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Management of Proximal Humeral Fractures 
John J. Basti, PT 
Emil Dionysian, MD 
Phyllis W. Sherman, PT 
louis U. Bigliani, MD 
The Shoulder Service, 
New York Orthopaedic Hospital, 
Columbia-Presbyterian Medica l 
Center, 
New York, New York 
T he shoulder joint has the greatest range of 
motion of any joint in the human body. Fol­
lowing proximal humeral fracture, a coordinated ef­
fort among the patient, surgeon, and therapist is 
essential to restoring shoulder function . A clear 
understanding of the injury, its treatment, and the 
progression of fracture healing is critical in rehabili­
tation of patients who have proximal humeral frac­
tures. The following is an overview of the manage­
ment of these fractures, including guidelines for 
rehabilitation. 
In the early part of the twentieth century, meth­
ods of closed reduction, traction, casting, and ab­
duction splinting were developed to achieve and 
maintain accurate anatomic alignment of displaced 
proximal humeral fractures. Unfortunately, stiffness 
and contracture were the major undesired outcomes. 
The dilemma is that starting motion too soon may 
lead to mal- or nonunion, and immobilizing too long 
will result in stiffness and contracture. An adaptive 
and progressive early physical therapy program that 
continues until full functional range of motion is at­
tained is the mainstay of the postoperative or post­
reduction treatment for the proximal humeral frac­
ture. 
INCIDENCE 
Osteoporosis is a significant etiologic factor in 
proximal -humeral fractures . These fractures, like 
proximal femoral fractures, have a higher incidence 
in older age groups. In one study,23 proximal hu­
meral fractures occurred at nearly 70% of the reported 
rate of proximal femoral fractures. 
The proximal humerus is the most common lo­
cation of fracture in the humerus (45%), and when 
considering adults more than 40 years old, this in­
cidence increases to 76%. There is a higher incidence 
in women than men by a rate of two to one. 23 There 
is also increased incidence of alcoholism and prior 
gastric resection in patients with proximal humeral 
fractures. 
Correspondence and reprint requests to Louis U. Bigliani, MD, 
161 Ft. Washington Avenue, New York, NY 10032. 
PATHOMECHANICS 
The most common mechanism of proximal hu­
meral fractures is a fall on the outstretched hand from 
standing height or lower. Osteoporosis is usually 
present in older individuals. 4 Another mechanism is 
excessive rotation of the arm, especially in the ab­
ducted position of the shoulder. The humerus locks 
against the acromion in a pivotal position and a frac­
ture can occur, especially in osteoporotic bone. Other 
less frequent causes are electric shock or a convulsive 
episode. Also, a metastatic tumor or a recent biopsy 
site may lead to fracture by weakening the bone . 
CLASSIFICATION 
The most commonly used classification for prox­
imal humeral fractures is the Neer four-part classi­
fication. 4 This encompasses the anatomy and bio­
mechanical forces that result in the displacement of 
the fracture fragments. It is based on the relationship 
of the four major parts of the proximal humerus: the 
greater tuberosity, lesser tuberosity, head, and shaft. 
Displacement is defined as separation of more than 
1 cm or angulation of more than 45 degrees. For 
example, a two-part fracture is one where there is 
"displacement" between any of the above four parts. 
If there are other fracture lines and the separation or 
angulation is not enough to meet the criterion, it is 
not considered "displaced" and not counted as an 
additional part in the classification (Chart 1).4 
DIAGNOSIS 
Clinical Presentation 
The majority of these fractures manifest acutely 
and the most common symptoms are pain and swell­
ing, especially in the area of the greater tuberosity, 
which corroborates the x-ray finding. Ecchymosis 
generally occurs within 24-48 hours and may spread 
to the chest wall, flank, and forearm. The diagnosis 
of proximal humeral fracture, however, is made ra­
diographically. 
April-June 1994 111 
CHART 1. The Neer Classification System for Proximal 
Humeral Fractures 
Anatomical 
Neck 
Surgical 
Neck 
Greater 
Tuberosity 
Lesser 
Tuberosity 
Fracture­
Dislocation 
Head­
Splitting 
Displaced Fractures 
2-part 3-part Articular 
Surface 
Reproduced with permission from: Bigliani LV: Fractures of 
the proximal humerus. In Rockwood CA Jr, Matsen FA II (eds): 
The Shoulder, vol. 1. Philadelphia, W. B. Saunders, 1990, pp. 
278-334. 
Neurovascular injuries are not uncommon. The 
most common nerve injured in fractures about the 
shoulder is the axillary nerve. This nerve supplies 
the deltoid muscle and skin overlying it. Occasion­
ally, in the postfracture or postoperative period there 
may be inferior subluxation of the humerus. In the 
majority of cases this is due to deltoid fatigue or 
atrophy rather than an injury to the axillary nerve. 
Gentle isometric exercises help recover the deltoid 
tone while the arm is in a sling. If the subluxation is 
severe and lasts for more than four weeks, an axillary 
nerve palsy must be considered. Brachial plexus in­
juries also can occur, with a reported incidence of 
6%.25 
Fracture dislocations of the proximal humerus 
are difficult to diagnose, particularly in the posterior 
direction where more than 50% of these injuries are 
missed by the initial treating physician. 4 Axillary and 
112 JOURNAL OF HAND THERAPY 
scapular radiographic views, or computed tomogra­
phy (CT) scans, are important in diagnosing fracture 
dislocations. 
Radiographic Evaluation 
The trauma series is the best initial method for 
diagnosing proximal humeral fractures. This consists 
of anteroposterior and lateral (Y view) radiographs 
in the scapular plane and, if possible, an axillary 
view. The axillary view is essential for evaluating the 
glenoid surface and very helpful in making the di­
agnosis of anterior or posterior fracture dislocation. 
The Velpeau axillary technique allows an axillary view 
to be obtained without removing the patient's arm 
from the sling. 4 Other diagnostic tests that are useful 
include tomography and CT. Tomograms are espe­
cially useful in evaluating a proximal humeral frac­
ture for nonunion or articular surface involvement. 
A CT scan is helpful in judging the amount of dis­
placement of tuberosity fractures, impression frac­
tures, and chronic fracture-dislocations. 
MANAGEMENT 
Fortunately, the majority of proximal humeral 
fractures are minimally displaced and can be satis­
factorily managed with a sling and early range of 
motion exercises. For significantly displaced frac­
tures, various methods of treatment have been pro­
posed, including closed reduction, casts, splints, per­
cutaneous pinning, 8, 13 external fixation,10 open 
reduction and internal fixation,6,9 and humeral head 
replacement. 17,25 Each method can have its useful 
role in fracture management. Some of the factors 
involved in the decision-making process are the frac­
ture type, quality of the bone, and compliance of the 
patient. The two major options are conservative or 
nonoperative and operative approaches. 
Conservative 
This method is ideally suited for patients who 
have minimally displaced fractures, those who are 
less than ideal surgical candidates, or those with lim­
ited functional goals. On occasion, closed reduction 
can improve alignment and function. In the case of 
two-part surgical neck fracture this is done, by flexing 
and adducting the arm to counteract the deforming 
forces of the pectoralis major muscle. Greater tub­
erosity fractures are less amenable to closed reduc­
tion, because they are pulled superior and posterior 
by the rotator cuff. Three-part fractures are quite un­
stable and difficult to manage optimally by closed 
reduction, and open reduction is required for accu­
rate reduction and optimal function. In the event of 
a closed reduction of a displaced fracture, testing the 
stability of thefracture under fluoroscopy can help 
with decisions of timing and intensity of physical 
therapy during the recovery period. 
Reduced or minimally displaced fractures are im-
mobilized in a sling with the patient's arm at the side 
or in the Velpeau position. A swath may enhance 
immobilization and comfort. An axillary pad is useful 
to prevent skin excoriation secondary to sweating. 
Gentle range of motion exercises can be started seven 
to ten days following the fracture, when the pain has 
diminished and the patient is less apprehensive. Ad­
vancement of the intensity and duration of therapy 
is based upon the fracture configuration, its apparent 
or tested stability, signs of fracture healing by ra­
diography, and the patient's tolerance. 16 
Intermittent radiographs taken in two perpen­
dicular planes are essential in ruling out progressive 
displacement. Overly aggressive exercises may dis­
tract a minimally displaced fracture and result in mal­
union or nonunion. The greatest amount of improve­
ment in range of motion occurs between the third 
and eighth weeks following injury. An organized and 
supervised physical therapy program is essential dur­
ing this period. The outline of the rehabilitation pro­
tocols is provided below. 
Operative 
Once the decision is made that conservative 
TABLE 1. Closed Reduction: Nondisplaced or Minimally 
Displaced Fracture of the Surgical Neck and the Anatomical 
Neck, and Less Than 1 cm Displaced Tuberosity Fracture 
Time 
Postfracture 
7-10 days 
10 days to 3 weeks 
(when pain has 
diminished and 
the patient is 
less apprehen­
sive) 
3-6 weeks 
4 weeks 
6-8 weeks 
8 weeks 
Phase Exercise Program' 
Early passive Pendulum 
motion Passive FE 
Passive ER 
Phase I 
Isometrics 
Phase II 
Phase III 
Pendulum 
AAFR 
AA ER to 40 degrees 
Pendulum 
AAFE 
AA ER 
AA HEt 
IR 
ER 
Anterior deltoid 
Posterior deltoid 
Middle deltoid 
Active FE, supine 
Active FE with weights, 
supine 
FE, erect, with stick 
Eccentric pulleys 
Resistive exercises 
Stretching 
Special stretching 
*FE = forward elevation; ER = external rotation; IR = in­
ternal rotation; HE = hyperextension; and AA = active assistive. 
tAt six weeks. 
TABLE 2. Open Reduction/Internal Fixation and Humeral 
Head Replacement for Four-part Fracture 
Time 
Postoperative 
3-5 days 
7-10 days 
3 weeks 
4-6 weeks 
12 weeks 
Phase Exercise Program' 
Early passive Supine ER to 40 degrees 
motion Supine FE 
Phase I Pendulum 
ER with stick 
FE IRt HEt 
Phase I Pulleys 
Isometrics IR 
Phase II 
Phase III 
ER 
Anterior deltoid 
Posterior deltoid 
Lateral deltoid 
Active FE, supine 
Active FE with weights, 
supine 
FE, erect, with stick 
Eccentric pulleys 
Resisted exercises 
Stretching 
Special stretching 
*ER = external rotation; FE = forward elevation; IR = in­
ternal rotation; and HE = hyperextension. 
tNot to be done with tuberosity fracture. 
treatment including closed reduction is not adequate, 
the following methods can be utilized for reduction 
and fixation of proximal humeral fractures. 
Open Reduction and Internal Fixation. Open re­
duction and internal fixation has been popular since 
the early part of this century. Various techniques and 
devices have been proposed to treat patients who 
have these fractures. This approach, in most cases, 
provides sufficient stability to allow careful controlled 
early range of motion exercises and helps to avoid 
stiffness and contracture.23 It is the treatment of choice 
for displaced three-part and two-part greater tuber­
osity fractures of the humerus. 4,1l,12,21-24 The stan­
dard exposure is through the deltopectoral approach. 
At times, insertion of the deltoid or the pectoralis 
major may be elevated for more exposure. This may 
affect the postoperative rehabilitation course by de­
laying the initiation of the active phase. The current 
trend is toward limited dissection of the soft tissue 
about the fracture fragments and using the minimal 
amount of hardware required for stable fixation. 6 After 
the open reduction and internal fixation, postoper­
ative rehabilitation should be adjusted to the stability 
of the fixation, the quality of the bone and soft tis­
sues, and the type of surgical approach and soft­
tissue repair. Some of the common postoperative 
protocols are detailed in the rehabilitation section. 
Following are some of the more commonly used op­
erative techniques. 
Wire or Sutures. Heavy sutures (or wires) allow 
utilization of the tension band principle to gain rel-
April-June 1994 113 
FIGURE 1. Passive forward elevation in the plane of the 
scapula is performed by the therapist with the patient either 
erect (top) or supine (bottom). 
atively stable fixation. This technique is especially 
useful in reattaching the greater or lesser tuberosity 
onto the shaft. This is done using transosseous suture 
in patients with strong bone or with suture through 
the rotator cuff in the elderly. The preferred suture 
is no. 5 nonabsorbable or 18-gauge wire in figure-of­
eight configuration. This method can be used alone 
or in conjunction with other types of hardware (rods 
or prostheses). 
Rods. Flexible intramedullary rods have been 
popular with many authors,l5,24,26 especially for in­
ternal fixation of two-part surgical neck fractures. The 
most commonly utilized devices are Enders nails and 
Rush rods. These also can be used in conjunction 
with wires or sutures through the standard open 
approach or through a very limited incision that splits 
the deltoid and rotator cuff. Frequent complications 
of this technique have been the inability to achieve 
stable fixation and impingement of the device against 
the acromion during shoulder elevation, necessitat­
ing removal of the hardware. 
Plate and Screws, The use of a buttress plate and 
screws has been associated with good results, es­
pecially with two-part surgical neck fractures. The 
best results have been in cases where bone quality 
has been good and soft-tissue dissection has been 
limited. Malposition of the plate can cause impinge-
114 JOURNAL OF HAND THERAPY 
FIGURE 2. Passive external rotation is performed by the ther­
apist with the patient's arm comfortably abducted in neutral 
with the patient in the sitting position (left) or supine (right) 
with the elbow supported. Verbal cues for relaxation should 
accompany motion . 
FIGURES 1 and 2. Early passive motion. 
ment, necessitating later removal. As with rods, the 
plate or screws can be an anchoring point for addi­
tional wires or sutures. 
Humeral Head Replacement. Humeral head re­
placement for the management of proximal humeral 
fracture dislocation was first reported by Neer in 1953. 
Currently, the humeral head replacement prosthesis 
is used in the treatment for four-part, selected os­
teoporotic three-part and head-splitting fractures. 
Important considerations regarding this technique are 
the restoration of humeral length, humeral head ver­
sion, and secure fixation of the tuberosities in their 
correct positions to prevent impingement. Passive 
range of motion can usually be started on the third 
day. 
COMPLICATIONS 
Many complications have been reported follow­
ing both closed and open treatments for displaced 
fractures. These can be categorized as early or late. 
Possible early problems include rupture of the rotator 
cuff or the biceps tendon, 3 neurovascular injuries,2.27 
and thoracic injuries. These problems, especially 
brachial plexus injuries, are usually the result of the 
initial trauma and in mild cases may become evident 
only during the rehabilitation period. 
Other complications may arise later during the 
rehabilitative period. The most common of these in­
clude avascular necrosis, nonunion, malunion, hard­
ware failure, frozen shoulder, and infection. 
Nonunion 
Nonunion of the proximal humerus is rare and, 
even if present, may not be debilitating. Treatment 
may be difficult because this complication often oc­
curs in older patients withosteoporotic bone. Some 
of the causes include soft-tissue interposition, sys­
temic disease, preexisting stiffness of the glenohu­
meral joint, uncooperativeness on the part of the 
patient, and overly aggressive physical therapy. In 
surgically managed cases it may be secondary to in­
adequate fixation, poor bone quality, or infection. 
There is typically a characteristic cavitation of the 
head fragment due to resorption of the bone beneath 
Osteonecrosis 
Even though osteonecrosis has been reported in 
relation to some two-part fractures, it is most com­
mon in three- and especially four-part fractures, oc­
curring in up to 34% of cases. The result usually is 
a stiff, painful joint. The treatment of choice for 
symptomatic osteonecrosis of the humeral head is 
humeral head or total shoulder arthroplasty. 
FIGURE 3. Passive as­
sisted exercises are started 
with the pendulum: small 
clockwise and counter­
clockwise motion with the 
patient bent at the waist with 
the back supported. 
fiGURES 3-7. Phase I, pendulum and 
passive assisted exercises. 
FIGURE 4. Supine for­
ward elevation with the 
noninvolved extremity as­
sisting the involved extrem­
ity. The elbow should be bent 
and gradually extended 
through the range of motion. 
fiGURE 6. Extension with 
the stick. The uninvolved 
extremity helps the involved 
extremity move into exten­
sion. 
FIGURE 5. Supine exter­
nal rotation with a stick. The 
arm is supported comforta­
bly at the side to prevent ex­
tension. The non involved 
side pushes the relaxed in­
volved extremity outward, 
with the elbow flexed at 90 
degrees. 
FIGURE 7. The use of 
pulleys, with the uninvolved 
extremity supplying power 
to raise the involved extrem­
ity. 
April-June 1994 115 
FIGURE 8. Supine resistive internal rotation. FIGURE 9. Supine resistive external rotation. 
FIGURE 10. Erect resis­
tive anterior deltoid. 
FIGURE 11. Erect resis­
tive middle deltoid. 
FIGURE 12. Erect resis­
tive posterior deltoid. 
FIGURES 8-12. Isometrics, which can be initiated with the patient supine and then progressed with the patient standing. 
the head. Open reduction and internal fixation, with 
the addition of bone graft, is the preferred treatment. 
In most cases a spica cast is necessary for six to eight 
weeks. Occasionally, humeral head replacement may 
be preferable. 
Malunion 
Healing of the fracture after inadequate reduc­
tion or failure of fixation leads to malunion. This 
problem can significantly contribute to loss of range 
of motion, weakness, and pain with active elevation. 
Greater tuberosity malunions lead to impingement 
against the acromion. 4,17,21 These are best managed 
by mobilization and reattachment of the tuberosity 
fragment. In cases with moderate displacement, 
anterior acromioplasty may also be helpful. In more 
complex cases, multiple osteotomies or prosthetic re­
placement may be indicated . 
Adhesive Capsulitis 
Adhesive capsulitis may result if rehabilitation 
following a fracture or its operative repair has not 
been adequate. A progressive organized exercise pro­
gram should be started following diagnosis. If the 
116 JOURNAL OF HAND THERAPY 
fracture is healed without significant malunion, ma­
nipulation with the patient under anesthesia and 
possible arthroscopic or open debridement of the jOint 
and the subacromial space may be the next step. 
Also, any possible mechanical cause, such as im­
pinging hardware, must . be addressed. 
REHABILITATION 
Appropriate rehabilitation following proximal 
humeral fracture is essential for maximum recovery 
of function. Management of these patients can be 
complicated and sometimes prolonged, 
Close communication between the surgeon, 
therapist, and patient is essential. It is important for 
therapists to understand that fracture management 
can be a lengthy process, with maximum recovery 
taking place anywhere from six postinjury months 
to a year. 20,25 A number of factors influence recovery: 
the complexity of the fracture, the type of reduction, 
and the extent of soft-tissue involvement, as well as 
the patient's age and compliance. Degenerative joint 
disease, concomitant rotator cuff tear, and gleno­
humeral dislocation must be considered during the 
rehabilitation process. More rigid motion restrictions 
apply to those patients who had dislocations or re­
quired rotator cuff repair. The fracture fixation must 
be secure, as determined by the surgeon prior to 
initiation of the exercise program. Range of motion 
should be discontinued if the therapist notes crepitus 
at the fracture site, and the surgeon should be no­
tified immediately. Overly aggressive range of mo­
tion may distract a minimally displaced fracture and 
result in malunion or nonunion. 4 Posttraumatic pain, 
postoperative pain, muscle spasm, and prior stiffness 
due to arthritis can limit the patients' ability to achieve 
early motion. 
Applications of electrical stimulation, heat, and 
cold are useful for decreasing edema, spasm, and 
pain. Massage for relief of spasm can facilitate range 
of motion. 
Obtaining a detailed history and performing an 
appropriate physical examination direct the estab­
lishment of realistic goals during rehabilitation. The 
FIGURE 13. Supine forward elevation with a 
stick is initiated with the elbows bent. 
success of the program relies heavily on patient ed­
ucation, compliance, and ability to participate in a 
home exercise program. Written instructions are given 
to provide a clear understanding of the home pro­
gram. The rate of exercise progression with all frac­
ture patients is coordinated by the surgeon and de­
pends on the severity of the fracture, the stability of 
the reduction, and the formation of callus. Consid­
eration of these elements will contribute to an optimal 
final result. 
Early passive motion,18 followed by a three-phase 
progressive exercise protocol,1O is a working model 
that addresses the principal requirements of fracture 
rehabilitation. Several authors4.18.2o believe that early 
passive motion tailored to the stability of the fracture 
is the keystone to successful fracture management, 
provided that the fracture be stable and that adequate 
pain control be achieved. A preliminary study of early 
passive motion with electromyographic analySis sug-
FIGURE 14. A one-to-two­
pound weight is added as 
strength improves. 
FIGURE 15. Active supine 
forward elevation is per­
formed. 
FIGURE 16. Activation of the anterior del­
toid is accomplished by sliding the hand across 
a smooth surface and elevating it simultane­
ously. 
FIGURES 13-18. Phase II, active and early resis­
tive exercises. Active assisted concentric and eccen­
tric exercises are initiated with the patient supine and 
are progressed to an erect position as tolerated. 
FIGURE 17. Exercise with 
the patient erect is then pro­
gressed to concentric and 
eccentric forward elevation 
with the stick. 
FIGURE 18. Pulley exer­
cises can be performed with 
eccentric lowering of the in­
volved extremity. 
April-June 1994 117 
FIGURE 19. As healing permits, forward elevation and ab­
duction are combined, with the uninvolved arm assisting. 
FIGURE 20. Internal ro­
tation with the assistance of 
the other hand. 
FIGURE 22. Combined abduction and exter­
nal rotation stretching is accomplished by put­
ting the forearms on the doorjamb and leaning 
into the doorway. 
FIGURE 21. Forward ele­
vation with the patient at­
tempting to press the upper 
body and axilla close to the 
wall. 
FIGURES 19-23. Phase III, stretching. 
FIGURE 23. Over-the-door 
stretching with both hands 
helps eliminate substitution. 
Gradual body weight should 
be applied by bending the 
knees as comfort permits. 
Remember that these exer­
cises should be done gently 
at first, and the patient should 
be progressed as tolerated. 
gested that adequate relaxation of the muscles and 
having a knowledgeable therapist supervision in­
cluding verbal cues for relaxation are effective in ac­
complishing safeearly passive motion. 19 Motion may 
be restricted completely or partially during the early 
healing phase, depending on the type of fracture and 
its method of treatment. Motion of the proximal and 
distal joints should always be incorporated into the 
program. 
Tables 1 and 2 and Figures 1 through 33 dem­
onstrate our protocol for fracture management. It 
consists of early passive motion followed by a three­
phase program: phase I, pendulum and passive as­
sisted exercises; phase II, active and early resistive 
exercises; and phase III, advanced stretching and 
118 JOURNAL OF HAND THERAPY 
strengthening. Isometric exercises are begun follow­
ing phase I. 
Patients are instructed to perform their range of 
motion exercises three to four times daily and to use 
pain medication and home application of heat or ice 
as needed. 10 Phase III strengthening exercises should 
be limited to one or two times daily. Later in the 
rehabilitation process, strengthening may be done 
three to four times per week as the intensity of the 
workout increases. Functional strength is the ulti­
mate goal. The requisite demands of the upper ex­
tremity vary with the patient's occupation, lifestyle, 
age, and leisure participation in athletics. Exercise is 
tailored to achieve the maximal requirement of each 
individual. Unfortunately, not all patients progress 
through the protocol predictably. Excessive stiffness 
or severe weakness may be present. 
Patients who exhibit prolonged weakness may 
have had extensive soft-tissue damage with resultant 
rotator cuff and deltoid insufficiency. In these in­
stances, when patients are unable to actively elevate 
the arm against gravity, the rehabilitation focuses on 
supine forward elevation, eccentric supine elevation, 
and graded manual resistive exercise by the thera­
pist. 
In cases of excessive stiffness, the rehabilitation 
must be focused on achieving normal range of motion 
instead of strengthening, although gentle strength­
ening may continue with a greater emphasis on 
stretching. 
In progressing these patients, it is important that 
full end range strength be attained, and this can 
sometimes lag in the recovery process. In resistive 
exercises, particularly in elevation of the arm, the 
therapist must be aware of arthrokinematics. Ade­
quate humeral head depression is necessary to avoid 
impingement during the strengthening process. In 
the presence of a weak rotator cuff, strengthening 
supine and below the horizontal should be empha­
sized. In addition to deltoid and rotator cuff strength­
ening, periscapular strengthening exercises, partic­
ularly for the rhomboids, trapezius, and serratus 
anterior, should be incorporated into the program. 
The scapula must rotate and set adequately so that 
the glenoid provides a fulcrum for the head of the 
humerus as the arm is elevated; therefore, it is in­
cumbent upon the therapist to address these muscle 
groups in the total rehabilitation regimen following 
shoulder fracture. 
FIGURE 24. Advanced internal rotation stretching is accom­
plished with the use of a towel over the shoulder (left) or by 
holding a door and bending the knees (right). 
FIGURE 25. The patient 
reaches the top of the door­
jamb and walks through the 
doorway. 
FIGURES 24-27. Phase III, special stretching. 
FIGURE 26. External ro­
tation with the arm held to 
the side by the uninvolved 
extremity and the body ro­
tating away from the hand. 
FIGURE 27. Cross-body or 
horizontal adduction for 
posterior capsular stretch, 
with the help of the unin­
volved extremity applying 
pressure to the elbow while 
the patient reaches over the 
opposite shoulder with the 
involved extremity. 
April-June 1994 119 
FIGURE 28. Standing press 
with the weight. FIGURE 29. Anterior del­
toid strengthening with an 
upper cut using Theraband. 
Motion in forward elevation 
should be 90 degrees. 
FIGURE 30. External ro­
tator strengthening with the 
elbow held at the side. The 
patient externally rotates 
against the Theraband. 
FIGURE 31. Middle del­
toid strengthening and cuff 
strengthening are accom­
plished by abducting with 
resistance supplied by the 
Theraband. 
FIGURES 28-33. Phase III, strengthening. 
SUMMARY 
The understanding of early controlled range of 
motion adapted to the stability of the fracture is cru­
cial in postfracture shoulder therapy. The diagnosis 
and management of proximal humeral fractures have 
been reviewed. 
120 JOURNAL OF HAND THERAPY 
FIGURE 32. The internal rotator is strength­
ened by attaching the Theraband to a doorknob 
and internally rotating. 
FIGURE 33. The posterior deltoid is strength­
ened by hyperextending the shoulder with a 
bent elbow. Progressive resistance continues 
until functional strength is attained. 
In addition, the aspects of therapy and the per­
tinent rehabilitation protocols are outlined. Although 
this article outlines standard treatment approaches, 
the specific therapy should be individualized to the 
patient's goals and abilities, and continuous com­
munication between all persons involved in the pa­
tient's care is essential for achieving the best possible 
outcome. 
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o CLINICAL SPECIALTY EDUCATION 0 
Focus on Splinting 
Hands-On Workshop 
Instructor: Patricia K. Roholt PT, CHT 
Dayton, OH· July 9-10 
Dallas, TX· Oct. 29-30 
Boston, MA • Nov. 10-11 
Presents 
Upper Extremity Rehab: An Integrated Approach 
Instructor: Joseph DiGiovanna, PT, OCS 
Kansas City, MO· Aug. 20-21 
Dallas, TX· Sept. 24-25 
Dayton, OH· Oct. 15-16 
Washington, DC· Nov. 19-20 
Fundamentals of Burn Rehabilitation 
Instructors: Reg Richard MS, PT - Marlys Staley, MS, PT 
Boston, MA • July 28-29 
Las Vegas, NY • Oct. 27-28 
Introduction to Hand Therapy 
Fundamentals of Hand Rehabilitation 
Instructors: Patricia K. Roholt, PT, CHT -
*Brad Kirkes, OTR 
Dayton, OH· July 7-8 
* Los Angeles, CA • July 22-23 
Chicago, II.. • Aug 4-5 
Washington, DC· Sept. 1-2 
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* Portland, OR· Sept. 23-24 
Charlotte, NC· Sept. 29-30 
Las Vegas, NV· Oct. 13-14 
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* San Jose, CA· Nov. 18-19 
Miami, FL· Dec. 1-2 
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