Proximal humerus fracture fixation — rehabilitation protocol

Who is this for?

Adults after stable proximal humerus fracture fixation with a locking LCP plate or anatomic intramedullary nail, with a typical postoperative course. This programme does not automatically apply to arthroplasty for a fracture, nonunion surgery or an unstable reconstruction.

Option 1 — locking LCP plate

The plan reflects the fragments actually reconstructed, fixation stability and bone quality. Having a plate does not authorise unrestricted movement or immediate lifting. If the tuberosities were fixed or rotator cuff tendons repaired, protecting them is part of the programme.²

Option 2 — anatomic intramedullary nail

Use the same main stages: protection, progressive restoration of movement and strengthening after assessment of healing. The operative report should also be checked for management of the rotator cuff at the nail entry site and any tuberosity fixation. A nail does not automatically justify faster rehabilitation than a plate.³

Movement is not the same as loading

Permission for passive or assisted movement does not authorise weight bearing, lifting objects or forceful pulling. Active movement also requires muscle work, even without a weight. Following tuberosity or tendon repair, rotation limits and the timing of active cuff work depend on individual instructions.^{2, 3}

Do not prescribe the same range for everyone from the implant name alone. The fracture pattern, fixation stability, soft-tissue condition and follow-up schedule must be known. Clarify unclear instructions with the orthopaedic surgeon.

What do the poster’s abbreviations mean?

PROM means passive range of motion; AAROM, active-assisted range of motion; and AROM, active range of motion. During passive movement, a therapist or an appropriate aid guides the relaxed arm. In assisted movement, the patient contributes, so it is not the same as passive movement.

Pendulums

After instruction, the patient supports themselves with the non-operated hand and leans forwards. The operated arm remains relaxed; small trunk movements produce a gentle swing. Do not use weights, large swings or active jerking of the shoulder. Pendulums do not replace the whole mobility programme.

Assisted elevation

Choose a supported position and a range appropriate to the phase. A physiotherapist or the unaffected hand provides assistance. Once assisted movement is permitted, a suitably selected table slide may be used. Do not try to gain range through excessive trunk leaning or abrupt scapular elevation.¹

Active movement and later strengthening

Reduce assistance gradually. Add resistance only when permitted, starting low. Rotation, abduction and weight-bearing exercises are not interchangeable: they may load the fixed fragments and repaired tendons differently. Selection depends on the operative report and patient assessment.

A daily programme and separate resistance training

The physiotherapist specifies exercises, permitted range, repetitions and frequency. Not every example needs to be performed at every session. Later resistance training has its own dosage and recovery intervals. Increase one element at a time and do not compensate for missed exercises with heavier loading.

Phase I — weeks 0–2: protection and early movement

Goals: protect fixation, control pain, maintain mobility of the distal joints and begin safe shoulder movement.

The sling provides comfort and support, usually for 1–2 weeks in this programme or for the period prescribed by the surgeon. Remove it for hygiene and prescribed exercises. If the fracture or tissue repair requires longer protection, do not shorten it based on the poster.

From the first days, introduce hand, wrist and elbow movement, gentle pendulums and gentle passive shoulder movement within permitted limits. Do not lift or bear body weight through the operated arm. With stable fixation, avoid unnecessary prolonged immobilisation, but do not force end range.

Progression: pain permits the prescribed exercises, the wound is satisfactory, and the patient can reproduce the permitted movements without jerking or overloading the arm.

Phase II — weeks 2–6: restoring mobility

Gradually increase passive and active-assisted movement. Progress flexion as tolerated, broadly towards 90–120° by the end of week 6. This is a reference point for this programme, not a required result at the first session or a fixed limit for every operation.

Develop scapular control. With stable fixation and the surgeon’s approval, active movement may progress earlier. Do not introduce it solely because pain has decreased. Continue to respect separate restrictions on rotation, lifting and weight bearing arising from the repair.

Progression: improving mobility and movement quality, good tolerance of the existing programme, and clinical and radiographic review permitting rehabilitation to advance.

Phase III — weeks 6–12: active movement and light resistance

Following clinical and radiographic review, progress towards fuller active movement. As adequate healing is achieved and loading is permitted, introduce light strengthening of the rotator cuff, deltoid and scapular muscles.

The start of week 6 does not automatically authorise resistance exercise. Its introduction depends on fixation, the condition of the tuberosities and tendons, and the surgeon’s assessment. Initially, controlled technique and tolerance of low resistance matter more than the weight used.

Progression: advancing healing, better control of active elevation, tolerance of the current load and improving ability in daily activities.

Phase IV — approximately months 3–6: strength and function

Develop strength, endurance and tasks required for work and recreation. Introduce higher loads after confirmation of union and recovery of appropriate arm control. Do not begin with maximal lifting or full overhead loading.

A locking LCP plate and anatomic nail follow the same overall progression. Differences in timing reflect the specific fracture and repair achieved. The 3–6-month period does not guarantee complete recovery for every patient.

Criteria: confirmed healing sufficient for the proposed load, range adequate for the task, good shoulder control and tolerance of activity without significant deterioration after exercise.