Executive Editor: Joseph Schatzker General Editor: Jonas Andermahr, Michael McKee, Diane Nam

Scapula 14.3 Body and processes, coracoid - nonoperative treatment

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Glossary

1 Introduction top

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Nonoperative treatment of a fractured scapula and postoperative care of a surgically stabilized scapula is aimed to provide mechanical support until the patient is sufficiently comfortable to begin shoulder movement.

Once rehabilitative exercises can begin one aims to restore range of motion, followed by strength, and function.

The three phases are thus

  1. Immobilization
  2. Passive/assisted range of motion
  3. Progressive resistance exercises

Duration of Immobilization should be as short as possible, and as long as necessary. Typically, immobilization is recommended for 2-3 weeks, followed by gentle range of motion exercises. Resistance exercises can generally begin at 6 weeks. Isometric exercises may help to maintain strength during the first 6 weeks.

2 Phase I: Day one top

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It is important to maintain full mobility of the unaffected joints to reduce arm swelling and to preserve joint motion. The following exercises are recommended.

  • Straightening and flexion of the elbow

Phase I: Day one enlarge

  • Bending of the wrist forward, backwards and in a circular motion.
  • Movement of an open hand from side to side


Phase I: Day one enlarge

  • Open and closure of the hand
  • Squeezing of a soft ball

 


Phase I: Day one enlarge

  • Squeezing the shoulder blades together, while shoulders remain relaxed

3 Phase II: Two to six weeks top

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Pendular exercises can be started when pain starts to subside after the first few days.


Phase II: Two to six weeks enlarge

One progresses gradually from passive to assisted active range of motion exercises making sure that assisted active abduction is done without elevation of the shoulder.


Phase II: Two to six weeks enlarge

Active assisted range of motion exercises are started with:

  • External rotation
  • Internal rotation
  • Forward flexion with the arms on the table
  • Forward flexion and elevation of the arm with a ball on the wall

Phase II: Two to six weeks enlarge

Sub-maximal isometric exercises with:

  • internal rotation
  • external rotation
  • abduction
  • extension

Note: Timing and progression of exercises is ultimately directed and determined by the operating surgeon since such factors as bone quality, type of fracture and fixation may vary from case to case.

4 Sling and swath top

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Optimal shoulder immobilization is achieved when the upper arm and forearm are secured to the chest. Traditionally, this has been done with a sling that supports the elbow and forearm and counteracts the weight of the arm. The simplest sling is a triangular bandage tied behind the neck.

Additional support is provided by a swath which wraps around the humerus and the chest to restrict further shoulder motion, and keep the arm securely in the sling.
Commercially available devices provide similar immobilization, with or without the circumferential support of a swath.

5 Shoulder immobilization top

Sling and swath (A), shoulder immobilizer (B), Gilchrist bandage (C), and other such devices all provide essentially similar support for the shoulder joint.

6 Activities of daily living top

Sleeping enlarge

Sleeping

The patient should sleep wearing the sling and lie either on his back or on the non-injured side.

When sleeping on the back, the injured side should be supported by placing a pillow underneath the arm and shoulder.

Some patients may find it more comfortable to sleep in a sitting or semi reclined position.


Sleeping enlarge

When sleeping on the side, a pillow can be placed across the chest to support the injured side.


Hygiene enlarge

Hygiene

A non-slip mat in the shower/bath tub will improve safety. The arm can hang gently at the patient's side while showering. Axillary hygiene is important. If assistance is not available, a long-handled sponge can be used to wash the back and legs.


Dressing enlarge

Dressing

Loose fitting clothing and button-up shirts are ideal. The unaffected arm may be used for buttoning and unbuttoning. The affected arm is dressed first, then the non-affected arm.  When undressing, start with the non-affected arm, then the affected arm.

7 Shoulder abduction cushion top

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In the case of coracoid fractures or acromial fractures and rotator cuff surgery, one attempts to relieve tension by elevation and abduction of the extremity. This can be achieved with the aid of a so-called airplane splint or an abduction cushion as shown in this diagram.

8 Mobilization: 2-3 weeks posttrauma top

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Nonoperative management of scapular fractures usually begins with maximal support - a sling and swath equivalent worn continuously. If the patient finds lying down uncomfortable, then a sitting position may be preferred for sleeping.

A patient who is very comfortable, at the beginning of treatment or after some recovery, may need less immobilization, and even begin gentle use of the injured arm.

The degree of required immobilization and the rate progression may be speeded up as comfort permits.


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When pain permits, begin with pendulum exercises (as illustrated).


Mobilization: 2-3 weeks posttrauma enlarge

At the same time active hand and forearm use should also be encouraged.


Mobilization: 2-3 weeks posttrauma enlarge

Isometric exercises can begin as soon as tolerated for the shoulder girdle including scapular stabilizers, and the upper extremity.
X-rays should be checked to rule out secondary fracture displacement.

9 Active assisted exercises: 3-6 weeks postoperative top

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As comfort and mobility permit, and fracture consolidation is likely, the patient should begin active assisted motion. Physical therapy instructions and/or supervision are provided as desired and available.

If passive range of motion exercises are progressing satisfactory, one can then cautiously progress to active assisted.

10 Shoulder therapy set: 3-6 weeks postoperative top

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A “shoulder therapy set” might be helpful. Typically included devices are:

1) An exercise bar, which lets the patient use the uninjured left shoulder to passively move the affected right side.


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2) A rope and pulley assembly. With the pulley placed above the patient, the unaffected left arm can be used to provide full passive forward flexion of the injured right shoulder.

11 Strengthening: from week 6 on top

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As passive motion improves, and active assisted exercises progress satisfactory, and the fracture becomes fully consolidated one can begin strengthening. First one strengthens by active motion against gravity. To increase muscle strength, one must increase the resistance against which the muscles are working. Endurance training follows.

Beware of premature forward flexion which is done passively but puts a significant strain on the supraspinatus and its repaired tendon.

Elastic devices are useful in providing varying degrees of resistance. Ultimately the athletic patient can progress to resistance machines and free weights.

Physical therapy instruction and supervision may be helpful for optimal rehabilitation or if the patient is not progressing satisfactorily.
Remember to monitor rotator cuff strength. Significant weakness may indicate an unidentified rotator tendon cuff rupture which is in need of surgical repair.

12 Pitfall: shoulder stiffness top

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To reduce the risk of stiffness, immobilization should be discarded as soon as possible. This can be done progressively, beginning with elimination of the swath (circumferential bandage) during the daytime and encouraging pendulum exercises.
The sling may be used on a part-time basis as soon as appropriate.
If formal physical therapy has not been prescribed, it should be considered for any patient whose range of motion is not improving as expected.

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