clavicle fracture physical therapy protocol
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Fracture is a term that can occur in any part of the bone. Fracture is not a little condition that has been seen because due to fracture patient’s lifestyle is also affected for several months. There are some common fractures that we can see in all ages such as clavicular fracture, humeral fracture, radial fracture, hairline fracture, and many more. But for fractures, physiotherapy plays an important role in the recovery of fractures. In this article, we will tell you about clavicle fracture physical therapy protocol.

What is a Fracture?

A fracture is defined as a break in the continuity of the bone. It is usually due to direct or indirect trauma. It can also occur in a diseased bone that is known as a pathological fracture.

What is a clavicle fracture?

The clavicle is one of the long bones which is placed horizontally in the human body. It is an S-shaped bone. It is a subcutaneous bone. The fracture of the clavicle is the commonest injury that is seen in all ages. It can occur due to direct trauma, fall on an outstretched hand, or fall on the point of the shoulder. The commonest site of fracture in the clavicle is the junction of the middle and lateral third of the clavicle and the uncommon site is the fracture of the lateral third of the clavicle.

In fracture of lateral one-third, coracoclavicular ligament could be intact or ruptured. If ruptured, the sternocleidomastoid muscle pulls the medial end up and the lateral end is pulled down by the weight of the arm or the gravity.

Clinical features

  • Swelling, ecchymosis, and tenderness
  • Decreased pulse due to subclavian artery injury
  • The unaffected hand gives support to the affected hand
  • Difficult breathing or diminished breath sound can be due to pneumothorax
  • Pseudoparalysis, i.e. beyond 90-degree abduction is restricted
  • Tenting and blending of the skin
  • Snapping and cracking sound at the fracture site
  • Shortening of the bone

Diagnosis

  • Anteroposterior view of the X-ray
  • CT Scan – useful for non-union assessment
  • Arteriography – If the vascular injury is suspected.

Treatment

Conservative management

  1. Triangular Sling – It is used to support the affected limb. It is used in undisplaced fractures in adults and displaced fractures in children. It should be maintained for a period of 2-3 weeks.
  2. The figure of Eight Bandage – It is tied over a pad of cotton wool in each axilla and crossed between the scapula in such a way that both the shoulders are braced up. It is kept in position for a period of 3-4 weeks. But the tight figure of eight bandages can cause compression in the axilla that can cause vascular compression on the brachial plexus resulting in tingling, numbness, and paresthesia in the affected upper limb.

Surgical Management

  1. Open reduction and internal fixation – It is rarely indicated in lateral one-third fracture, non-union cases, and the presence of neurovascular injury. It is indicated where sharp spurs of the bone endanger the underlying vessels or threaten to perforate the skin. The clavicle can be internally fixed by a nail or plate.

Physiotherapy Management

Physiotherapy management is of various types like mobilization, strengthening exercise, stretching, and many more. It mostly starts after 3 weeks of immobilization.

Immobilization phase

During the first week of treatment either by sling, strapping, or figure of eight bandages, the shoulder should be held in abduction, internal rotation and the elbow are in 90-degree flexion.

  • No ROM or muscle-strengthening exercise should be prescribed for the shoulder.
  • The unaffected arm is used for dressing, self-care, and personal hygiene.
  • The patient is advised initially to sleep on a reclining chair and in later stages to roll over the unaffected arm to come to the upright position. 
  • Weight-bearing is not permitted.
  • Full ROM is advised for the wrist, hand, and digits.
  • At the end of the second week, gentle pendulum exercises to the shoulder in the sling as pain permits, and the gentle isometric exercises to the deltoid are begun.

 Mobilization phase

  • At the end of 4 weeks, gradual mobilization of the shoulder is begun.
  • By the 6 weeks, gentle active ROM to the shoulder is allowed. Abduction is restricted to 80 degrees.
  • Pendulum exercise with the gravity eliminated, isometric exercise to the rotator cuff, and deltoid are begun.
  • The patient is permitted to use the affected extremity for self-care and personal hygiene. Weight-bearing is still not permitted.
  • By the end of 6-8 weeks, full active to active-assisted ROM is permitted. Resistive exercise for the shoulder girdle muscle is also started. 
  • The patient is permitted to use the affected limb for self-care, personal hygiene, and light work. Gradual weight-bearing is now permitted.
  • After 8-12 weeks, full active motion, abduction, isometric, isotonic, and resistive exercises are prescribed. Full weight-bearing and normal use of the hand are allowed.

Post Surgical Physiotherapy

  • In the event of open reduction and internal fixation, gradual mobilization should be started within 8-10 days.
  • Initially, mobilization is started within the sling by teaching pendulum exercises.
  • Pain at the site of operation needs some adjuncts such as thermotherapy and cryotherapy.
  • Others are the same as the mobilization phase.

When do you start physical therapy after a clavicle fracture?

Physical therapy is started in the first week of fracture. Treatment of fracture has two parts-Immobilization phases and the mobilization phase. Both phases require physiotherapy. 

In surgical treatment, physical therapy should start after 8-10 days of operation.

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