Physical Therapy Management Of Clavicle Fractures

Summary of the Condition: Clavicle Fracture

The clavicle serves as an important connection from the upper arm (appendicular skeleton) to the trunk (axial skeleton). The clavicle contributes to the freedom of motion seen at the shoulder by acting as a movable ‘strut’ to which the scapula and upper arm are suspended at a distance from the body[1]. When fractured, this can lead to pain at the fracture site, decreased strength & ROM of the involved upper extremity, and pain and difficulty with functional activities due to impaired biomechanics of the shoulder.

While there is extensive research on the types of surgical management of clavicle fractures, as well as studies comparing surgical versus conservative management of clavicle fractures, there is little high level research regarding physical therapy interventions of this diagnosis. The following guidelines are based on available research and protocols for both conservative and post-operative treatment.

Guide to PT Practice—Practice Pattern & Suggested Management[2]

Pattern 4G: Impaired Joint Mobility, Muscle Performance, & Range of Motion Associated with Fracture

The Guide estimates that individuals will return to their highest level of function within 3-6 months post fracture, and that 80% of patients in the 4G pattern will reach anticipated goals and outcomes within a range of 6-18 visits.

ICD-9 Code for Fracture of Clavicle: 810

Link to The Guide to PT Practice: http://guidetoptpractice.apta.org/content/1/SEC14.body?sid=038e7c5d-c45d-4ea4-b745-344ca38918af

Relieving Pain & Decreasing Swelling

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Cryotherapy, in the form of an ice pack or GameReady, can be used in the post-op phase or in the acute stage of conservative treatment. Cryotherapy will generally be used after treatment, but in cases of excessive pain or swelling, it may be used prior to rehabilitation as well[4][5].

In week 2 and beyond, if signs of inflammation have been alleviated, thermotherapy may be used prior to treatment for 15 minutes, in conjunction with cryotherapy received after treatment. Most commonly hot packs are used as thermotherapy[4][5].
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Soft tissue mobilization may be used at any stage of the rehabilitation process to alleviate muscular tension in the shoulder or cervical musculature[5].

Increasing Strength[5]

  • Beginning in Week 1, patients may begin grip, wrist and tricep strengthening, as well as shoulder isometrics with arm at side in all directions.
  • In Weeks 2-4, patients may begin isometric scapular PNF in mid-range
  • At 4 Weeks, patient may begin mid-range ROM for internal and external rotations through 75% of range, limited by patient symptoms. Pt must use care to avoid shoulder elevation and extremes of ROM
  • Week 12 post-op and beyond: Begin a more progressive & comprehensive strengthening program as tolerated (Please see protocols below regarding post-operative, conservative or accelerated progression)
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Improving Range of Motion[5]

  • Pendulum exercises may begin Week 1
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  • Weeks 2-4, patients may begin gentle pulley exercises for shoulder ROM 2x/day
  • Begin glenohumeral and scapulothoracic joint mobilizations to increase shoulder ROM
  • Weeks 8-12, seek to attain full AROM of shoulder in all planes
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Functional Activities[5]

  • Week 12 post-op & beyond, gradually increase intensity and functionality of activities for gradual return to sport/previous level of function
  • Return to specific sport is determined by physical therapist using functional testing

Modality Use

While low intensity pulsed ultrasound has previously been believed to facilitate healing in fractures, a systematic review of randomized controlled trials performed in 2009 has disputed the efficacy of this treatment. While some studies demonstrated accelerated healing on X-rays, there did not appear to be any significance in patient-perceived improvement or return to function[3]. Therefore, low intensity pulsed ultrasound as a method to accelerate fracture healing is unsupported by quality evidence and should not be utilized in the rehabilitation of clavicle fractures.

Protocols

Special Instructions

Post-Operative Physical Therapy Guidelines[5]

  • Do NOT elevate surgical arm above 70 degrees in any plane for the first 4 weeks post-op
  • Do NOT lift any object greater than 5 pounds with the surgical arm for the first 6 weeks post-op
  • Avoid repeated reaching for the first 6 weeks
  • Ice shoulder 3-5 times per day (for 15 minutes) to control swelling and inflammation
  • Maintain good shoulder girdle posture at all times and especially with sling use
  • Intermittent X-ray to monitor healing as needed
Bibliography
1. Moore KL, Dalley, AF, Agur AM. Clinically Oriented Anatomy. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010, 687.
2. Interactive Guide to Physical Therapist Practice. American Physical Therapy Association.
2003.DOI : 10.2522/ptguide.978-1-931369-64-0.
3. Busse JW, Kaur J, Mollon B, et al. Low intensity pulsed ultrasonography for fractures: Systematic review of randomised controlled trials. BMJ. 2009;338:b351. doi: 10.1136/bmj.b351.
4. Rabe SB, Oliver GD. Clavicular fracture in a collegiate football player: A case report of rapid return to play. Journal of Athletic Training. 2011;46(1):107-111. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=58509273&site=ehost-live.
5. The Stone Clinic. Clavicle Fracture Rehabilitation. Available at http://www.stoneclinic.com/Broken-Collar-Bone-Repair-Rehabilitation. Accessed March 9, 2012.
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