REHABILITATION OF HUMERUS FRACTURE FROM 20-90 YEARS

CASE STUDY OF JMILITARY HOSPITAL AND ICRC JUBA

BY

VIOLA KEJI FLEIX

INDEX NUMBER: SMC/19/031/REH

SUPERVISOR: ERICA BONETTI

A RESEARCH PROJECT SUBMITTED TO THE SCHOOL OF

REHABILITATION SCIENCE

IN THE DEPARTMENT OF PHYSIOTHRAPY IN PARTIAL

FULFILMENT OF THE

REQUIREMENT FOR AWARD OF BACHELOR DEGREE IN

PHYSIOTHRAPY

ACADEMIC YEAR 2023-2024

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 DECLARATION

I VIOLA KEJI FELIX MICHAEL here by declaring that this thesis represents my
own work, which has been under supervision, and it was my own ability to start until I
finish nobody has ever presented this research project.

Student Name………………………… Signature…………………………

Date………………………….

I
 APROVAL

This thesis had been submitted for examination with our approval as the college
supervisors of St. Mary’s University College School of Rehabilitation Sciences.

Supervisor Name……………………….

St. Mary’s University College

School of rehabilitation Sciences

Signature………………………………………

Date………………………………………………

Dean of the School of Rehabilitation Sciences

Name…………………………………………….

Signature…………………………………………

Date……………………………………………….

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 DEDICATION

I am so delight to the almighty God for keeping me save and healthy from the beginning
of my studies until the end that am able to reached this so far.

I also dedicate this research project to my lovely father who raised me from birth until
today and for paying my tuition fees although there were challenges but I thank God not
forgetting my elder brother who really helped me by advising me always and his
financial support in the process of this research compellation.

Not forgetting you mom, thank you for checking every time every moment although you
are not near me, I believe that one day I will see you when you come back. See you soon
mummy.

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 ACKNOLEGEMENT

I would like to acknowledge all the entire teaching staff and non-teaching staff of Saint
Mary’s University College-Juba for their contribution towards the academic milestone. I
am very delight to the dean of faculty; Elena Roncoroni (PT.) for her administrative role-
played in running the affairs of the School of Rehabilitation Sciences until our
completion. Her guidance and positive feedbacks made me complete this research
project.

I sincerely acknowledge my supervisor Erica Bonetti for the tireless responses for me
during this research season.

I also want to acknowledge Fr. Alfred Ladu Modi for the great role played during this
journey. You always encourage us to be the good. Your guidance, medical oath you
though it will forever be implemented and your advice contributed intensively in
achieving this academic journey.

I acknowledge my fellow colleagues for the help they offered me academically.

I would like to acknowledge the friends of goodwill and family members who gave me
the morale, financial and spiritual support throughout my academic journey.

I am so grateful for my patients who were so cooperative in following their treatment

despite of their laziness.

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 Table of Contents
DECLARATION..................................................................................................................................I
APROVAL...........................................................................................................................................II
DEDICATION....................................................................................................................................III
ACKNOLEGEMENT........................................................................................................................IV
LIST OF ABBREVISION...............................................................................................................VIII
ABSTRACT........................................................................................................................................IX
CHAPTER ONE..................................................................................................................................1
GENERAL INTRODUCTION...........................................................................................................1
1.1General introduction.....................................................................................................................1
1.2 Background of the study..............................................................................................................1
1.3 Statement of the problem.............................................................................................................4
1.4 Purpose of the study....................................................................................................................4
1.5 Specific objectives.......................................................................................................................4
1.6 Research questions......................................................................................................................4
1.7 Significance of the study..............................................................................................................5
1.8 Scope of the study........................................................................................................................5
Content scope..................................................................................................................................5
Geographical scope.........................................................................................................................5
Time scope.......................................................................................................................................5
Sample size scope............................................................................................................................5
1.9 Layout of the study......................................................................................................................5
1.10 Definition of key term...............................................................................................................6
1.11Conceptual Framework...............................................................................................................6
CHAPHTER TWO..............................................................................................................................7
LITERATURE REVIEW...................................................................................................................7
2.1 Introduction.................................................................................................................................7
2.2 Causes of humerus fracture........................................................................................................10
2.3 Types of humerus fracture.........................................................................................................10
2.3.1 Proximal fracture....................................................................................................................10
2.3.2 Mid-shaft humerus fracture.....................................................................................................14
2.3.3Distal Humerus fracture...........................................................................................................15
2.4 Risk factors for humerus fracture...............................................................................................16
2.5 Complications of humerus fracture............................................................................................17
2.6Treatment for Humerus Fracture.................................................................................................18

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 2.6.1 Non -surgical treatment for Humerus fracture........................................................................18
2.6.2 Surgical treatment for Humerus fracture.................................................................................21
CHAPTER THREE...........................................................................................................................25
RESEARCH METHODOLOGY AND DESIGN............................................................................25
3.0 Introduction...............................................................................................................................25
3.1 Research design.........................................................................................................................25
3.2 Population of the study..............................................................................................................25
3.3 Sample selection and size..........................................................................................................26
3.4 Areas of the study......................................................................................................................26
3.5 Data collection method and instruments....................................................................................26
3.6 Data collection procedures.........................................................................................................26
3.7 Data analysis..............................................................................................................................26
3.8 Limitation..................................................................................................................................27
3.9 Delimitation...............................................................................................................................27
3.10 Definition of key terms............................................................................................................27
CHAPTER FOUR.............................................................................................................................29
DATA PRESENTATION, ANALYSIS, INTERPRETATION AND DISCUSSION...................29
4.1Case study 1................................................................................................................................29
4.2 Case study 2...............................................................................................................................30
4.3 Case study 3...............................................................................................................................31
4.4Case study 4................................................................................................................................32
4.5Case study 5................................................................................................................................33
CHAPTER FIVE...............................................................................................................................35
SUMMARY OF THE FINDINGS, LIMITATION, CONCLUSION AND
RECOMMENDATION.....................................................................................................................35
5.1 Summary of the findings............................................................................................................35
5.2 Conclusion.................................................................................................................................36
5.3Recommendation........................................................................................................................37
REFERENCES..................................................................................................................................38

VI
List of Figures

Figure 1:showing conceptual framework.............................................................................................

Figure 2:showing Anatomy of the humerus bone................................................................................

Figure 3showing the four categories of proximal humeral fracture.....................................................

Figure 4 Showing proximal humerus fracture according to the neer classification a)one-part
b)two-part c)three part d)four-part ......................................................................................................

Figure 5 showing midshaft humerus fracture.......................................................................................

Figure 6 showing distal humerus fracture............................................................................................

Figure 7: showing arm immobilization................................................................................................

Figure 8: showing shoulder pulley.......................................................................................................

Figure 9: showing intramedullary nail fixation of a proximal humerus fracture..................................

Figure 10: showing hemi arthroplasty of humerus fracture.................................................................

Figure 11: showing reverse shoulder arthroplasty...............................................................................

VII
 LIST OF ABBREVISION

RTA: Road Traffic Accident.

ICRC: International Committee of the Red Cross.

JMH: Juba Military Hospital.

CDC: Center for Disease Control.

PHF: Proximal Humerus Fracture.

RSA: Reverse Shoulder Arthroplasty.

BMD: Bone mineral density.

NSAIDS: Non-steroidal Anti-inflammatory Drugs.

GWS: Gunshot Wound.

OT: Operation Theater.

VAS: Visual Analog Scale.

VIII
 ABSTRACT

Background: Humerus fracture is a break on the long upper limb bone that articulate
with the scapula at the glenohumeral joint and the radius and ulnar at the elbow joint, it
can occur proximally, midshaft, and distally. It mostly happens to victims who are old
due to their bone mass being low and a ratio of 3:1 which is 75 % females and 25
%males, not only this but also its RTA, Gunshot, Falls. Low bone mineral density, visual
impairment, some previous fractures and lack of calcium can lead to high risk of
humerus fracture. Neurovascular injuries are the early complications after humerus
fracture and some of this include stiffness, which is the most common.

Objectives of the study: To determine the causes of humerus fracture, to fine out the
types of humerus fracture, and finally to determine the possible physiotherapy
management of humerus fracture in adults

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Methodology: A descriptive case study was used in gathering raw data from ICRC/JMH
in Juba. The target populations were Humerus fracture victims and physiotherapist. A
sample of three physiotherapists, five patients who were all males was randomly and
purposively selected from ICRC/JMH.

Results: The researcher found that nearly 80percent of humerus fracture are non-
displaced and can be treated non-operatively. The elderly are the most victims to be
treated surgically due to their bone being week and not growing anymore.

The researcher found; all the patients complain of pain. In the case study 3 percent
patients complained of mild pain, 1 percent complains of moderate pain and 1 percent
complains of severe pain therefore after three weeks the pain reduced from mild to
normal from moderate to normal and from severe to moderate.

Conclusion: The study concludes that, the early the better for humerus fracture to be
intervene to avoid deformities such as stiffness, and complications, which includes nerve
injuries.

In addition, to give patients to room to do their activities of daily living independently.

Finally, language barrier had become a challenge for the researcher to do treatment of the
patients.

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XI
 CHAPTER ONE

GENERAL INTRODUCTION

1.1General introduction.

This research will base on the topic of Rehabilitation of humerus fracture from age
20-90years.’’ Case study of ICRC/JMH. This research tends to provide possible
solution to humerus fracture victims in ICRC/JMH in other parts of Juba town. And,
in this chapter, the following will be handled: The background of the study,
statement of the problem, purpose of the study, research objectives, research
questions, justification, scope of the study, the layout of the study, conceptual
framework, and definition of key terms.

1.2 Background of the study.

A humerus fracture is a condition that occurs when there is a break in the humerus that
commonly occurs because of severe trauma. Fracture of the humerus can affect the
movement and function of your arm as well as your work and activities of daily living.
Humerus fractures are quite common and occur in individuals of all ages from children
to the elderly (Anon., n.d.)

Humerus fracture is the medical term for breaking a bone. You can break your humerus
during trauma, like a fall or car accident. Some people also experience humerus fractures
during playing sports (Anon., 2023)

Humerus fractures comprise approximately all adult fractures, and their incidence
increases with age. As such, comorbidities and bone quality can complicate clinical
decision-making. These injuries represent a significant burden to the patients themselves,
as well as the healthcare system. Humeral fractures can involve the proximal, shaft, or
distal aspect of the bone and management depends on the location of the fracture. The
most common humeral fracture occurs in the proximal humerus. Accounting for
approximately half of all humerus factures, these injuries are a common fragility fracture
in older adults and remain one of the most controversial orthopedics trauma injuries to
treat. While there is more consistent evidence surrounding the management of humeral

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shaft and distal humerus fractures, there are still many issues to consider regarding
optimal treatment (Anon., 2018)

Humeral fractures are among the most common fractures in the elderly and in adults.
These fractures are more simple fractures and do not cause problems after treatment.
However, sometimes when some important points are neglected during treatment, this
may lead to some complications and it is becoming very serious problems. According to
the Centers for Disease Control and Prevention (CDC), at least 250,000 people age 65 or
older are hospitalized with fractures each year. The reasons vary according to the
patient’s age. Sometimes the fracture may be the result of a sharp object or a gunshot
wound (Razaq, 2019)

Proximal humeral fractures (PHF) account for all adult fractures. There is increasing
recognition given in regard to managing these fractures in the setting of elderly, low-
energy falls as these events are contributing to the global impact of direct and indirect
costs of osteoporosis and fragility fractures (Pencle, 2021).

Proximal humeral fracture (PHF) can be managed surgically and non-surgically. Locking
plates have been the preferred head-preserving surgical technique while hemi
arthroplasty (HA) or reversed shoulder arthroplasty (RSA) have been used in join
replacement surgery (Stig Brorson , 2022).

The ultimate goal of management of proximal humeral fractures in the patient is to get
the patient independently mobile. This relies on a multidisciplinary team approach in
which operative intervention may or may not be indicated.

Many authors have suggested that up to 85% do not require surgery. Despite this, there
appears to be a trend towards increased surgical intervention, which has been attributed
to newer designs of plating systems, as well as the promotion of the reverse shoulder
replacement as a treatment option. The ideal outcome for a patient with a PHF is a pain-
free shoulder with an acceptable range of motion according to the individual's specific
functional requirements (Anley C, Vrettos BC,Rachuene P,Roche SJL, 2019)

Humeral shaft fractures are common injuries. Like many orthopedics injuries, they have
a bimodal distribution, occurring in both younger patients due to high-energy trauma and

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in elderly patients following low impact injuries. Due to the location of the radial
nerve within the spiral groove, there is a reasonably high risk of injury; the overall
incidence is around 10%, although this is much higher (~25%) in Holstein-Lewis
fractures (as discussed below). The risk factors for humeral shaft fractures
include osteoporosis, increasing age, or previous fractures. Humeral shaft fractures can
also occur as pathological fracture (Anon., 2022).

Humeral shaft fractures may be defined as the disruption of the bony cortex along the
diaphysis aspect of the humerus. The earliest records of this injury come from around
1600 BC in ancient Egypt, with references in Greco-Roman texts such as Corpus
Hippocratic. More recent twentieth-century literature demonstrates that this was a
difficult fracture to treat, and in 1924 Campbell stated that delayed, and non-union
occurred more often in fractures of the shaft of the humerus than in any other long bone’,
which was later corroborated in 1935 by Chorley and Mors of the Mayo Clinic who
found a 65% non-union rate (Ahmed Daoub, Pedro Migual Oliveira,Ferreira,Srinivas
Cheruvu, Matthew Walker,William Gibson,Georgios Orfanos, Rohit,Singh, 2022).

A distal humerus fracture is a break in the lower end of the upper arm bone (humerus),
one of the three bones that come together to form the elbow joint. A fracture in this area
can be very painful and make elbow motion difficult or impossible. Most distal humerus
fractures are cause by some type of high-energy event such as receiving a direct blow to
the elbow during a car collision. In an older person who has weaker bones, however,
even a minor fall may be enough to cause a fracture. Treatment for a distal humerus
fracture usually involves surgery to restore the normal anatomy and motion of the elbow
(Anon., n.d.)

Distal humerus fractures in the adult population represent about 2% of all fractures and
33% of all humerus fractures. They typically present in a bimodal distribution as either
younger males or elderly females. They are usually the result of high-energy trauma in
the young population and low-energy falls in the more elderly patient. These
fractures can be very challenging to manage, as they often can involve an articular as
well as a diaphysis component. As with all intra-articular fractures, anatomic reduction
of the articular surface is paramount in keeping the chances of developing post-traumatic
arthritis as low as possible. This often requires surgical intervention to achieve, with

3
specific rehabilitation protocols set in place for successful recovery and to avoid certain
complications, such as elbow stiffness, heterotopic ossification, and nerve injury (Crean,
2022).

According to (Lotto, 2023) in South Sudan, fracture of humerus can be the result of
numerous factors, the most common being treated in ICRC/ Juba Military hospital is
trauma related to gunshot wound. Fracture of humerus if not correctly manage it affects
functioning and quality of life at varying degree depending on the level of fracture. The
more proximal more resulting in greater loss of function.

1.3 Statement of the problem.

Humerus fracture is a break in the upper arm bone. Physiotherapist in ICRC/JMH tried to
manage it, but not to the best content. It is a problem because it can affect the functional
movement of the upper limb when a nerve is damage that can restrict patient from doing
the activities of daily living. The victims are adults and females are more affected than
males. It is normally occurs inform of fall on an outstretch hand this has promoted the
researcher to carry out research on humerus fracture. This has become rampant in South
Sudan that requires special attention.

1.4 Purpose of the study.

The purpose of this study is to question humerus fracture in adults in ICRC/Juba

military hospital. Moreover, the research intends to find out the causes of humerus
fracture in adults, types of humerus fracture in adults, and the possible solution for the
rehabilitation of humerus fracture in adults

1.5 Specific objectives.

To determine the causes of humerus fracture, to fine out the types of humus fracture, and
finally to determine the possible physiotherapy management of humerus fracture in
adults

1.6 Research questions.

1.6.1What are the causes of humerus fracture in adults aged 20-90 years old?

4
1.6.2What are the types of humerus fracture.

1.6.3. What are the possible techniques and treatment of managing humerus fracture in
adults?

1.7 Significance of the study.

There are a lot of complication if it is not properly intervene. The study will help the
researcher gain more knowledge and to find out new management of humerus fracture

1.8 Scope of the study.

The scope of the study covers the following areas:

Content scope. Physiotherapy management of humerus fracture in adults aged 20-90

years old.

Geographical scope. The research project will be carried out at ICRC/JMH in Jebel,
Juba the capital of South Sudan.

Time scope. This research will be from June 2023 to October 2023.

Sample size scope. The research will include seven participants that will be two
physiotherapists and five patients.

1.9 Layout of the study.

Chapter one. Included general overview of the study, statement of the problem,
objective of the research, justification of the study, research questions, organization of
the study, definition of key terms and conceptual framework.

Chapter two. Covers literature review which information was obtained from secondary
sources and some previous researches. This will be reviewed thematically.

Chapter three. Covers research design, area of the study, population of the study,
sampling procedure, sample size, sampling techniques, data collection approach, data
sources, data quality control, data management and processing, data analysis, ethical
consideration and limitations.

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Chapter four. Concerned with primary data presentation, analysis and discussion.
Chapter five. Included summary of key findings, general conclusion.

1.10 Definition of key term.

Research. Is a systematic investigation to establish facts.

Physiotherapy. Therapy that uses physical agents.

Osteoporosis. A condition in which the bone becomes weak.

Multidisplinary team. A group of professional working together.

Immobilization. Is the process of stopping something from moving.

Range of motion. The extent to which a part of the body can be moved.

Complication. Is a secondary result of a condition if not well managed.

Femoral neck. Is the neck of the femur.

Heterotopic ossification. Abnormal formation of the bone.

1.11Conceptual Framework.

The researcher attempts to analyse the relationship between the independent, dependent
and intervening physiotherapy management of humerus fracture.

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Figure 1: showing conceptual framework.

Independent variables Dependent variables

 Falls  Humerus fracture

 Gunshot  Adults
 Vehicles
accidents

Intervening Variables

 Orthopedic surgeons
 Physiotherapist
 Nurses

CHAPHTER TWO

LITERATURE REVIEW

2.1 Introduction.

In this chapter, the researcher will consult books; magazine, Newspapers, internet and
reports related to the topic of humerus fracture cases in order to come up this chapter.

Anatomy of the humerus.

The humerus (arm bone), the largest bone in the upper limb, articulates with the scapula
at the glenohumeral joint, and the radius and ulna at the elbow joint. The proximal end of

7
the humerus has a head, surgical and anatomical necks, and greater and lesser tubercles.
The spherical head of the humerus articulates with the glenoid cavity of the scapula. The
anatomical neck of the humerus is formed by the groove circumscribing the head and
separating it from the greater and lesser tubercles. It indicates the line of attachment of
the glenohumeral joint capsule. The surgical neck of the humerus, a common site of
fracture, is the narrow part distal to the head and tubercles. The junction of the head and
neck with the shaft of the humerus is indicated by the greater and lesser tubercles, which
provide attachment and advantage to some scapulohumeral muscles. The greater tubercle
is at the lateral margin of the humerus, whereas the lesser tubercle projects anteriorly
from the bone. The intertubercular sulcus (bicipital groove) separates the tubercles, and
provides protected passage for the slender tendon of the long head of the biceps muscle.
The shaft of the humerus has two prominent features: the deltoid tuberosity laterally, for
attachment of the deltoid muscle, and the oblique radial groove (groove for radial nerve,
spiral groove) posteriorly, in which the radial nerve and profunda brachii artery lie as
they pass anterior to the long head and between the medial and the lateral heads of the
triceps brachii muscle. The inferior end of the humeral shaft widens as the sharp medial
and lateral supra-epicondylar (supracondylar) ridges form, and then end distally in the
especially prominent medial epicondyle and the lateral epicondyle, providing for muscle
attachment. The distal end of the humerus including the trochlea, capitulum, olecranon,
coronoid, and radial fossae make up the condyle of the humerus. The condyle has two
articular surfaces: a lateral capitulum (L. little head) for articulation with the head of the
radius, and a medial, spool-shaped or pulley-like trochlea (L. pulley) for articulation with
the proximal end (trochlear notch) of the ulna. Two hollows, or fossae, occur back-to-
back superior to the trochlea, making the condyle quite thin between the epicondyles.
Anteriorly, the coronoid fossa receives the coronoid process of the ulna during full
flexion of the elbow. Posteriorly, the olecranon fossa accommodates the olecranon of the
ulna during full extension of the elbow. Superior to the capitulum anteriorly, a shallower
radial fossa accommodates the edge of the head of the radius when the forearm is fully
flexed (Keith L.Moore,Arthur F.Dalley,Anne M.R. Agur,
2014,2010,2006,1999,1992,1985,1980) (Charlotte O`Lesry BSc,MBChB, n.d.)

8
Figure 2:showing Anatomy of the humerus bone.

Source: (Keith L.Moore,Arthur F.Dalley,Anna M.RAgur, 2014,2010,2006).

9
2.2 Causes of humerus fracture.

According to (Lotto, 2023), fracture of humerus can be the result of numerous factors,
the most common being treated in ICRC/ Juba Military Hospital is trauma related to
gunshot, car accident, motorcycle accident and sports accident.

Humerus fractures can be pathologic fractures, which happen as the result of a condition
that weakens your bones. This leaves your bones more vulnerable to breaks from
everyday activities that would not usually cause any injuries. Pathologic humerus
fractures can be cause by bone cancer, osteoporosis, bone cysts or tumor and bone
infection (Anon., 2018)

Humerus fractures are caused by direct trauma to the arm or shoulder or by axial loading
transmitted through the elbow. Attachments from pectoralis major, deltoid, and rotator
cuff muscles influence the degree of displacement of proximal humerus fractures
(Adarsh K Srivastava,MD, 2019)

Age. Approximately 75% of proximal humeral fractures occur in people over the age of
60 because bones get weaker and more brittle with age, making them more likely to
break. Fractures of the proximal humorous are the third most common type of broken
bone in the 65’s after hip and wrist fractures (Wilson, 2015-2023).

Low energy trauma can cause proximal humeral fracture due to fall from a standing
position or a direct blow to the shoulder and vehicles accidents (Anon., n.d.)

2.3 Types of humerus fracture.

Humerus fracture is a break in the upper arm bone that connects the shoulder to the
elbow are generally divided into three types based where they occur.

2.3.1 Proximal fracture.

Is a break in the top part of the humerus they can be categorized into:

Greater tuberosity fractures: Greater tuberosity is the insertion site for attachment of
rotator cuff tendons. Greater tuberosity fractures are less common and are seen in cases
of shoulder dislocations and in those with osteoporosis. Greater tuberosity fragment is

10
pulled off when cuff muscle contracts or anterior shoulder dislocates. Direct impact to
the shoulder causes the tuberosity bone to break into multiple fragments partial rotator
cuff tears often accompany non-displaced fractures and these fractures can be diagnosed
using MRI.

Lesser tuberosity fractures: These fractures often caused by posterior shoulder

dislocations or traumatic muscle contractions by electrical shock or convulsions. If left
untreated, these fractures cause subscapularis muscle (stabilizer and mobilizer muscle)
deficiency and requires a major muscle transfer procedure.

Surgical neck fractures: Fractures of the surgical neck are most common in patients
with osteoporotic bone. These fractures also damage the axillary nerve that carries
sensory information from shoulder.

Humeral head fractures: Humeral head fractures are very often in elderly individuals
and chances are more in those with osteoporotic bone. These fractures occur in younger
individuals by significant trauma whereas a mild traumatic injury can cause fracture in
elderly individuals with osteoporosis (Anon., n.d.)

Figure 3showing the four categories of proximal humeral fracture

11
Source: (Anon., n.d.)

Classification of the proximal humeral fracture.

Proximal humeral fracture is classified into the Neer classification.

Figure 4 Showing proximal humerus fracture according to the neer classification a) one-
part b) two-part c)three part d)four-part .

12
Source: (Anon., n.d.)

One-Part Fractures.

13
A one-part proximal humeral fracture is where there is no bone displacement. Any one or
more of the four parts may be fractured, but there is less than 1cm separation and less
than 45-degree angulation.

For example, there could be a fracture of the surgical neck and the greater tuberosity, but
as long as neither of the parts are displaced, it is still classed as a one-part fracture.

Almost 75% of proximal humeral fractures are one part fractures.

Two Part Fractures.

Two part fractures are where one part is displaced more than one cm or rotated more
than 45 degrees. Again, there may be multiple fractures in multiple parts, but only one
part is displaced here.

Approximately 20% of proximal humeral fractures are two part fractures.

Three Part Fractures.

Three part proximal humeral fractures are where two parts are displaced. There will most
likely be displacement of the surgical neck and one of the tuberosities (most commonly
the greater tubercle), while the other tuberosity remains attached.

Approximately 5% of proximal humeral fractures are three part fractures.

Four Part Fractures.

This is where all four parts of the proximal humorous are fractured with three of them
displaced in relation to the fourth. Four part proximal humeral fractures are a rare (less
than 1%) but severe injury and almost always requires surgery (Fabio J.Pencle,Matthew
Varacallo, 4 september 2022)

2.3.2 Mid-shaft humerus fracture.

Is the fracture of the humerus bone that lies between the proximal and the distal aspect of
the bone? The shaft of the humerus constitutes of the middle third of the entire humerus.
It is cylindrical but distally it becomes triangular (SINGH, 2022)

14
Figure 5 showing midshaft humerus fracture.

Source: (SINGH, 2022)

2.3.3Distal Humerus fracture.

A distal humerus fracture occurs when there is a break anywhere within the distal region
(lower end) of the humerus. The bone can crack just slightly or break into many pieces
(comminuted fracture). The broken pieces of bone may line up straight or may be far out
of place (displaced fracture) (Anon, n.d.)

Figure 6 showing distal humerus fracture.

15
Source: (Anon, n.d.)

2.4 Risk factors for humerus fracture.

Some factors related to low bone energy mass including number of fracture since45years
and low dietary calcium intake is associated with increased risk of humeral fracture
(Sarah P.Chu,Jennifer L. Kelsey,Therasa H.M. Keegan,Barbara Sternfeld,Milla
Prill,Charles P.Quesenberry,Stephen Sidney, 15 August 2004).

Low bone mineral density (BMD) has long been recognized as a major risk factors for
fracture in the elderly. In the elderly, falling appears to be another major determinant of
humerus fractures, because most appendicular fractures are the consequence of a fall
(Sun H.Lee,Patricia Dargent-Molina Ph.D.,Gerard Breart, 2 December 2009), (Jennifer
K Kelesy,Warren S Browner,Dana G Seeley,Micheal C Nevitt,Steven R Cummings,
1992).

Visual impairment. Visual impairment is assumed as an indicator for a higher risk of to

fall since reduced vision leads to an impossible looking of obstacles in the daily life and
there are different comorbidities that go along with visual impairment e.g. DM (Anon.,
13 may 2017).

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2.5 Complications of humerus fracture.

Early complications may include nervous injury (brachial plexus) and vascular injury
(axillary artery) that occur during trauma as a result of dislocation of bony fragments and
concomitant rotator cuff lesions (Giorgio Maria Calori,Massimiliano Colombo, Miguel
Simon Bucci, Piero Fadigati,Alessandra Ines Maria Colombo,Simone Mazzole, Vittrorio
Cefalo.Emilio Mazza, October), (Emily J.Bounds;Nicholas Fran;,Lawrence Jajou;
Stephanie J.Kok., 2023)

Stiffness is the most common sequela after ORIF of distal humeral fractures and is often
observed even after optimal stable fixation and proper rehabilitation. Sanchez-Sotelo et
al treated 34 complex distal humeral fractures with the parallel plate technique and
reported only 41% of elbows obtained at least 30° of extension and 130° of flexion.
While some authors reported that about one-third of patients failed to regain functional
arc of motion after ORIF of intercondylar fractures, most patients can expect to have
good to excellent results (Anon., 2018).

Pin migration is a common complication following CRPP of proximal humorous

fractures with potentially devastating complications. Previous studies have demonstrated
that threaded pins placed into the proximal humorous can migrate and cause
neurovascular injury to major vascular or intra thoracic structures. There is an increased
risk of infection if pins are left protruding through the skin. Superficial infections are
typically treated with pin removal, local wound care, and oral antibiotics. However,
deeper infections, though less common, can lead to complications including
osteomyelitis. (Hayden P.Baker, Joseph Gutbrod, Jason A.Strelzow, Nicholas H.Maassen
and Lewis Shi, 18october2022).

Loss of reduction and malunion more commonly occur than nonunion. Varus angulation
of the articular surface and poster superior displacement of the greater tuberosity are the
most common malunions, which can lead to sub acromial impingement pain, and loss of
function. There is a higher risk of early pin loosening and loss of fixation in patients with
osteoporosis and increased age (Anon., 2/November/2022), (Wilson, n.d.) (Aggarwal,
2019)

17
2.6Treatment for Humerus Fracture.

2.6.1 Non -surgical treatment for Humerus fracture.

Nearly 80% of proximal, humeral fractures are un displaced or only minimally displaced
fractures and non-operative treatment is appropriate and it include;

Immobilization.

The fracture needs to be completely immobilized for 10-14 days to allow time for the
bones to start knitting back together and healing, so the sling must be worn all the time
initially, day and night. After this, you can gradually reduce how much you wear the
sling and by around 12 weeks, you should not need it at all.

Typically, a shoulder immobilizer or sling and swath are used. These support the elbow,
forearm, and counteract the weight of the arm. The extra strap around the body helps to
keep the upper arm immobilized.

In some cases of proximal humeral fractures, a collar and cuff sling is used instead. They
provide less support but allow the weight of the arm to provide gentle traction which can
help improve the alignment of the fracture.

Figure 7: showing arm immobilization

18
Source: (Anon., n.d.)

Medication.

Medication to relieve pain and inflammation after a proximal humeral fracture will be
prescribed by your doctor such as NSAIDS – non-steroidal anti-inflammatories e.g.
ibuprofen or naproxen. If you have an open fracture, you will also be given antibiotics to
reduce the risk of infection.

Exercises.

For the first couple of weeks after a proximal humeral fracture the shoulder should be
immobilized in the sling, but it is important to do elbow, wrist and hand exercises to
prevent any stiffness or weakness. Usually you can take your arm out of the sling to do
these.

Exercises should be started as soon as possible and be done at least four times a day. It is
important to move the elbow, wrist and fingers through their full range of motion to
prevent stiffness and handgrips and balls are a great way to maintain strength.

After 10-14 days, patient should be able to start gentle exercises to get the shoulder
moving. A physiotherapist will work on a rehabilitation program with patient. Pendulum
exercises are the best place to start for regaining mobility. These are exercises where
patient use gravity to move the arm so the muscles do not have to do anything, so they do
not pull on the fracture site.

After around three weeks patient can start, active assisted exercises where patient use the
good arm or a bar/stick to support and move the broken arm. Patient may also be given a
pulley system to use.

In terms strengthening, patient will start with isometric exercises. These are exercises
where patient push against resistance but without moving the arm so that patient do not
aggravate the fracture site. Patient may be allowed to start these as soon as pain allows or
patient may need to wait until the fracture has fully healed – check with their doctor or
physical therapist.

19
After approximately six to nine weeks the fracture should have united and patient can
move on to active mobility exercises and progressive strengthening exercises
including resistance band exercises to regain rotator cuff strength.

Rehabilitation will continue until patient have regained full movement, strength and
stability in the shoulder and elbow. Patient may need to keep doing exercises for up to a
year to achieve this. Not everyone does regain full range of movement after a proximal
humeral fracture and some people will have ongoing difficulty lifting their arm above
head height.

It is essential to rigorously follow your rehabilitation program and do exercises daily to

ensure patient regain as much range of motion, flexibility and strength as possible.
Failure to do so will lead to reduced shoulder movement, which will likely affect
function.

Patient’s doctor will see patient regularly and x-ray the shoulder periodically to check on
the healing process. Everyone heals at different rates so follow the guidance of patient’s
doctor or physical therapist as to when patient can progress to the next stage of
rehabilitation.

Figure 8: showing shoulder pulley.

20
Source: (Anon., n.d.)

2.6.2 Surgical treatment for Humerus fracture.

Intramedullary nail.

Traditionally intramedullary nailing has been used to treat humeral shaft fractures. The
development of nails with polyaxial screws has given the implant more stability making
it a valid option for the management of proximal humeral fractures. Difficulties in
accurately reducing the fracture and fixing the tuberosity fragments make two-part
fractures more amenable to nail fixation than three- or four-part fractures and even then,
this may be inferior to fixation with locking plates. The advantage of the technique is
that less soft tissue disruption is required at the fracture site lessening the risk of
revascularization of the humeral head and fracture fragments. However, care should be
taken when treating proximal and comminuted fractures to avoid propagation of fracture
and the entry point violates the rotator cuff and has been reported to lead to residual
shoulder pain. An example case managed with an intramedullary nail.

21
Figure 9: showing intramedullary nail fixation of a proximal humerus fracture.

Source: (Anon., n.d.)

Hemi arthroplasty.

Neer first described the use of hemi arthroplasty for proximal humeral fractures reporting
a 98% satisfactory or excellent rate. The procedure provides immediate stability and
provides patients with reliable pain relief following surgery. However, its ability to
restore normal shoulder kinematics and function is debated. Indications for hemi
arthroplasty include fracture dislocations and humeral head splitting fractures.

22
Figure 10: showing hemi arthroplasty of humerus fracture.

Source: (Anon., n.d.)

Reverse arthroplasty.

Traditionally the reverse shoulder arthroplasty was designed and used for degenerative
rotator cuff arthroplasty. The reverse arthroplasty functions by medialising and lowering
the center of rotation of the glenohumeral joint. This improves the torque of the deltoid,
by increasing tension and recruiting more muscle fibers, and allows greater shoulder
elevation independent of the rotator cuff. The procedure has been recommended for
patients over 75 years with three- and four-part fractures as it provides similar pain relief
to hemi arthroplasty without reliance on tuberosity union for function in this elderly
group (Wilson, 2015) (Anon., n.d.).

23
Figure 11: showing reverse shoulder arthroplasty.

Source: (Anon., n.d.)

24
 CHAPTER THREE

RESEARCH METHODOLOGY AND DESIGN

3.0 Introduction.

This chapter will talk about the research design, tagged population, data collection
instruments, sampling procedures, measurement of validity and reliable instruments,
description of data collection procedures, description of data analysis and the ethical
consideration.

3.1 Research design.

(KO, 1993) research design is the conceptual structure with which the research is
conducted. It constitutes the blue print for data collection process, data measurement
that comprises data identification, arrangement and summarization, and data
analysis. A descriptive study is one in which information is collected from the
respondents without changing their environment (Macklin, 2006).

This research is design as a descriptive case study of the JMH/ICRC hospital in

South Sudan not only this but also a qualitative design it is a non-numerical
examination and interpretation of observation since it emphasizes on the description
of variables of the study in-depth.

3.2 Population of the study.

This is a group of individuals, animal, and items, from which a sample is selected
for study. It also refers to an entire group of people or elements having common
characters. The population of the study comprised of humeral fracture victims and
physiotherapists the research will be carried out in JMH/ ICRC in South Sudan.

25
3.3 Sample selection and size.

3 physiotherapists were purposively selected because of their experience in

managing humerus fracture. A sample size of 3 physiotherapists, 5 humeral
fracture victims in order for the researcher to get a huge knowledge about humerus
fracture.

3.4 Areas of the study.

The research will be carried out in ICRC. It is located in jebel market road it is in
JMH Compound in South Sudan. The study will be conducted on adults. The
researcher chooses ICRC because there humerus fracture victims are in huge
number than in other centers.

3.5 Data collection method and instruments.

These are methods of collecting data it can be inform of observation guide, which is
a case study.

In this project case study will be the main instrument of the study. An interview will
also be used in this study using oral interview. This is unstructured interviews where
researcher ask questions and record answers as said by respondents.

3.6 Data collection procedures.

Data collection is the gathering of specific information and aimed at proving some
facts about a problem under the study. However, prior to collection of data, the
researcher sought permission from the school of Rehabilitation Sciences in St. Mary
University College for data collection. The respondents were requested through a
letter to cooperate and provide answers to the interview guide.

26
3.7 Data analysis.

The data analysis will be done using a case report. Presentation of the findings was put
in inform of case report respectively and through direct observation according to the
research questions of the study.

3.8 Limitation.

The researcher faced problem in meeting the respondents because the researcher had
to move long distance.

The researcher had to spend a lot in printing papers, and to gather information from
the respondents, the researcher face language barrier. The researcher got it difficult
to type the research.

3.9 Delimitation.

In overcoming the challenges, the researcher had to be helped by the parents with
financial support for transport, printing. Concerning language barrier, the researcher
had to get a translator in order to get clear information from the respondents with the
supervisor.

3.10 Definition of key terms.

Greater tuberosity: Is the break in the prominent area of the bone at the top of the
humerus.

Visual impairment: Is the loss of vision

Fragment: Is the part of a broken bone

Concomitant: Accompanying or together

Devasting: Breaking beyond recovery

Intra thoracic structures: This are structures in the thorax.

Osteomyelitis: Is infection of the bone.

27
Malunion: Is the healing of bone in an abnormal position

Nonunion: Failure of bone healing

Angulation: The formation of abnormal angles

Immobilization: Is the process of stopping something from moving

Inflammation: Is the body's natural reaction against injury and infection

Intramedullary nail: Surgical rod inserted into the bone

Devascularization: Loss of blood supply

Hemi arthroplasty: Half of joint replacement

Kinematics: The study of motion

Reverse shoulder arthroplasty: An artificial ball

Glenohumeral joint: Joint between the glenoid and humerus

Elevation: something above

Amenable: Not capable

Residual: Remminase

28
 CHAPTER FOUR

DATA PRESENTATION, ANALYSIS, INTERPRETATION AND

DISCUSSION

This chapter presents the findings and the results obtained. The chapter contains detailed
case report findings and an in-depth talk on the case report findings.

4.1Case study 1

A 22 years old male sustain RTA in June 19 2023, x-ray was taken showing fracture
of the left mid humerus.

Main problems.

Pain on the pin site, which is 3/ 10 with the VAS.

Limited elbow joint range of motion;

Flexion is 125 degrees.

Extension is 35 degrees.

Muscle weakness;

Biceps, which is, grade 4/5.

Triceps, which is, grade 4/5.

Goals to achieve.

29
To reduce pain.

To increase elbow range of motion especially in extension.

To increase muscle power.

Treatment plan.

Mobilization at the maximum range of motion to improve elbow extension.

Strengthening exercise actively while stabilizing the shoulder from protraction.

Discussion of the outcomes.

On 2 July2023, operation was done by an orthopedic surgeon, who inserted a plate

to the humerus. After three weeks, the plate caused infection, then it was removed
on 1 August 2023 and an external fixator was fixed. There is a great shoulder flexion
and extension. Every day the researcher does passive and active mobilization of the
elbow that led to increase in elbow flexion from 125 degrees to 140 degrees but
elbow extension is worsening from 35 degrees to 70 degrees. On 18 October 2023,
the researcher tested the power of the elbow flexors and the elbow extensors that
was 4/5.

4.2 Case study 2

A 37 years old male sustain GSW on the left humerus on 15 June 2023.X-ray was
taken showing fracture of the left mid humerus.

Main problem.

Pain on the pin site which is 2/10 with the the VAS.

Not able to do external rotation of the shoulder.

Pain in the proximal aspect of the posterior shoulder.

Goals to achieve:

To reduce pain.

30
To improve external rotation of the shoulder.

To improve the strength of the rotators cuff.

Treatment plan:

Mobilization of the shoulder in external rotation.

Active exercise for the functional motion of the limb.

Massage on the shoulder rotators.

Discussion of the outcome.

On 30 July 2023, this patient was admitted, but no intervention was done until after
three weeks. On the 24 august 2023, external fixator was fixed into the humerus
bone. In the process of physiotherapy program, the limitated range of motion of
shoulder external rotation slightly improved not to its full range of motion. Active
exercise was done for to improve the strength of the SITS muscle known by the
name rotator cuff. In the due course of strengthening the muscles, the researcher did
massage to avoid muscle wasting and stiffness. One challenge is that he normally
complains of pain while during the night.

4.3 Case study 3

A 42 years old male sustain GSW on 11 September 2023 on the right humerus, x-ray
was taken and showed fracture on the proximal, mid shaft of the right humerus.

Main problems.

No functional movement of the right upper arm

Pain during night

Goals to achieve:

To reduce the tension of the superior trapezius.

To maintain the strength and the range of motion.

31
Treatment plans:

Immobilization of the fracture.

Isometric contraction of the muscles.

Active mobilization of the wrist.

Massage of the shoulder.

Discussion of the outcome:

This patient was admitted on the 11 September 2023, then he was casted on 29
September 2023, with a U-Slab after three weeks of no intervention was done. The
researcher gave the patient isometric exercise to avoid further atrophy of the
muscles. The researcher taught the patient to do active mobilization of the wrist,
fingers for fine movement of the hand. Not only that but also massage, and
mobilization of the shoulder to avoid retraction.

4.4Case study 4

A 26 years old male sustain GSW on the left humerus on 31 July 2023, x-ray was
taken showing fracture of on left distal humerus.

Main problem:

Pain in the hand.

Partial injury of the median nerve.

Limitation of the elbow joint in extension which is 20 degrees.

Limitation of the elbow joint in flexion which is 100 degrees.

Weakness of the shoulder flexors and the deltoids.

Goals to achieve:

To reduce pain.

32
To improve the range of motion of the elbow.

To improve the strength of the shoulder muscle.

Treatment plans:

Stimulation of the nerve and muscles to improve sensation.

Strengthening exercise.

Stretching to reduce limitation.

Discussion of the outcome:

On admission, POP was applied, and then an external fixator was fixed on 5August
2023.The researcher gave the patient exercise on how to do fine manipulation of the
nonfunctional fingers by closing, opening and opposition of the fingers. One
problem is the patient cannot do full shoulder flexion. But it is because of the pin it
is more proximally. There is improvement of elbow flexion from 100 degrees to 120
degrees but no improvement in elbow extension which is limitaed by 20 degrees to
go to full extension. Increase in power elbow flexors and extensor of 4/5. Shoulder
flexors and extensors have a muscle power of 3/5. No improvement in the fine
movement of the left second finger.

4.5Case study 5

A 76 years old male sustain GSW on 1 September 2023 on the right humerus, x-ray
was done showing communicative, intra-articular fractures of the right humerus

Main problem:

Pain, which is 7/10 with the VAS.

Edema.

Instability of the humerus.

Goals to achieve:

33
To reduce pain.

To reduce edema.

To avoid the limitation of shoulder and elbow joint range of motion.

To prevent muscle weakness.

To stimulate colors formation.

Treatment plan:

Positioning of the patient.

Elevation of the limb to reduce edema.

Muscle strengthening (isometric contraction).

Mobilization of the joint above and below the fracture.

Discussion of the outcome:

On admission, the arm was immobilized with splint. On 4 September, he was taken
to OT for debridement and then after the fracture was immobilized with POP U-slab
and triangular sling. On 11 September 2023, the researcher started with isometric
exercise to improve the strength of the shoulder, in every two hours the researcher
changes the position of the patient to avoid pressure sore. On the 25 September
2023, the patient started ambulation out of bed but with the researcher support.
Mostly the patient complains of pain in the process of doing the exercise.

34
 CHAPTER FIVE

SUMMARY OF THE FINDINGS, LIMITATION, CONCLUSION AND

RECOMMENDATION
5.1 Summary of the findings

Case one Pain on the pin site, which is 3/ 10 with the VAS.

Limited elbow joint range of motion; Flexion is 125 degrees; Extension is 35

degrees.

Muscle weakness; Biceps, which is, grade 4/5, Triceps, which is, grade 4/5.

Case two Pain on the pin site which is 2/10 with the the VAS.

Not able to do external rotation of the shoulder.

Pain in the proximal aspect of the posterior shoulder.

35
Case three No functional movement of the right upper arm.

Pain during night.

Case four Pain in the hand and Partial injury of the median nerve,

Limitation of the elbow joint in extension, which is 20 degrees.

Limitation of the elbow joint in flexion, which is 100 degrees.

Weakness of the shoulder flexors and the deltoids.

Case five Pain, which is 7/10 with the VAS.

Edema, and Instability of the humerus.

5.2 Conclusion

Based on the research work completed project on Rehabilitation of humerus fracture. All the
physiotherapists agree that the intervention is very important immediately after injury and
physiotherapists must make sure the limb is immobilized properly to avoid further
complication, to prevent bed sores, muscles weakness and to improve range of motion and
activity of the daily life.

They said physiotherapy treatment is long term process, factors that contributes to healing
process and independency of patient

X-ray is the effective way leading to diagnosis of humerus fracture and Humerus
fracture is mostly cause by gunshot due to cattle riding.

75% of the patient complained of pain, which was mild.

36
5.3Recommendation

Management of Humerus fracture require orthopedic surgeon and then

physiotherapist to intervene as soon as possible to avoid complications.

The medical personal need to be educated and given some training and workshop for
them to learn more technique in the field especially the physiotherapists.

The researcher recommends Immobilization of the fracture to prevent abnormal

alignment.

37
The researcher recommends Positioning of the patient after every two hours to
prevent bedsores and Elevation of the limb to reduce edema.

The researcher, recommends strengthening exercise actively to prevent the shoulder

from protraction.

The researcher recommends Stimulation of the nerve and muscles to improve

sensation and if there is nerve injury.

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