elevation and ice
• Gentle PROM - working to get full extension
• Splinting as needed
• General cardiovascular and muscular conditioning program
• Strengthen through ROM
• Soft tissue mobilization if indicated – especially assess the brachialis
myofascia
Phase II: Weeks 5-8
Goals: Control any residual symptoms of edema and pain
Full ROM
Minimize deconditioning

Intervention:
• Active range of motion (AROM) exercises, isometric exercises, progressing to
resisted
exercises using tubing or manual resistance or weights
• Incorporate sport specific exercises if indicated
• Joint mobilization, soft tissue mobilization, or passive stretching if indicated
• Continue to assess for neurovascular compromise
• Nerve mobility exercises if indicated
• Modify/progress cardiovascular and muscular conditioning program
Phase III: Weeks 9-16
Goals: Full range of motion and normal strength
Return to preinjury functional activities
Intervention:
• Interventions as above
• Modify/progress cardiovascular and muscular conditioning
• Progress sport specific or job specific training

FRACTURE OF HEAD OF RADIUS
• COMMON IN ADULTS
• NEVER IN CHILDREN, SINCE HEAD OSSIFIES AT THE AGE OF
5 YRS.
• FOOSH
• HAND FORCES ELBOW INTO VALGUS & PUSHES RADIAL
• HEAD AGAINST CAPITULUM
• RADIAL HEAD SPLIT & BROKEN

MASON CLASSIFICATION
• TYPE I : UNDISPLACED
• TYPE II : DISPLACED
• TYPE III : SEVERELY COMMINUTED
• TYPE IV : FRACTURE WITH DISLOCATION OF ELBOW

FRACTURE CAPITULUM
• FRACTURE OCCURS AT CORONAL PLANE & FRAGMENT MOVES
UPWARDS.
MECHANISM OF INJURY
• FOOSH
• FALL ON ELBOW

PHYSIOTHERAPY PROTOCOL
2—4 WEEKS
• ACTIVE RANGE OF MOTION TO
DIGITS
• ACTIVE & ACTIVE ASSISTED
EXERCISES TO SHOULDER
• ISOMETRIC EXERCISE TO BICEPS,
TRICEPS & DELTOID
• ISOMETRICS TO FOREARM
MUSCLES
• BEGIN GRIP STRENGTHENING
EXERCISES (BALL , PUTTY)
4—6 WEEKS
• Stability is achieved
• Begin Supervised Elbow movements
• Continue Grip exercises
• Avoid PROM to elbow
• Teach Home program & advise about complications
8—12 WEEKS
• Continue active &Add PROM exercises to all joints
• Continue grip strengthening exercises
• Resistive exercises using weights

FOREARM FRACTURES
• FRACTURE OF THE RADIUS & ULNA
• FRACTURE OF RADIUS ALONE
• FRACTURE OF ULNA ALONE
• MONTEGGIA FRACTURE
• GALEAZZI FRACTURE

FRACTURE OF THE RADIUS & ULNA
• IN FOREARM WHEN ONE OF THE BONES IS FRACTURES & DISPLACED, THE OTHER
ALSO IS USUALLY FRACTURED.
• IF ONLY ONE BONE SHOWS A FRACTURE WITH DISPLACEMENT AND THE OTHER
SHAFT IS INTACT, ONE MUST EXPECT A DISPLACEMENT EITHER AT THE SUPERIOR OR
INFERIOR RADIO ULNAR JOINT.
• THE AXIS OF ROTATION OF THE FOREARM IS THE LINE JOINING THE SUPERIOR &
INFERIOR RADIOULNAR JOINT.
• THE RESTORATION OF THE INTEROSSEOUS SPACE BY PROPER CORRECTION OF
OVERRIDING, ANGULATIONS & ROTATION IS VERY IMPORTANT IN THE MANAGEMENT
OF THIS FRACTURE. IF IT IS NOT PROPERLY DONE THEN, IT RESTRICTS SUPINATION/
PRONATION
• ROTATIONAL DEFORMITY PRODUCED BY PULL OF MUSCLES ATTACHED TO RADIUS.
• BICEPS & SUPINATOR IN UPPER 1/3
• PRONATOR TERES IN MID 1/3

FRACTURE OF RADIUS
• VERY RARE
• IMMOBILIZED IN ABOVE ELBOW PLASTER CAST
• 3—6 WEEKS

MECHANISM OF INJURY
• FOOSH.
• DIRECT INJURY.
IN CHILDERN MANAGEMENT IS DONE BY LONG PLASTER CAST
FROM AXILLA TO METACARPAL
• HELPS TO CONTROL MOVEMENT
• CAST APPLIED WITH ELBOW 90° FLEXION
• SPLINT IS APPLIED FOR 6—8 WEEKS
• AVOID CONTACT SPORTS
• IF FRACTURE PROXIMAL TO PRONATOR TERES FOREARM IN
:SUPINATION
• IF FRACTURE DISTAL TO PRONATOR TERES FOREARM IN :
NEUTRAL.

Some surgeons keep Forearm in different positions
• For Upper 1/3 fracture — Supination
• For Mid 1/3 fracture — Mid Prone
• For Lower 1/3 fracture — Pronation
• Mid prone is prefer to facilitate Functional activity & Prevent Elbow stiffness
• POP for 3—6 weeks : children
• POP for 8—10 Weeks: Adult
COMPLICATION
• Non union
• VIC
• Mal union
• Cross union
• Compartmental Syndrome.

FRACTURE OF ULNA
• FRACTURE OF LOWER 1/3 IS VERY COMMON
MECHANISM:
• DIRECT TRAUMA
• TREATMENT:
• ABOVE ELBOW PLASTER SLAB

MONTEGGIA FRACTURE
DISLOCATION
• PROXIMAL THIRD OF THE ULNA WITH DISLOCATION OF THE HEAD OF THE
RADIUS.
MECHANISM OF INJURY
• FOOSH—FALL WITH FORCIBLE PRONATION
• DIREST VIOLENCE ON POSTERIOR FOREARM.

BADO CLASSIFICATION
ANTERIOR TYPE
TYPE-I
• EXTENSION
TYPE
• COMMONEST
TYPE
• HEAD OF
RADIUS IS
DISLOCATED
ANTERIORLY &
• ULNA IS
FORWARD
ANGULATIONS
POSTERIOR
TYPE
TYPE II
• Flexion type
• Head of radius
is
dislocated
posteriorly
• Ulna is in
posterior
angulations.
LATERAL TYPE
Type III
• Adduction type
• Very rare
• Head of radius is
dislocated laterally
• Ulna is angulated
laterally
Type IV
• Proximal
3rd of both
bone forearm
fractured with
• Anterior
dislocation of
Head of
radius

GALEAZZI FRACTURE
DISLOCATION
• FRACTURE OF THE DISTAL SHAFT OF THE RADIUS
ASSOCIATED WITH A DISLOCATION OF THE ULNA

• CAST/ SPLINTS
• IMMEDIATE TO ONE WEEK
• ACTIVE & PASSIVE ROM TO
SHOULDER
• AROM WRIST, FINGERS
• IF ISOLATED ULNA FRACTURE
• INITIATE ACTIVE, ACTIVE ASSISTED
ROM TO SHOULDER, ELBOW.
ONE TO TWO WEEKS:
• Active or Active Assisted ROM to digits
• Active or Active assisted ROM to shoulder
• Ulna fracture
• Elbow movements
• AROM or PROM to digits
FOUR TO SIX WEEKS:
• AROM or PROM to digits
• AROM or AAROM to shoulder
• Add gentle ROM to ELBOW
• Pronation / Supination added
• Ball squeeze
• Isometrics for Triceps, Biceps, Deltoid

EIGHT TO TWELVE WEEK:
• Full or Active or PROM to all joints
• Pronation / Supination continued
• Putty or Ball Squeeze
• Resisted exercises with weights
POST OPERATIVE PHYSIOTHERAPY MANAGEMENT
IMMEDIATE TO ONE WEEK:
• No cast with stable fixation
• Active & Passive ROM to Shoulder
• AROM wrist, Fingers
• AROM to elbow is initiated
• Pain free movements
TWO WEEKS:
• No cast with stable fracture
• Active & Passive ROM to Shoulder
• AROM wrist, Fingers
• AROM to elbow is initiated
• Pain free movements

FOUR TO SIX WEEKS:
• AROM to digits
• Ball squeeze
• AROM to shoulder, Elbow, Wrist.
• Pronation / Supination added
• Isometrics for Triceps, Biceps, Deltoid.
• No lifting or Weight bearing
• Gentle resistive exercises added.
• Functional activities encouraged ( Eat, Write)
EIGHT TO TWELVE WEEK:
• Full or Active or PROM to all joints
• Pronation / Supination continued
• Putty or Ball Squeeze
• Resisted exercises with weights.

SCAPHOID FRACTURE
• COMMON CARPAL BONE TO GET FRACTURED
• 75% OF ALL CARPAL INJURIES ARE INVOLVE SCAPHOID
• RARE IN CHILDREN & ELDERS
MECHANISM OF INJURY: FALL ON DORSIFLEXION OF
HAND

Scaphoid has two nutrient arteries:
1) Entering the palmar surface of the Tubercle
2) Entering through Dorsal surface of the Body
Occasionally both the blood vessels pass through the tubercle or through the
distal half of the bone.
In such a case fracture may deprive the proximal half of the bone of its blood
supply leading to Avascular Necrosis
Commonly occur in middle third fracture. 30% TYPES
TYPES
Fracture occurs at Waist / Midline
Fracture occurs at Proximal Pole
Fracture occurs at Tubercle
Stable fracture
Unstable fracture
Unstable fracture displaces fragments and associated Carpal instability & dorsal
tilting of Lunates.

TREATMENT
CONSERVATIVE:
Scaphoid plaster cast
Wrist Slight flexion & Radial Deviation
Thumb in Glass Holding Position.
Tubercle Fracture: 3—4 Weeks of POP
Proximal pole fracture : 8—12 Weeks
Surgical:
ORIF
Screw fixation

COLLE’S FRACTURE
• THE INJURY WAS FIRST DESCRIBED BY ABRAHAM COLLES IN 1814.
• COMMON IN WOMEN
• HIGHER RATE ON INCIDENCE FOLLOWING POST MENOPAUSAL
• THIS IS A TRANSVERSE FRACTURE AT THE CORTICO-CANCELLOUS
JUNCTION OF THE DISTAL RADIUS OFTEN ASSOCIATED WITH A
FRACTURE OF THE ULNAR STYLOID PROCESS.
• IT COMMONLY OCCURS IN ELDERLY WOMEN

MECHANISM OF INJURY
• FOOSH
TREATMENT
• IMMOBILIZED WITH PLASTER CAST
• BELOW ELBOW
• FOREARM PRONATED
• WRIST PALMAR FLEXED
• ULNAR DEVIATED
• FRACTURE UNITES WITHIN 6 WEEKS

SMITHS FRACTURE
• ALSO CALLED AS REVERSE COLLE’S FRACTURE
• FRACTURE AT THE DISTAL END OF THE RADIUS WHERE THE
DISPLACEMENT OF THE DISTAL FRAGMENT IS THE OPPOSITE TO
THE COLLE’S.
• FRACTURE OCCURS SAME LEVEL AS LIKE COLLE’S.

MECHANISM
• FALL ON FLEXED WRIST
• DIRECT VIOLENCE AT THE BACK OF WRIST
• DISTAL FRAGMENT DISPLACED PALMAR WARDS
MANAGEMENT
• AFTER REDUCTION
• WRIST IS IMMOBILIZED IN A BELOW ELBOW CAST
• 30° DORSI FLEXION POSITION
• FOREARM SUPINATED FOR 6 WEEKS

BARTON’S FRACTURE
• FRACTURE OF A DISTAL END OF RADIUS
• IT INVOLVES ARTICULAR SURFACE
• DISTAL END IS SPLIT VERTICALLY IN THE CORONAL PLANE WITH
• SMALL FRAGMENT GETTING DISPLACED ALONG WITH THE
• WRIST DORSAL WARD OR PALMAR WARD
TWO TYPES OF FRACTURE
• VOLAR BARTON’S
• DORSAL BARTON’S

BENNETT’S FRACTURE
• IT IS AN OBLIQUE INTRA ARTICULAR FRACTURE OF THE BASE OF THE FIRST
METACARPAL WITH SUBLUXATION OR DISLOCATION OF THE METACARPAL
MECHANISM OF INJURY
• DIRECT INJURY
• PUNCHING
TREATMENT
CONSERVATIVE:
• BELOW ELBOW PLASTER CAST WITH ABDUCTION & EXTENSION 4 WEEKS
SURGICAL:
• K—WIRE FIXATION
• SCREW FIXATION

ROLANDO’S FRACTURE
• EXTRA-ARTICULAR FRACTURE ACROSS THE BASE OF THE FIRST METACARAPAL.
• REDUCTION IS DONE WITH THUMB SPICA
• IMMOBILIZE FOR 3 WEEKS.
COMPLICATION:
• OA

LUNATE DISLOCATION
• LUNATE IS THE COMMONEST
CARPAL BONE TO BE
DISLOCATED.
MECHANISM OF INJURY
• HYPER EXTENSION
VIOLENCE
• BONE DISLOCATED TO THE
PALMAR WARDS
TWO TYPES:
Lunate dislocation:
Here Lunate dislocates
Anteriorly, Rest of carpal bones
remain in Position.
Peri-lunate dislocation:
Lunate remain in Position
Rest of the carpal bones
dislocated dorsally

DAY ONE TO ONE WEEK
• FULL ACTIVE ROM TO DIGITS
• FULL OPPOSITION OF THUMB
• ATTEMPT ISOMETRIC EXERCISE TO INTRINSIC MUSCLES OF HAND.
• USE UNINVOLVED HAND FOR SELF CARE & ADL
• NO WEIGHT BEARING ON AFFECTED SIDE.
PRECAUTIONS:
• NO SUPINATION/PRONATION
• NO ROM TO WRIST.

TWO WEEKS
• FULL ROM TO DIGITS,
• AROM TO WRIST IF IT IS IN ORIF OR EXTERNAL FIXATION.
• ISOMETRICS TO INTRINSICS, WRIST FLEXORS, EXTENSORS.
• ATTEMPT ACTIVITIES WITH UNINVOLVED LIMB.
• NO WEIGHT BEARING.
• NO SUPINATION/ PRONATION
• NO PROM TO WRIST ( ORIF & EF)

FOUR TO SIX WEEKS
• FULL AROM TO WRIST & FINGERS.
• SUPINATION / PRONATION ARE ENCOURAGED.
• ACTIVE ULNAR & RADIAL DEVIATIONS ARE DONE.
• GENTLE RESISTED EXERCISE TO DIGITS.
• ISOMETRICS TO FLEXORS, EXTENSORS, RADIAL/ ULNAR
DEVIATORS.
• GENTLE RESISTED EXERCISE IF TREATED BY ORIF OR EF.
• INVOLVED HAND USED AS A STABILIZER IN TWO HAND ACTIVITIES.
• INITIATE SELF CARE
• AVOID WEIGHT BEARING UP TO 6 WEEKS.

SIX TO EIGHT WEEKS
• FULL ROM TO ALL JOINTS OF UPPER EXTREMITY.
• STRESS SUPINATION / PRONATION & RADIAL / ULNAR DEVIATION.
• ACTIVE ASSISTED ROM TO PROM IS INITIATED.
• GENTLE RESISTIVE EXERCISES TO DIGITS & WRIST
• INVOLVED HAND USED FOR SELF CARE ACTIVITIES & ADL.
• IMPROVE POWER GRIP.
• WEIGHT BEARING TOLERATED

EIGHT TO TWELVE WEEKS
• FULL ROM ACTIVE OR PASSIVE IN ALL PLANES OF WRIST &
DIGITS.
• STRESS SUPINATION OR PRONATION.
• PRE
• SELF CARE ACTIVITIES.
• FULL WEIGHT BEARING AS TOLERATED.

METACARPAL FRACTURE
• FRACTURE OF THE METACRAPAL SHAFT IS VERY COMMON AT ALL
AGES.
• COMMONEST CAUSE IS FALL ON THE HAND
• BLOW ON THE KNUCKLES ( BOXING).
• CRUSHING HAND UNDER HEAVY OBJECTS.

CLASSIFICATION
• FRACTURE THROUGH THE BASE OF METACARPAL, USUALLY THROUGH
TRANSVERSE AND UNDISPLACED.
• FRACTURE THROUGH THE SHAFT—TRANSVERSE OR OBLIQUE
• USUALLY NOT MUCH DISPLACED
• DUE TO INTEROSSEI MUSCLES.

Neck of 5th Metacarpal fracture is due
to:
Boxing injury.
It is so called as Boxer’s Fracture.
Conservative management:
Splint
Cast
Surgical : ORIF—K-wire fixation

PHALANGES FRACTURE
• THESE ARE COMMON FRACTURES
MECHANISM:
• DIRECT INJURY
• INDIRECT TRAUMA
• BOTH DISPLACED & UNDISPLACED ARE SEEN.

TREATMENT
• CLOSED MANIPULATION
• SIMPLE STRAPPING WITH NEIGHBOR FINGER ( BUDDY SPLINT)
• 2—3 WEEKS
• ORIF:
• K-WIRE
• SMALL SCREWS

MALLET FRACTURE
• AVULSION OF FRACTURE OF TERMINAL PHALANX
MECHANISM
• SUDDEN FLEXION OF DISTAL PHALANX IN CASE OF CRICKET,
• BASE BALL OR MAKING UP BED.

MANAGEMENT
• IMMOBILIZE THE FINGER IN POP WITH PROXIMAL INTERPHALANGEAL JOINT IN
FLEXION
• 3—4 WEEEKS
• SURGICAL
• ORIF
• K—WIRE ,
• ARTHRODESIS

DAY ONE TO ONE
WEEK:
• ROM OF DIGITS.
• GENTLE ROM OF
SHOULDER.
• ISOMETRICS TO
SHOULDER.
TWO WEEKS
• Active or Passive ROM to
Digits.
• AAROM to Shoulder.
Isometrics to Shoulder
FOUR TO SIX
WEEKS
• Continue AROM & PROM
to digits
• Active & AAROM to
Shoulder & Elbow.
Limit Supination /
Pronation
EIGHT TO
TWELVE WEEKS
• Gentle ROM to wrist.
Movements of Thumb
• Continue exes to
Shoulder & Elbow.
Gentle Supination/
Pronation Grip
exercises
TWELVE TO SIXTEEN
• ROM to all digits, Elbow, Shoulder.
• Grip strengthening exercises
• PRE Strengthening exercises for Biceps, Triceps,
Deltoid.
• Hydro therapy to reduce discomfort

SHOULDER
IMPINGEMENT SYNDROME
BICEPS TENDON DISORDERS
ROTATOR CUFF TEARS
PERI ARTHRITIS OF SHOULDER
THORACIC OUTLET SYNDROME(TOS)
ELBOW
LATERAL EPICONDYLITIS
MEDIAL EPICONDYLITIS
HAND AND WRIST
TRIGGER FINGER
CARPAL TUNNEL SYNDROME
DE QUERVAINS TENOSYNOVITIS
DUPUYTREN’S CONTRACTURE

TOS
COMPRESSION OF THE NEUROVASCULAR STRUCTURES AS THEY EXIT THROUGH THE THORACIC OUTLET
(CERVICOTHORACOBRACHIAL REGION). THE THORACIC OUTLET IS MARKED BY THE ANTERIOR SCALENE
MUSCLE ANTERIORLY, THE MIDDLE SCALENE POSTERIORLY, AND THE FIRST RIB INFERIORLY.
TOS AFFECTS APPROXIMATELY 8% OF THE POPULATION AND IS 3-4 TIMES AS FREQUENT IN WOMAN AS IN MEN
BETWEEN THE AGE OF 20 AND 50 YEARS.
CAUSE
CERVICAL RIBS ARE PRESENT IN APPROXIMATELY 0.5-0.6% OF THE POPULATION, 50-80% OF WHICH ARE
BILATERAL, AND 10-20% PRODUCE SYMPTOMS; THE FEMALE TO MALE RATIO IS 2:1.
CONGENITAL
• CERVICAL RIB
• PROLONGED TRANSVERSE PROCESS
• ANOMALOUS MUSCLES
• ABNORMALITIES OF THE INSERTION OF THE SCALENE MUSCLES
• FIBROUS MUSCULAR BANDS
• EXOSTOSIS (BENIGN GROWTH) OVER THE FIRST RIB
• CERVICODORSAL SCOLIOSIS
• CONGENITAL UNI- OR BILATERAL ELEVATED SCAPULA

ACQUIRED CONDITIONS
DROPPED SHOULDER CONDITION
WRONG WORK POSTURE (STANDING OR SITTING
WITHOUT PAYING ATTENTION TO THE
PHYSIOLOGICAL CURVATURE OF THE SPINE)
HEAVY MAMMARIES
TRAUMA
CLAVICLE FRACTURE
RIB FRACTURE
HYPEREXTENSION NECK INJURY, WHIPLASH
REPETITIVE STRESS INJURIES (REPETITIVE
INJURY MOST OFTEN FORM SITTING AT A
KEYBOARD FOR LONG HOURS)

MUSCULAR CAUSES
HYPERTROPHY OF THE SCALENE MUSCLES
DECREASE OF THE TONUS OF THE M.
TRAPEZIUS, M. LEVATOR SCAPULAE,
M.RHOMBOIDS
SHORTENING OF THE SCALENE MUSCLES,
M. TRAPEZIUS, M. LEVATOR SCAPULAE,
PECTORAL MUSCLES

CLINICAL PRESENTATION
PATIENTS WITH THORACIC OUTLET
SYNDROME WILL MOST LIKELY PRESENT
PAIN ANYWHERE BETWEEN THE NECK, FACE
AND OCCIPITAL REGION OR INTO THE
CHEST, SHOULDER AND UPPER EXTREMITY
AND PARESTHESIA IN THE UPPER
EXTREMITY. THE PATIENT MAY ALSO
COMPLAIN OF ALTERED OR ABSENT
SENSATION, WEAKNESS, FATIGUE, A
FEELING OF HEAVINESS IN THE ARM AND
HAND

WHEN THE ARM IS ABDUCTED OVERHEAD AND
EXTERNALLY ROTATED WITH THE HEAD ROTATED
TO THE SAME OR THE OPPOSITE SIDE. AS A RESULT
ACTIVITIES SUCH AS OVERHEAD THROWING,
SERVING A TENNIS BALL, PAINTING A CEILING,
DRIVING, OR TYPING MAY EXACERBATE SYMPTOMS.
WHEN THE UPPER PLEXUS (C5,6,7) IS INVOLVED
THERE IS A PAIN IN THE SIDE OF THE NECK AND
THIS PAIN MAY RADIATE TO THE EAR AND FACE.
OFTEN THE PAIN RADIATES FROM THE EAR
POSTERIORLY TO THE RHOMBOIDS AND
ANTERIORLY OVER THE CLAVICLE AND PECTORALIS
REGIONS. THE PAIN MAY MOVE LATERALLY DOWN
THE RADIAL NERVE AREA. HEADACHES ARE NOT
UNCOMMON WHEN THE UPPER PLEXUS IS

PATIENTS WITH LOWER PLEXUS (C8, T1)
INVOLVEMENT TYPICALLY HAVE
SYMPTOMS THAT ARE PRESENT IN THE
ANTERIOR AND POSTERIOR SHOULDER
REGION AND RADIATE DOWN THE
ULNAR SIDE OF THE FOREARM INTO
THE HAND, THE RING AND SMALL
FINGERS.
THERE ARE FOUR CATEGORIES OF
THORACIC OUTLET SYNDROME AND
EACH PRESENTS WITH UNIQUE SIGNS
AND SYMPTOMS

Arterial TOS Venous TOS True TOS Disputed Neurogenic
TOS
•Young adult
with vigorous arm activity
•Pain in the hand
•Claudication
•Pallor
•Cold intolerance
•Paresthesias
•S/s usually appear
spontaneously
•Younger men with
vigorous arm activity
•Cyanosis
•Feeling of heaviness
•Paresthesia in fingers
and hand (result of
oedema)
•Oedema of the arm
•Hx of neck trauma
•Pain, paresthesia,
numbness, and/or
weakness
•Occipital headaches
•S/s present-day and/or
night
•Loss of fine motor skills
•Cold intolerance
(possible Raynaud's
phenomenon)
•Objective weakness
•Compressors*: s/s
day>night
•Hx of neck trauma
•Pain, paresthesia, and
"feeling" of weakness
•Occipital headaches
•Nocturnal paresthesias
that often wake patient
•Loss of fine motor skills
•Cold intolerance
(possible Raynaud's
phenomenon)
•Subjective weakness
•Releasers*: s/s
night>day

SPECIAL TESTS
ADSON’S TEST
ELEVATED ARM STRESS/ ROOS TEST
PHYSIOTHERAPY MANAGEMENT
STRENGTHENING OF THE LEVATOR SCAPULAE, STERNOCLEIDOMASTOID AND
UPPER TRAPEZIUS (THIS GROUP OF MUSCLES OPEN THE THORACIC OUTLET BY
RAISING THE SHOULDER GIRDLE AND OPENING THE COSTOCLAVICULAR SPACE)
STRETCHING OF THE PECTORALIS, LOWER TRAPEZIUS AND SCALENE MUSCLES
(THESE MUSCLES CLOSE THE THORACIC OUTLET)
MOBILIZE FIRST RIB
POSTURAL CORRECTION EXERCISES
RELAXATION OF SHORTENED MUSCLES
MASSAGE
IF CONSERVATIVE MANAGEMENT FAILS: SURGERY

IMPINGEMENT SYNDROME IS A CLINICAL ENTITY IN
WHICH THE ROTATOR CUFF WAS
PATHOLOGICALLY COMPRESSED AGAINST THE
ANTERIOR STRUCTURES OF CORACOACROMIAL
ARCH, THE ANTERIOR THIRD OF THE
ACROMION,THE CORACOACROMIAL LIGAMENT,
AND THE AC JOINT.
CLINICAL FEATURES
SYMPTOMS USUALLY START GRADUALLY, IN THE
TOP-OUTER PORTION OF THE SHOULDER. THERE
MAY BE MILD PAIN ALL THE TIME, WITH SUDDEN
PAIN WHEN REACHING OVERHEAD AND PAIN
WHEN LOWERING THE ARM FROM AN OVERHEAD
POSITION. THERE MAY BE WEAKNESS OF THE
SHOULDER. IF NOT TREATED, THE CONDITION MAY

TREATMENT SURGICAL TREATMENT
FOR PRIMARY IMPINGEMENT SURGICAL
TREATMENT INVOLVES WIDENING THE
SUBACROMIAL OUTLET BY PERFORMING A
SUBACROMIAL DECOMPRESSION
(ACROMIOPLASTY)
FOR SECONDARY IMPINGEMENT THE SURGICAL
TREATMENT IS DIRECTED TOWARD THE ETIOLOGY
OF THE SYMPTOM
NON-OPERATIVE TREATMENT
THE INITIAL GOALS OF REHABILITATIVE PROCESS
ARE TO OBTAIN PAIN RELIEF TO REGAIN ROM
CRYOTHERAPY AND ULTRASOUND – TO RELIEVE
PAIN.

SUPRASPINATUS TENDINITIS
DEFINITION
INFLAMMATION OF SUPRASPINATUS TENDON
ANATOMY
ORIGIN: SUPRASPINOUS FOSSA
INSERTION GREATER TUBERCLE OF HUMERUS
MORE COMMON IN PITCHING IN BASEBALL, SWIMMING FREESTYLE, BUTTERFLY, OR
BACKSTROKE, LIFTING HEAVY WEIGHTS OVER THE SHOULDER
CAUSES
INJURY
OVER USE
PATHOLOGY
OVER USE
REPETITIVE STRESS
IRRITATION & INFLAMMATION

CLINICAL FEATURES
PAIN (ABDUCTION OF SHOULDER BETWEEN
60-120 DEGREE PAINFUL)
INFLAMMATION
TENDERNESS
LIMITED ROM
MUSCLE WEAKNESS

SPECIAL TESTS
SUPRASPINATUS TENDINITIS TEST
EMPTY CAN TEST
APLEY SCRATCH TEST
HAWKINS-KENNEDY IMPINGEMENT TEST
INVESTIGATIONS
X RAY MAY SHOW CALCIFICATION IN CALCIFIC
TENDINITIS.

AIM
TO RELIEVE PAIN
TO REDUCE INFLAMMATION
TO PREVENT PERI ARTICULAR ADHESIONS
TO INCREASE ROM
TO STRENGTHEN THE MUSCLE

ACUTE STAGE(0-7DAYS)
REST
CRYOTHERAPY
GRADE I MOBILISATION
SUB ACUTE STAGE (7DAYS-7WEEKS)
PULSED S W D
PULSED U S
LASER, IONTOPHORESIS
FRICTION MASSAGE
GRADE II &GRADE III MOBILISATION
PENDULAR EXERCISE

CHRONIC STAGE (ABOVE 7 WEEKS)
CONTINUOUS SWD
CONTINUOUS US
GRADE IV MOBILISATION TECHNIQUE
STRENGTHENING EXERCISES
(PROGRESSIVE RESISTED EXERCISE)

BICEPS TENDINITIS
DEFINITION
INFLAMMATION OF LONG HEAD OF THE BICEPS TENDON IN THE BICIPITAL GROOVE
ANATOMY
ORIGIN:
LONG HEAD: UPPER BORDER OF GLENOID CAVITY
SHORT HEAD: APEX OF CORACOID PROCESS
INSERTION: RADIAL TUBEROSITY
CAUSES
INJURY
OVER USE
PATHOLOGY
OVER USE
REPETITIVE STRESS
IRRITATION &INFLAMMATION

CLINICAL FEATURES
PAIN
INFLAMMATION
TENDERNESS OVER THE BICIPITAL GROOVE
LIMITED ROM
MUSCLE WEAKNESS

SPECIAL TESTS
GILCREST SIGN
LUDINGTON TEST
SPEEDS TEST
YERGASON TEST

AIMS
TO RELIEVE PAIN
TO PREVENT PERIARTICULAR ADHESIONS
TO INCREASE ROM
TO STRENGTHEN THE MUSCLE

ACUTE STAGE(0-7DAYS)
REST
CRYOTHERAPY
GRADE I MOBILISATION
SUB ACUTE STAGE (7DAYS-7WEEKS)
PULSED S W D
PULSED U S
LLLT
FRICTION MASSAGE
GRADE II &GRADE III MOBILISATION

CHRONIC STAGE (ABOVE 7 WEEKS)
CONTINUOUS S W D
CONTINUOUS U S
GRADE I V MOBILISATION TECHNIQUE
STRENGTHENING EXERCISES (P R E)

SUBACROMIAL BURSITIS
SUBACROMIAL BURSITIS
DEFINITIONS
INFLAMMATION OF SUB ACROMIAL BURSA
ANATOMY
LOCATED BETWEEN ACROMION AND JOINT CAPSULE

CAUSES
DEGENERATION OF ACROMIO CLAVICULAR JOINT
SUPRASPINATUS TENDONITIS
BICEPS TENDONITIS
PATHOLOGY
OVER USE
REPETITIVE STRESS
IRRITATION &INFLAMMATION
CLINICAL FEATURES
PAIN OVER THE SHOULDER
TENDERNESS AT THE TIP OF ACROMION
LIMITED ROM
WEAKNESS OF SUPRASPINATUS MUSCLE

SPECIAL TEST
SUB ACROMIAL PUSH BUTTON SIGN
DAWBARNS TEST
INVESTIGATION
X RAY SHOWS LOOSE RICE BODIES

ACUTE STAGE
ICE THERAPY TO CONTROL PAIN AND
INFLAMMATION
SUB ACUTE STAGE
PULSED U S TO ANTERIOR PART OF
SHOULDER IN EXTENDED ARM POSITION
WHICH OPENS THE SUBACROMIAL SPACE.
PULSED S W D

CHRONIC STAGE
CONTINUOUS U S
CONTINUOUS S W D
STRENGTHENING OF SUPRASPINATUS
MUSCLE
SURGICAL MANAGEMENT
ACUTE-ASPIRATION OF SYNOVIAL FLUID
CHRONIC-ARTHROSCOPY

TREATMENT
ACUTE PHASE
THE INITIAL GOALS OF THE ACUTE PHASE OF
TREATMENT FOR BICIPITAL TENDINITIS ARE TO
REDUCE INFLAMMATION AND SWELLING.
PATIENTS SHOULD RESTRICT OVER-THE-
SHOULDER MOVEMENTS, REACHING, AND
LIFTING.
PATIENTS SHOULD APPLY ICE TO THE
AFFECTED AREA FOR 10-15 MINUTES, 2-3 TIMES
PER DAY FOR THE FIRST 48 HOURS
PHONOPHORESIS, IONOTOPHORESIS TO
RELIEVE PAIN AND INFLAMMATION.

PERIARTHRITIS SHOULDER
DEFINITION
IT INVOLVES THE PATHOLOGY IN THE PERI ARTICULAR STRUCTURES LEADING TO
ARTHRITIS OF
SHOULDER JOINT.
CAUSES
• SUPRASPINATUS TENDINITIS
• SUBACROMIAL BURSITIS
• BICEPETAL TENDINITIS
• O A OF ACROMIO CLAVICULAR JOINT
• ROTATOR CUFF INJURY
• HEMIPLEGIA
• DIABETES
• SURGERY ON THORAX –THOROCOPLASTY, MEDIAN STERNOTOMY

PATHOLOGY I
OVER USE
INFLAMMATION OF TENDON
INFLAMMATION OF CAPSULE
LIMITATION OF MOVEMENT

PATHOLOGY II
PROLONGED ACTIVITIES
WEAKNESS OF MUSCLE
ALTERED SCAPULO HUMERAL RHYTHM
MORE STRESS ON GLENO HUMERAL JOINT
INFLAMMATION OF TENDONS AND CAPSULE
LIMITATION OF R O M

CLINICAL FEATURES
 PAINFUL STAGE
• PAIN WITH MOVEMENT
• GENERALIZED ACHE THAT IS DIFFICULT TO PINPOINT
• MUSCLE SPASM
• INCREASING PAIN AT NIGHT AND AT REST
• ADHESIVE STAGE
• LESS PAIN
• INCREASING STIFFNESS AND RESTRICTION OF MOVEMENT
• DECREASING PAIN AT NIGHT AND AT REST
• DISCOMFORT FELT AT EXTREME RANGES OF MOVEMENT
• RECOVERY STAGE
• DECREASED PAIN
• MARKED RESTRICTION WITH SLOW, GRADUAL INCREASE IN RANGE OF
MOTION
• RECOVERY IS SPONTANEOUS BUT FREQUENTLY INCOMPLETE

PAINFUL STAGE
MOIST PACK
PULSED S W D
GRADE I OSCILLATORY MOBILIZATION TECHNIQUE
ADHESIVE STAGE
PULSED S W D
PULSED U S
GRADE II-GRADE III OSCILLATORY TECHNIQUE
PENDULAR EXERCISE
OVER HEAD PULLEY EXERCISE

RECOVERY STAGE
S W D
WAX THERAPY
PENDULAR EXERCISE
WALL LADDER EXERCISE
GRADE IV MOBILIZATION
STRENGTHENING EXERCISES FOR ROTATOR
CUFF MUSCLE

ROTATOR CUFF INJURIES
ACUTE TEAR
SUDDEN POWERFUL RAISING OF THE ARM AGAINST RESISTANCE, OFTEN IN
AN ATTEMPT TO CUSHION A FALL (EXAMPLES: HEAVY LIFTING, A FALL ON THE
SHOULDER)
INJURY USUALLY ASSOCIATED WITH A SIGNIFICANT AMOUNT OF FORCE IF
PERSON IS YOUNGER THAN 30 YEARS
CHRONIC TEAR
• FOUND AMONG PEOPLE IN OCCUPATIONS OR SPORTS REQUIRING EXCESSIVE
OVERHEAD ACTIVITY (EXAMPLES: PAINTERS, BASEBALL PITCHERS)
• VARIATIONS IN THE SHOULDER STRUCTURE CAUSING NARROWING UNDER
THE OUTER EDGE OF THE COLLAR BONE.

CLINICAL FEATURES OF ACUTE TEAR
SEVERE PAIN SHOOTING THROUGH THE ARM
MUSCLE SPASM
MOTION LIMITED BY PAIN
POINT TENDERNESS OVER THE SITE OF
RUPTURE
WITH LARGE TEARS, INABILITY TO RAISE THE
ARM OUT TO THE SIDE, ALTHOUGH THIS CAN
BE DONE WITH ASSISTANCE

CHRONIC TEAR
OCCUR MORE OFTEN IN A PERSON'S DOMINANT
ARM
MORE COMMONLY FOUND AMONG MEN OLDER
THAN 40 YEARS
PAIN USUALLY WORSE AT NIGHT AND INTERFERES
WITH SLEEP
WORSENING PAIN FOLLOWED BY GRADUAL
WEAKNESS
DECREASE IN ABILITY TO MOVE THE ARM,
ESPECIALLY OUT TO THE SIDE
ABLE TO USE ARM FOR MOST ACTIVITIES BUT
UNABLE TO USE THE INJURED ARM FOR ACTIVITIES
THAT ENTAIL LIFTING THE ARM AS HIGH OR HIGHER

ACUTE STAGE
MOIST PACK
PULSED S W D
GRADE I OSCILLATORY MOBILIZATION TECHNIQUE
SUB ACUTE STAGE
PULSED S W D OR MWD
PULSED U S
GRADE II-GRADE III OSCILLATORY TECHNIQUE
PENDULAR EXERCISE
OVER HEAD PULLEY EXERCISE
SHOULDER WHEEL EXERCISES
WALL LADDER EXERCISES

CHRONIC STAGE
S W D/MWD
PENDULAR EXERCISE
WALL LADDER EXERCISE
GRADE IV MOBILIZATION
STRENGTHENING EXERCISES FOR ROTATOR
CUFF MUSCLE

SURGICAL TREATMENT
IF SUPRASPINATUS TEAR
FOR PARTIAL TEAR
IMMOBILIZATION FOR 2 WEEKS
FOR COMPLETE TEAR
SUTURING OF THE TENDON

LATERAL EPICONDYLITIS (TENNIS ELBOW)
PRIMARY INVOLVES DEGENERATION OF THE EXTENSOR CARPI RADIALIS BREVIS
TENDON 1 TO
2 CM DISTAL TO ITS ORIGIN AT THE LATERAL EPICONDYLE
CAUSES
GRIPPING ACTIVITIES (HAMMERING NAILS, PICKING UP HEAVY OBJECTS)
OVER USE OF THE MUSCLES OF THE FOREARM
CLINICAL FEATURES
 PAIN
 TENDERNESS
 LIMITED R O M
 MUSCLE WEAKNESS
 DIFFICULTY IN DOING GRIPPING ACTIVITIES

SPECIAL TESTS
MILLS TEST
COZENS TEST
ACUTE
PRICE PROTOCOL
WRIST COCK UP SPLINT AT 20 DEGREES MAY BE
USED TEMPORARILY(5-7 DAYS) ONLY AT NIGHT
SUB ACUTE
PULSED U S, LLLT
IONTOPHORESIS / PHONOPHORESIS
TRANSVERSE FRICTION MASSAGE
GENTLE ACTIVE ROM OF THE ELBOW, WRIST AND
HAND
LATERAL OR MEDIAL COUNTER BRACE

CHRONIC
CONTINUOUS ULTRA SOUND
STRETCHING- WRIST FLEXORS, PRONATORS
AND ELBOW EXTENSORS
LATERAL OR MEDIAL COUNTER BRACE
SHOCK WAVE THERAPY
EXERCISES

SURGICAL MANAGEMENT
EXCISION OF PATHOLOGICAL TISSUE AND
REMOVAL OF ABNORMAL BONE GROWTH

THE TRIANGULAR FIBROCARTILAGE COMPLEX
(TFCC)
LOAD-BEARING STRUCTURE BETWEEN THE LUNATE, TRIQUETRUM,
AND ULNAR HEAD. A TFCC TEAR IS A COMMON INJURY IN GOLF,
BOXING, TENNIS, WATER SKIING, GYMNASTICS, POLE VAULTING
AND HOCKEY.
FUNCTION: TO ACT AS A STABILIZER FOR THE ULNAR ASPECT OF
THE WRIST.
• TFCC IS AT RISK FOR EITHER ACUTE OR CHRONIC DEGENERATIVE
INJURY.
MOI: FORCED ULNAR DEVIATION
PATIENTS PRESENTS WITH ULNAR-SIDED WRIST PAIN THAT MAY
PRESENT WITH CLICKING OR POINT TENDERNESS BETWEEN THE

TFCC
DIAGNOSIS: MRI
ARTHROSCOPY IS THE DIAGNOSTIC GOLD STANDARD.
PROGNOSIS: GOOD
ETIOLOGY
OCCURS WITH COMPRESSIVE LOAD ON TFCC DURING MARKED
ULNAR DEVIATION
FORCED ULNAR DEVIANCE (I.E. SWINGING BAT, RACKET, ETC)
CAUSES INCREASED LOAD ON TFCC
PATIENTS COMPLAINS OF ULNAR-SIDED WRIST PAIN THAT OFTEN
GETS WORSE WITH ACTIVITY.

WEAKNESS IN THE GRIP, INSTABILITY, OR CLICKING SOUND
SPORTS INJURY LIKE BASEBALL PLAYERS: RESULT OF THE HEAVY
LOAD PLACED ON THE WRIST DURING THE SWING.
IN GYMNASTICS THE TFCC CAN BE INJURED THROUGH OVERUSE
INJURY.
ANY REPETITIVE WEIGHT BEARING ACTIVITIES (BOTH
COMPRESSIVE AND TENSILE).
SPECIAL TESTS
TFCC COMPRESSION TEST
TFCC STRESS TEST
PIANO KEY TEST
GRIND TEST

MANAGEMENT
CONSERVATIVE TREATMENT
• THE REHABILITATION PROGRAM SHOULD CONSIST OF REST,
ACTIVITY MODIFICATION TO REMOVE THE INCITING FORCE OF
INJURY, ICE APPLICATION AND SPLINT IMMOBILISATION FOR 3 TO 6
WEEKS
• AFTER THE IMMOBILISATION, THE PATIENT SHOULD RECEIVE
PHYSICAL THERAPY
SURGICAL
COMMON SURGICAL OPTIONS INCLUDE ARTHROSCOPIC REPAIR,
ARTHROSCOPIC DEBRIDEMENT (INDUCES BLEEDING TO
STIMULATE HEALING).

POST-OPERATIVE REHABILITATION
FOR TYPE 1 INJURIES
• WRIST WILL BE IMMOBILIZED FOR 1 WEEK AFTER THE
ARTHROSCOPY.
• AFTER ONE WEEK, RANGE OF MOTION EXERCISES CAN BE
STARTED.
• RETURN TO NORMAL SPORTS ACTIVITY IN 4 TO 6 WEEKS.
• WHEN THE SYMPTOMS REMAIN, ULNO-CARPAL
CORTICOSTEROID INJECTION CAN BE AN OPTION.
AFTER 4 WEEKS: THE WRIST IS PLACED IN A SHORT ARM SPLINT
WHICH ALLOWS PROGRESSIVE MOTION TO THE WRIST.
• THE IMMOBILIZATION WILL DECREASE THE WRIST PAIN AND

CONT.…
• PATIENTS CAN THEN START WITH RANGE OF MOTION AND GRIP-
STRENGTHENING EXERCISES.
• OTHER CO-ACTIVATION EXERCISES CAN ALSO BE INCLUDED TO
IMPROVE THE GLOBAL WRIST STABILITY.
AT 8 WEEKS POST OPERATIVE:
• ACTIVE MUSCLE TRAINING SHOULD BE STARTED
• A GRADED PAIN-FREE EXERCISE PROGRAM IS RECOMMENDED.
• PHYSIOTHERAPY MANAGEMENT SHOULD INCLUDE PATIENT
EDUCATION AND ACTIVITY MODIFICATION.
• ISOMETRIC EXERCISES SHOULD BE INCLUDED TO HELP
STRENGTHEN THE AREA AND REDUCE THE RISK OF INSTABILITY.

TRIGGER THUMB / FINGER
DEFINITION
TENOSYNOVITIS OF THE FLEXOR TENDON SHEATH OCCURRING AT THE LEVEL
OF THE METACARPO PHALANGEAL JOINTS.
CAUSES
OFTEN IDIOPATHIC
MAY BE CAUSED BY DIRECT TRAUMA
DIABETES

CLINICAL FEATURES
NODULE PRESENT AT MCP JOINTS
FINGER FLEXION MAY BE PAINFUL
AUDIBLE SNAP PRODUCED WHILE DOING
EXTENSION

DUPUYTREN'S CONTRACTURE
DEFINITION
IT IS A CONTRACTURE OF THE PALMAR FASCIA OF THE RING AND LITTLE
FINGERS.
CAUSES
UNKNOWN. IN SOME PEOPLE THE CONDITION IS INHERITED
RISK FACTORS
AGE: 40 AND OVER
SEX: MALE > FEMALE
A PARENT WITH DUPUYTREN'S CONTRACTURE
DIABETES

PATHOLOGY
CHANGES IN THE PALMAR FASCIA
FIBRO PLASTIC PROLIFERATION
FIBROSIS
CONTRACTURE
CLINICAL FEATURES
SYMPTOMS ARE MILD BUT THEY BECOME
PROGRESSIVELY WORSE
RING FINGER IS USUALLY AFFECTED FIRST
FOLLOWED BY LITTLE
FINGER
NODULE PRESENT AT THE LEVEL OF METACARPO
PHALANGEAL JOINT

SURGICAL TREATMENT
MAKING SMALL INCISIONS IN THE
THICKENED TISSUE
REMOVING DISEASED TISSUE
REMOVING DISEASED TISSUE AND
OVERLYING DAMAGED SKIN, AND THEN
REPAIRING RESULTING GAPS IN SKIN WITH
SKIN GRAFTS
POST OPERATIVE SPLINTING AND
PHYSIOTHERAPY ARE VERY ESSENTIAL TO
PREVENT RECURRENCE.

DEQUERVAINS TENOSYNOVITIS
DEFINITION
INFLAMMATION OF THE TENDON SHEATH OF EXTENSOR POLLICIS BREVIS AND ABDUCTOR
POLLICIS LONGUS.
CAUSES
OVERUSE OF THE THUMB (PINCHING OR EXCESSIVE RADIAL DEVIATION)
EG- GOLFERS, SQUASH AND BADMINTON PLAYERS
CLINICAL FEATURES
INSIDIOUS ONSET
PAIN OVER THE FIRST DORSAL COMPARTMENT OF WRIST
SWELLING
TENDERNESS
LIMITED ROM
MUSCLE WEAKNESS OF APL AND EPB

SPECIAL TEST
FINKELSTEINS TEST
POSITIVE IF PAIN IS ELICITED OVER THE
FIRST DORSAL COMPARTMENT WHEN THE
THUMB IS HELD IN THE PALM AND WRIST IS
ULNARLY DEVIATED.

AIMS
TO RELIEVE PAIN
TO INCREASE ROM
TO STRENGTHEN MUSCLE

TO RELIEF PAIN
REST
ICE
ULTRA SOUND, LLLT
PHONOPHORESIS AND IONTOPHORESIS
MOIST HEAT
IONTOPHORESIS
SPLINTING
THUMB SPICA SPLINT, WITH THUMB IMMOBILIZED
IN ABDUCTION,
WRIST IN EXTENSION

TO INCREASE ROM
PAIN FREE ACTIVE ROM OF ENTIRE WRIST/THUMB
UNIT.
MODIFICATION OF ACTIVITY TO AVOID COMBINED
THUMB FLEXION AND ULNAR DEVIATION.
SURGICAL MANAGEMENT
THICKENING OF THE FIBRO-OSSEOUS CANAL
BECOME STENOTIC. RELEASE THE TIGHT
STRUCTURES.

GANGLION
The most common locations are the top
of the wrist the palm side of the wrist, the
base of the finger on the palm side, and
the top of the end joint of the finger.
The ganglion cyst often resembles a
water balloon on a stalk and is filled with
clear fluid or gel. The cause of these
cysts is unknown although they may form
in the presence of joint or tendon irritation
or mechanical changes. These cysts may
change in size or even disappear
completely, and they may or may not be
painful. These cysts are not cancerous
and will not spread to other areas

TREATMENT CAN OFTEN BE NON-SURGICAL. IN MANY CASES, THESE CYSTS
CAN SIMPLY BE
OBSERVED, ESPECIALLY IF THEY ARE PAINLESS. IF THE CYST BECOMES
PAINFUL, LIMITS ACTIVITY,
OR IS COSMETICALLY UNACCEPTABLE, OTHER TREATMENT OPTIONS ARE
AVAILABLE. THE USE OF
SPLINTS AND ANTI-INFLAMMATORY MEDICATION CAN BE PRESCRIBED IN
ORDER TO DECREASE
PAIN ASSOCIATED WITH ACTIVITIES. AN ASPIRATION CAN BE PERFORMED TO
REMOVE THE FLUID
FROM THE CYST AND DECOMPRESS IT. THIS REQUIRES PLACING A NEEDLE
INTO THE CYST,
WHICH CAN BE PERFORMED IN MOST OFFICE SETTINGS. IF NON-SURGICAL
OPTIONS FAIL TO
PROVIDE RELIEF OR IF THE CYST RECURS, SURGICAL ALTERNATIVES ARE
AVAILABLE. SURGERY
INVOLVES REMOVING THE CYST ALONG WITH A PORTION OF THE JOINT
CAPSULE OR TENDON
SHEATH IN THE CASE OF WRIST GANGLION CYSTS, BOTH TRADITIONAL OPEN
AND ARTHROSCOPIC TECHNIQUES MAY YIELD GOOD RESULTS. SURGICAL
TREATMENT IS GENERALLY SUCCESSFUL ALTHOUGH CYSTS MAY RECUR.

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Fractures.pptx