The mean time to fracture healing was 12.4 weeks (range 8–16 weeks).
    There were 4 cases (7.8%) of primary subacromial impingement of the plate due to a varus inclination of the humeral head <120°and malreduction >5° in all cases (Fig. 1).
    Among these fractures (type 2B1, 1B2 and 1C1 fractures), all patients were 67 years old or older (mean 71 years).
    Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications

    Radiological union was seen at 12±4.6 weeks.
    Treatment of Proximal Humerus Fractures using PHILOS Plate

    In Neer’s second article from 1970 (8) immediate active exercises for the hand and elbow is advocated.

    During the initial 3 weeks, passive exercises were recommended and between
    the sessions the shoulder and the arm was immobilized in a shoulder bandage.

    The following 3 weeks the arm was still supported in a sling and active assisted exercises began. Active elevation above the shoulder was to be avoided until the tuberosities healing was radiologically sanctioned, after 9 weeks at the earliest.
    Passive stretching or weighted exercises were not to begin until 12 weeks after surgery. This regimen is the most frequent cited in the literature

    l isometric exercises for the shoulder joint are started as soon as 4-6 weeks after surgery followed by active exercises with the patient lying down on the back or up to shoulder level, to reduce the impact of gravity on the joint. Nevertheless, it is also recommended in the Axelina rehabilitation program that active exercises above shoulder level is not to be introduced until after 8-12 weeks post-operatively, followed by passive stretching and weighted exercises. The purpose of treatment with the Axelina rehabilitation program aims, except for increased range of motion in the shoulder joint, to give the patient implements for the post-operative treatment and rehabilitation regimen, understanding of the anatomy of the shoulder, the healing of the

    The arm was usually immobilized in a sling for a mean time of 2 week

    immediate active movements for the elbow and hand was usually advocated followed by passive pendulum movements for the shoulder

    However, there seemed to be a common concern that the tuberosities should be radiologically healed before weighted exercises should be initiated, at the earliest 9 weeks

    Physiotherapeutic interventions and rehabilitation regimen of the surgically stabilized proximal humeral fracture – a literature review

    Estimated time for bone healing is 8 weeks.

    Phase 1: Time Frame:0-6 weeks

    Immobilization:Sling Immobilizer / Brace with 15degrees abduction x 6weeks.
    Wear continuously except for therapy, HEP and hygiene /bathing.

    Restrictions: Avoid AAROM, AROM and strengthening. Limit FF to 140, IR to
    chest level, and ER to Neutral.
    ROM should be a slow stretch (not forceful).

    Exercises: Gripping exercises, elbow, wrist and finger ROM.
    Shoulder pendulums (slow,small circles) and PROM for shoulder in line with restrictions.
    Instruct patient on HEP to perform twice daily.

    Phase2: Time Frame: 6-10 weeks
    Immobilization: None

    Restrictions: PROM only until 6 weeks. Allow full ROM for FF, limit IR to chest
    level and ER to 30 degrees. No strengthening.
    Instruct patient to continue to protect shoulder. No strengthening.

    Exercises: Gradually increases PROM exercises in line with restrictions.
    Add AAROM at 6 weeks and AROM at 8 weeks.
    Modalities used as needed.

    TimeFrame: 10-14weeks
    Immobilization: None

    Restrictions: Exercise advancement should be gradual and in slow increments
    while avoiding pain.
    If patient develops pain, drop back to early phase of rehabilitation, until pain free.
    Allow full ROM without restrictions.

    Exercises:Continue with shoulder PROM, AAROM and AROM (Goal is 75% or
    greater of normal PROM by 12 weeks).
    At 10 weeks begin shoulder isometric strengthening with arms at side (IR, ER, scapular stabilization).
    At 12weeks add shoulder resistance strengthening exercises.Progression should be gradual and in slow increments while avoiding pain.

    The patients remained immobilized with a simple sling for a period three week, but were already submitted to assisted passive gain of movements with the physiotherapist's help.

    After three weeks they were started on isometric strengthening and active gain of movements. The average duration of the rehabilitation was four months.
    Results of treatment of proximal humerus fractures using locking plates

    Patients were instructed to do the elbow mobilization,pendular and griding exercises passively after three weeks of surgery and active exercises after 6 weeks of surgery under the guidance of a physiotherapist.
    Treatment of proximal humerus fracture using proximal humerus locking plating file:///C:/Users/Ishioka1/Downloads/440-1926-2-PB.pdf

    ロッキングプレートの立場から 帝京大学整形外科 小林 誠

    Radiographic findings by type

    I - normal(1, 2)

    II(1, 2)
    lateral end of clavicle may be slightly elevated
    x-ray usually normal but may demonstrate slight widening of AC joint
    100% separation of clavicle and acromion not seen on stress views

    obvious separation of AC joint(2)
    25-100% increase in coracoclavicular distance compared to normal side(2)
    clavicle appears high on stress views, but in actuality, acromion and remainder of upper extremity displaced inferior to horizontal plane of lateral clavicle(1)

    posteriorly displaced clavicle on axillary x-ray(1)
    evaluate sternoclavicular joint for possible anterior dislocation of sternoclavicular joint and posterior dislocation of AC joint(1)

    100-300% greater clavicle-to-acromion distance(1)
    type VI - distal clavicle may be(1)
    clavicle lodged behind intact conjoined tendon
    posterior superior AC ligaments (often still attached to acromion) displaced into AC interval


    types I and II
    sling for 1-3 weeks(2)
    ice(1, 2)
    immobilization for 3-7 days(1)
    with relief of pain, range of motion and strengthening exercises(2)

    type III
    similar to treatment for types I and II, but sling for 2-4 weeks(2)
    special considerations for type III injuries(1)
    usually treated nonoperatively, especially in patients who participate in contact sports with high risk of reinjury evaluate on case-by-case basis, with consideration of occupation hand dominance risk for reinjury heavy labor position/sport requirements (quarterbacks, pitchers)

    scapulothoracic dysfunction athletes involved in throwing or contact sports may be special cases
    preferred treatment is nonoperative some posit that throwing requires anatomic reduction of AC joint
    reports of successful nonoperative treatment of Major League Baseball pitchers postoperative care may include(1) period of immobilization range of motion program strengthening program
    conservative approach appears adequate prospective study of 25 patients with acute grade III acromioclavicular separation were treated nonoperatively with sling for comfort and progressive range of motion as tolerated 20 patients were followed for 1 year 1 patient had surgery at 2 weeks for cosmetic reasons 4 (20%) considered their outcome suboptimal at 1 year but only 1 thought surgery would have been warranted to prevent this outcome objective testing found no limitations in strength or range of motion at 1 year

    Reference - Am J Sports Med 2001 Nov-Dec;29(6):699
    review of athletic taping for shoulder and elbow can be found in J Musculoskel Med 2004 Sep;21(9):477

    In general, a consequent and strict immobilization of the clavicle is not possible. Based on the tension forces of the muscles of the shoulder girdle, the frequent changes of position during day and night, and the constant respiratory excursions, there is always some motion in the fractured clavicle [9]. In line with these observations, former techniques like painful closed reduction techniques are neither successful regarding enduring alignment nor recommended anymore.

    Initial treatment involves immobilization of the affected shoulder. Among other options, a simple sling or a figure-of-eight brace is commonly used. There is no clear evidence regarding the best technique and the duration of immobilization [16]. A figure-of-eight brace is often thought to prevent or reduce secondary fracture shortening during the time of fracture healing. Stepwise tightening of the brace is recommended to counteract the shortening forces. However, there is no evidence for this view and studies have shown no difference between a sling and a figure-of-eight brace regarding healing time and the rate of nonunion [15]. With no evident advantage compared to a sling, the figure-of-eight brace is associated with more discomfort and pain. Nerve compression with temporary brachial plexus palsies and restriction of venous blood return have been reported in the literature [27].

    When a sling is used, immobilisation in internal rotation is usually recommended for 3-4 weeks. Self-mobilisation of the elbow out of the sling is required several times a day to avoid stiffening of the elbow. The range of motion of the shoulder should usually be limited to pendulum excercises for the first 1-2 weeks followed by active movements up to the horizontal plane within the first 6 weeks. Free range of motion is usually allowed after 6 weeks [19]. Weight bearing should be avoided until clinical fracture consolidation. However, all these recommendations are rather based on expert opinions and experience than on clear evidence [16].

    Many clinicians allow their patients to begin with isometric physiotherapy and resistance exercises depending on residual pain and discomfort. Sporting activities and work, demanding weight bearing and the use of the arm, are usually suspended until the patient is free of pain with radiographic signs of progressing fracture consolidation, usually after 6-12 weeks [21, 18]. Contact sports should be avoided for 3-4 months [18, 21].

    Fracture healing may take more time in nonoperative treatment. In a Canadian multicenter randomized controlled trial, mean time to union was significantly higher for conservative treatment compared to plate fixation (28 vs. 16 weeks) [21]. Regular clinical follow-up examinations including radiographs should be performed to monitor fracture healing. Conservatively treated fractures of the clavicular midshaft usually unite between 18 and 28 weeks after the injury [21, 28]. In case there is no union evident on the radiographs at this point in asymptomatic patients, no more clinical and radiological follow-ups are necessary due to the absence of any therapeutic consequences [29, 30]. In symptomatic patients, conversion to surgery may be considered [19, 22].

    Reference Nonoperative Treatment of Midshaft Clavicle Fractures in Adults Open Orthop J. 2018; 12: 1–6.

    mention above

    ・Many clinicians allow their patients to begin with isometric physiotherapy and resistance exercises depending on residual pain and discomfort. Sporting activities and work, demanding weight bearing and the use of the arm, are usually suspended until the patient is free of pain with radiographic signs of progressing fracture consolidation, usually after 6-12 weeks

    ・In a Canadian multicenter randomized controlled trial, mean time to union was significantly higher for conservative treatment compared to plate fixation (28 vs. 16 weeks)

    Figure8と三角巾で保存治療の効果(骨癒合期間 痛みの改善)に有意差なし


    受傷初日― 肘より遠位の自動運動 振り子運動を許可



    保存の場合骨癒合は平均28.4週、opeで16.4週(p-value ≦0.001)


    ROMex :肘より遠位の自動運動  振り子運動 1st potition で内旋、外旋
    MMTex :isometric cuff ex:1st potition で
    禁忌:持ち上げない 引っ張らない 押さない 運転しない (箸、書字、パソコン等は許可)

    ROMex: 90度以上の自動拳上を許可、以降はROM制限なし
    MMTex: isotnic cuff ex sidelying ER with towel ↓


    肩甲骨面上で缶やペットボトル持って拳上  壁を使ってプッシュアップまたは臥位からベンチプレス
    二頭筋筋トレ(biceps curl)  回内・回外筋トレ

    10週ー (6週のプログラムが疼痛なく、かつ90度以下の範囲でMMT5/5 になったら)

    Reference from
    Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial.

    There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment.

    In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed.

    The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001).

    Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

    Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures

    The mean time to radiographic union was 28.4 weeks in the nonoperative group compared with 16.4 weeks in the operative group (p = 0.001).

    Conservative treatment of fractures of the clavicle  BMC Res Notes. 2011; 4: 333.

    I. Phase I – Early Motion Phase (0 – 5 weeks)

    A. Week 1 Early Passive Motion
    1. Wear the sling at all times except to exercise
    2. Hand, wrist, elbow, and cervical AROM
    3. Grip and wrist strengthening
    4. PROM: ER to 30° and flexion to 130º
    5. Modalities as needed for pain relief or inflammation reduction

    B. Week 2 Active Assisted ROM
    1. Apply hot packs 10 minutes before exercising
    2. Begin pendulum (Codman) exercises
    3. Begin pulley for flexion and abduction
    4. Begin gentle AAROM flexion to 140º
    5. Supine ER with a stick to 40º
    a. Keep arm in plane of scapula
    6. Scapular Stabilization
    a. S/L scapular clocks
    b. Seated scapular retractions

    C. Week 3 – 4 AAROM and Isometrics
    1. Continue all exercises
    2. Begin S/L assisted forward elevation
    3. Begin submaximal isometrics IR, ER, Flex, Ext, and ABD
    4. Begin flexion and ABD on slide board or table

    II. Phase II – Active Motion Phase (Week 4 – 12)

    A. Week 4 – 6 AROM

    1. Establish full PROM

    2. Begin AROM
    a. Supine flexion with and without stick
    b. Progress to sitting (or standing) flexion with a stick
    c. Sitting flexion with elbow bent and arm close to the body
    d. Raise arm over head with hands clasped
    e. Perform ER and ABD with hands behind head
    f. Eccentric pulleys
    g. Sidelying ER
    h. Prone Ext and ABD
    i. Serratus Punches

    3. Continue PROM and begin patient self stretching (week 6)
    a. Wall Walking
    b. Doorway ER stretch
    c. S/L post. Capsule stretch

    4. Begin multi-angle isometrics

    B. Week 8 Early Resisted ROM

    1. Begin Theraband for IR, ER, flexion, ABD, and extension
    2. Begin supine IR, ER with 1# (with arm supported at 15° ABD)
    3. Begin UBE no resistance
    4. Progress to adding weight to above exercises only if pain-free
    5. Biceps / Triceps strengthening with dumbbells

    III. Phase III – Aggressive Stretching and Strengthening Phase (beginning week 12)

    1. Isotonic strengthening with weights all directions
    2. Increase theraband or use rubber tubing
    3. Increase stretches on door and add prone stretches
    4. Begin functional or sport activity for strength gain


    術後3週からfull rangeの自動ROM訓練と,1stpositionにおける回旋を許可した
    ARISTO proximal humeral nailを用いた上腕骨近位端骨折の治療経験


    After surgery, all patients were treated with a similar postoperative protocol. Patients were placed in an arm sling for the first 6 weeks.

    Isometric deltoid, biceps, and triceps strengthening out of the sling were started on the first postoperative day.

    Passive range of motion exercises were started at the second week postoperatively and continued for 4–6 weeks until radiographic evidence of fracture healing was apparent, and then, active range of motion with a formal physiotherapy program was begun.

    Treatment of Two-Part Proximal Humerus Fractures: Intramedullary Nail Compared to Locked Plating

    The shoulders were supported in a sling and gentle pendulum exercises commenced as comfort allowed.
    Assisted exercises followed by active exercises were commenced at week 2.
    Patients were followed up at weeks 2 and 6,

    month 6, and every 6 months thereafter. Radiographs were obtained at each follow-up to assess bone union and complications. The Constant and Oxford scores were assessed at the final follow-up. The Constant score assesses pain, activities of daily living (ADL), range of motion, and power.

    Intramedullary nailing for displaced proximal humeral fractures

    The rehabilitation protocol consisted of active assisted exercises of the shoulder under physiotherapeutic guidance for 6 weeks up to 90 degrees abduction or elevation.
    Mean hospital stay was 11 days (SD 4.4 days). Mean follow-up was 23.2 months (SD 8.92)
    The Treatment of the Proximal Humeral Fracture with the Use of the PHN Nailing System:
    the Importance of Reduction

    Postoperatively, the arm was suspended in an envelope sling and the patient was advised to flex the ipsilateral elbow from the first postoperative day as many times a day as possible. Strict advice was given against any attempt at external rotation of the arm for the first 4 weeks. Sling was disregarded after a month, and the patient started active external rotation along with muscle strengthening exercises. At 6 weeks, exercises to improve external rotation were initiated that usually lasted for 2-3 weeks. Assisted forward flexion of the shoulder was encouraged from day 1 with care not to perform simultaneous external rotation of the affected arm. Further mobilization of the shoulder was done according to a protocol for cuff tear repair.
    Intramedullary nailing of humeral diaphyseal fractures. Is distal locking really necessary?

    prognostic scale

    abduction 111º (SD, 47º; range, 30º–180º),
    forward flexion 143º (SD, 41º; range, 45º–180º).

    operative method
    hemiarthroplasty for comminuted 3-part (n=13) or 4-part (n=14) proximal humeral fractures

    rehab protocol
    Postoperatively, a sling pouch was used.
    day 1 Gravityassisted pendulum exercises and passive motion exercises
    week 3 assisted forward elevation and supine external rotation and full elbow ROMex
    week 6 stretching and strengthening of the shoulder with the help of a theraband
    activities of daily living (bathing, eating, and personal hygiene) were allowed

    Hemiarthroplasty for comminuted proximal humeral fractures

    Rehabilitation Following Total Shoulder Arthroplasty. J Orthop Sports Physical Therapy

    Of the patients, 49 (mean age, 70 years) met the inclusion criteria and were followed up for 12 months. Greater tuberosity migration occurred in 3 cases in the early mobilization group and once in the late mobilization group (P > .10). There was no significant difference in the Constant Shoulder Assessment and Oxford scores between the 2 groups. Although there was a decreased incidence of tuberosity migration in the group undergoing late mobilization, this was not statistically significant.

    Early versus late mobilization after hemiarthroplasty for proximal humeral fractures.

    Standard rehabilitation regime following hemiarthroplasty for trauma is early mobilisation to prevent the development of a stiff shoulder. However, an aggressive early rehabilitation may lead to non-union of the greater tuberosity. We hypothesise that a delayed rehabilitation will result in a good union rate without undue risk of shoulder stiffness.

    Between December 1996 and June 2003, 40 patients with three or four part fracture of proximal humerus with or without dislocation, not amenable to open reduction and internal fixation underwent hemiarthroplasty with reconstruction of tuberosities and a conservative rehabilitation regime at our centre (age range of 39-92 with a mean of 68). Pathologic fractures and non-cooperative and/or demented patients were excluded. Patients were kept in a sling for 4 weeks before physiotherapy was commenced. They were reviewed at an average of 55 months (12-95) for assessment of pain, range of movement, activities of daily living and strength. Radiographs were taken to evaluate the union of the greater tuberosity.

    One patient lost to follow up. In 12.8% of the patients (mainly elderly, with mean age of 78.8) the greater tuberosity failed to heal. In those with a healed greater tuberosity the average elevation was more than 130 degrees , and the average external rotation was 40 degrees . A total of 51.3% of the patients had excellent results, 33.3% had satisfactory and 15.4% had unsatisfactory results.

    Postoperative immobilisation did not result in excessive stiffness and excellent functional results were achieved, especially in those younger than 70 years of age. However, tuberosity union could not be guaranteed in very old patients.

    Shoulder hemiarthroplasty for fracture with a conservative rehabilitation regime.

    Training-induced strength and functional adaptations after hip fracture.
    65歳以上、 frail: MPPT 12-28 に該当する大腿骨骨折術後患者 について高負荷でエクササイズを指導(65%RM 1 or 2 sets of 6 to8 repetitions )することで、半年後の最大筋出力が有意に改善

    Association Between Wait Time and 30-Day Mortality in Adults Undergoing Hip Fracture Surgery
    JAMA. 2017;318(20):1994-2003. doi:10.1001/jama.2017.17606
    42230人、平均年齢80.1歳、70.5%が女性 股関節骨折後に手術を受けるまでの時間が①24時間以内 ②24時間以上 の2群に分けて予後、合併症(肺炎、静脈血栓、心筋梗塞等)、死亡率を比較  前者で30日、90日、1年以内の死亡率、合併症発症率が有意に低下 3分の2の患者で24時間以内に手術を受けることができなかった

    Early maximal strength training is an efficient treatment for patients operated with total hip arthroplasty.

    OAの後で人工股関節となった患者を術後4週の間、①標準リハビリ ②高負荷リハビリ の2群に分けて治療効果を検証 メニューは以下
    ①除重力(スリング使用) 股関節内転ー外転 屈曲ー伸展 MMT,低負荷:12–15 repetitions または負荷なし、水中で

    ② 術後1週経過後 ①に加えて、エルゴメーターを50% of V˙ O2maxと、 
    5RMのトレーニング 2種実施 ↓
    leg press(股関節 屈曲90度ー45度の範囲 、膝関節 屈曲90度ー0度の範囲となるように調整=脱臼防止のため)、
    hip abduction(立位 外転25-0度で調整) 

    ダウンロード (3)

    結果 高負荷群で筋力と心肺能力が有意に改善

    Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review.

    人工股関節、膝関節 術後のリハビリ開始時期についてレビュー 術後24時間以内に離床 48時間以内に歩行開始すると、副作用なくROM MMT QOL 有意に改善、入院期間短縮効果あり

    Early inpatient rehabilitation after elective hip and knee arthroplasty.

    人工股関節、膝関節 術後のhigh risk とされる患者(70歳以上独居 70歳以上で合併症を2つ以上 70歳以下で合併症を3つ以上)でも早期にリハビリ開始できるか検証
    退院の目安は45m以上歩行可、屋内ADL自立 とした
    ①術後3日以内にリハ開始 ②術後7日以降に開始 の2群に分けて比較した(平均年齢73.5歳)結果、

    Effect of Inpatient Rehabilitation vs a Monitored Home-Based Program on Mobility in Patients With Total Knee Arthroplasty: The HIHO Randomized Clinical Trial.

    人工膝関節術後の患者168人(平均年齢66.9 years )を、
    ①10日間の入院期間中リハビリした後、退院後に8週間外来リハフォロー ②退院後にエクササイズ方法を収録したDVDを渡され、自主トレのみ実施

    結果 26週後のアウトカム(歩行速度 心肺機能 ROM MMT ADL)に有意差なし 副作用報告なし
    結論 人工膝関節術後リハについて、お手本としてDVDを見ながら自宅でエクササイズに取り組んでも、入院+外来リハビリと同じ効果が得られる

    Rotational Dynamics of the Talus in a Normal Tibiotalar Joint as Shown by Weight-Bearing Computed Tomography


    結果:足関節回内、回外時の脛距間距離は保たれたまま、平均10°回旋した 上記アウトカムは患者間、また患者内で差はあるが、足関節回内、回外のtotal ROMはほとんど差が無かった よって足関節回旋時の安定性を評価するときは一般に用いられる正常値よりも患者の非受傷側のROMと比較した方がより正確であろう

    Prognostic reliability of the Hawkins sign in fractures of the talus.
    J Orthop Trauma. 2007 Sep;21(8):538-43.

    距骨骨折31名の患者について、術後 距骨に阻血性壊死が患者5名には、距骨体部の軟骨下骨の萎縮所見すなわちHawkins'signが見られなかった 阻血性壊死の無かった残りの患者 26名にてHawkins'signが観察されたのは術後6-9週の間であった

    結論 距骨骨折後、後期にHawkins'signが見られた場合、阻血性壊死は無いものと考えて良いだろう

    Clinical outcomes of surgical treatment for talar malunions and nonunions
    Acta Ortop Bras. 2013 Jul-Aug; 21(4): 226–232.

    距骨骨折 術後に変形治癒、または偽関節となった患者26名について 平均術後14週後に再手術した
    再手術後 2-3週 short leg cast(石膏) 固定、手術翌日よりROMex開始した 部分荷重は6週、フル荷重は平均14週から、骨癒合を確認後に開始した

    結果 30か月フォローアップした結果、感染することなく骨癒合が得られた  AOFAS score 上も有意な改善が見られた

    Postoperative Rehabilitation of Patients with Shoulder Arthroplasty – A Review on the Standard of Care

    肩人工関節置換後の術後療法について2358文献をレビューした論文(Kraus et al., Int J Phys Med Rehabil 2014,)によれば

    およそ3フェーズ(Neer, JBJSがオリジナル passive assistive active の3段階に分ける) と 4フェーズ (最後に筋トレを追加) の2種に大別、3フェーズが主流であるが「特にどの方法が良かった」というエビデンスなし 

    2358文献のうち、上記文献には3,4フェーズで代表例を10あげており、早くて6週、遅くて8週から standard な場合(各種文献を総合)↓

    Phase1 -4week
    passiveROM  F 130 ER 30
    Wrist, hand and elbow can be trained actively

    Phase 2 4-8week
    passiveROM  F 160 まで  ER 60 まで
    active-assistive F 痛みの無い範囲まで 外転 120度まで

    Phase 3 8week-
    activeROM開始 痛みの無い範囲まで
    isometric MMTex 開始 2.5kg まで

    Phase 4 12week-
    可動域制限 MMT制限解除 

    Effectiveness of Soft Tissue Massage for Nonspecific Shoulder Pain: Randomized Controlled Trial.
    Phys Ther. 2015 Nov;95(11):1467-77. doi: 10.2522/ptj.20140350. Epub 2015 May 28.

    肩痛患者 80人、平均年齢62.6歳 を①自主トレ指導(ROM MMT モーターコントロール を個別に設定) ②自主トレ指導+軟部組織マッサージ(カフ、三角筋、大胸筋) の2群に分けて治療効果を比較
    頻度は週に2回を2週 1回を3週の計7回

    結果 12週後の治療効果は変わらず
    結論 肩痛患者へのマッサージに、特別な治療効果はない

    Outcome of humeral shaft fractures treated by functional cast brace
    上腕骨骨幹部骨折、 functional cast brace 後の平均骨癒合期間 10.3週(range 6-16W)

    Distal radial metaphyseal forces in an extrinsic grip model: implications for postfracture rehabilitation.
    J Hand Surg Am. 2000 May;25(3):469-75.

    1kgのGripに対して遠位橈骨には2.7kgの、橈尺関節には5.3kgの負荷発生 術後の再骨折を防ぐためには、骨癒合するまでにGripは16kgまでに留めておくことが推奨される

    Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up.


    Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.

    平均年齢56歳、21名(うち大断裂および広範囲断裂は11名)の腱板縫合術後 25ヶ月フォローアップ 
    (リハは術後6週間装具固定で肩のpassiveROM禁忌、肘から先のROMのみ 6週からpassive 12週からassitive 腱板のストレッチと筋トレは4ヵ月後)

    再断裂例が少なかったことの原因として、症例の約半数がone posterior rotator cuff tendon と損傷腱が一箇所のみだったこと、参加者の平均年齢が比較的若いこと、リハビリが通常よりも慎重に進められていたことなどが挙げられる

    Development of fatty atrophy after neurologic and rotator cuff injuries in an animal model of rotator cuff pathology.


    Time to failure after rotator cuff repair: a prospective imaging study.
    再断裂はいつ起きるか?1-4cm完全断裂(と過去3ヶ月以内に診断)113例の腱板修復術後をフォローアップ、年齢は12-75歳と幅広い。(50歳代が中心 75歳以上、4cm以上の完全断裂、高度の脂肪浸潤は除外) 喫煙者はほとんどいなかった。(10名)

    再断裂はコンスタントスコア、VAS,Penn shoulder scoreなどと相関せず 筋力は26週をピークに徐々に低下していた。(非断裂群では52週以降も緩やかに改善)
    対側の外転筋力と比較して、52週の時点で断裂群 75%止まり 非断裂群は92% 内旋、外旋筋力は両群で有意差なし




    Effect of plane of arm elevation on glenohumeral kinematics: a normative biplane fluoroscopy study.
    ・健常者のGHリズムは外転で2:1 肩甲骨面挙上 1.6:1 屈曲 1.1:1と減少する。

    Current Concepts Review Massive Tears of the Rotator Cuff
    腱板損傷による機能障害は、断裂がどこにあるかによって異なる。肩関節の後上方部分で断裂が起きると、肩関節屈曲、外転、ER ROMが減少 この時、ERはpassive-active でlagを生じることが多い 断裂の範囲が広くなれば小円筋が働かなくなるのでhornblower sigh(…肩の外転を伴わずに手を口元まで持っていくこと このテストで特異度93% 感度100%で小円筋の機能不全を同定できる。)ができなくなる。

    肩峰―骨頭間の距離短縮は広範囲な腱板断裂を示唆する。 MRIを使用すれば感度100%で腱板断裂の診断とサイズの同定、脂肪変性の有無を鑑別できる。

    非手術―保存療法はエビデンスレベルgrade B



    The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears.

    修復困難な退行性広範囲断裂をきたした高齢者17名をリクルート 彼らは全員70歳以上(平均年齢80歳 range 70-96)、認知機能障害-、英語圏、激しい痛みを訴え日常生活上、90度以上に上肢を挙上するのが困難、可動域制限- である。


    結果、6週目で既に90%の被験者で肩関節機能、疼痛が改善 三角筋疲労が軽減するに従い日常生活動作レベルもアップした。

    コンスタントスコアは治療前の平均60点から26点Up  Active ROM 40度Up(平均屈曲角度160度) 


    The Natural History of Asymptomatic Rotator Cuff Tears: A Three-Year Follow-up of Fifty Cases
    3年間のフォローアップ期間中、①ASESスコア80点以下 ②日常生活上の痛み、或いは夜間痛が6週以上続く ③痛み止めや関節内注射、手術などが処方された のいずれかに当てはまれば無症候→症候性に移行したものとする。

    10cm-VAS 0.3cm悪化に対し3.6cm悪化
    肩関節屈曲可動域(active、疼痛の起きない範囲) 7度減少に対し 34.4度減少
                同じく  外転          3.6度減少 対  40.8度
                      外旋          8.4度減少 対  12.5度 

                      断裂サイズ     3.3mm増加 対  10.6mm

    腱板断裂サイズが7.3mm以上悪化すると症候性に有意に移行した。しかし、断裂サイズが広がったからといって症候性に移行するとは限らなかった。(10mm以上断裂が悪化しても無症候であった者 4名、13%) また断裂サイズの悪化がわずかであっても症候性に移行するケースもあった。(断裂悪化5mm以下なのに症候性に移行 7名、39%)
    上腕二頭筋長頭腱 の脱臼または損傷は 無症候性 対 症候性 で6% 対 33% (オッズ比7.5)
    12% 対 35% (オッズ比4.0)
    4% 対 35% (オッズ比13.1)

    無症候性の完全腱板断裂は3分の1が症候性腱板断裂に移行すると言われている。それは断裂サイズの拡大、筋の量と質の変化(すなわち萎縮と脂肪変性)、上腕二頭筋長頭腱 の脱臼または損傷などによって起こるとされ今回の研究結果を裏付けている。

    Does This Patient With Shoulder Pain Have Rotator Cuff Disease?
    The Rational Clinical Examination Systematic Review

    ・肩痛は筋骨格系疼痛で3番目に多く成人の7-26%が有すると言われている その主な原因が腱板損傷 30歳を越えると2.8%ずつ、70歳以上では15%/年ごとに罹患者が増える
    ・腱板損傷を鑑別するために、徒手的検査がMRI、手術など 主訴は腕や肩の痛みで頭上に腕を挙げたときに特に痛みが強くなる 他に夜間痛、筋力低下、硬化など
    ・腱板は肩関節を動かす初期に動員され(棘上筋:外転 棘下筋:外旋 肩甲下:内旋と内転 小円:外旋、外転)、上腕骨頭の軌道が一定に保たれるよう、骨頭を安定させる働きがある。
     ③ 腱板損傷者ではpainful arc test (外転した際に60度から120度の範囲でのみ痛みが起きる。60度で痛みが始まれば腱板損傷疑い+)陽性率が高い。一方Hawkins testやNeer testでは信頼性が低かった。
     ④lag test (external or internal rotation)は腱板断裂の鑑別で最も有効
     ⑤Drop arm test (外転抵抗試験 90度外転から抵抗を加えて耐えられなければ+)陽性なら腱板に何らかの問題を有するサインとなる。


    Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study




    以上を8週間実施 8-12週は頻度を半分に減らす。負荷時の痛みスコアはVAS5/10まで 負荷は個々に増やす。


    Ellenbecker TS, Cools A. Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: an evidence-based review.
    ・腱板トレーニングは15-20回(50-65%RM)×3セット 4週間で腱板は8-10%増加する。

    ・より鍛えたければscapula plane上、90/90ポジションで

    *腱板修復術後、棘上筋の増大または減少が機能予後に相関 減少すれば34%の患者で再断裂 トレーニングによって棘上筋増大した群の再断裂は0%

    Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med2007;35:1744-51


    下部では A,B,D 

    Distal humerus fracture in the elderly: Does conservative treatment still have a role?
    Orthopaedics & Traumatology: Surgery & Research Volume 99, Issue 8, December 2013, Pages 903-907

    平均年齢84.7 years (range, 68—100 years) 56人の上腕骨通穎骨折に保存療法を実施
    A 18名 B 8名 C 30名(C1 16名 C2 10名 C3 4名 )
    (手術の場合は以下 typeB,Cで保存療法は稀、とされている)
    A1 Screw Fixation A2、A3 Screw or Double Plate Fixation
    B1、B2 Screw or Single Plate Fixation B3 Screw Fixation(Hebert screw など)
    C Double Plate Fixation or 人工関節

    上腕―前腕―手関節までカバー、肘関節屈曲90度以上で固定を平均7 weeks (range, 15—120 days) 骨癒合確認後に固定を解除(リハビリ時)、可動域訓練開始

    平均最終可動域 肘 屈曲110から120度 伸展-26から-29度  
    前腕回内 80-90% ,回外 80-85% の患者でnormal可動域獲得 
    Quick-DASH 31-34点
    2例で外反、内反変形 二頭筋筋力normal またはやや減少 93% 三頭筋筋力normal またはやや減少 85%
    偽関節 3例 前額面で15度以上の変形 62% 矢状面で10度以上の変形 46% OA発生率 50%

    副作用: 変形治癒 3例(手術適応となるほどの変形にはならなかった) 皮膚損傷 2例 血腫 1例

    (先行研究 1971,aug )
    Intercondylar T-shaped fractures of the humerus. Results in ten cases treated by early mobilization
    J Bone Joint Surg Br, 53 (1971), pp. 425-428

    上腕骨通穎骨折の重篤なタイプ(typeⅢ Ⅳ) 10例(14-80歳 平均年齢49歳)について

    ・受傷直後は肘屈曲120度で固定 (徒手整復および麻酔無し 開放骨折例で消毒)
    ・振り子運動 手関節、指のactiveROMは直後より開始
    ・受傷数日後 腫れが引いていたら肘のactive,assitiveROM開始 passiveは禁忌 

    結果 (平均追跡期間 2年半)
    6週で骨癒合→固定解除 リハビリはその後も3-4か月間継続
    平均可動域:屈伸totalで98度 日常生活を送る上で最低限伸展―20、屈曲120度 すなわちtotal 100度なので治療は成功、との考察 さらに当初は屈曲120度で固定するのが望ましい、と

    (先行研究 1937)
    T-shaped fractures of the lower end of the humerus
    J Bone Joint Surg Am, 19 (1937), pp. 364-374

    上腕骨通穎骨折14例 麻酔下に徒手整復後cast固定 肘屈曲角度は60-90度 できるだけ早期に歩行開始 肩固定は初日のみ 手関節、手指は初日からactiveROM開始 肘は2日目から、屈曲はできるところまで、伸展はcastの範囲内で

    結果 上記 J Bone Joint Surg Br, 53 (1971), pp. 425-428 と同等

    (先行研究 1969 )
    fractures of the humerus in the adult: a comparison of operative and non-operative treatment in twenty nine cases
    J Bone Joint Surg Am, 51 (1969), pp. 130-141

    上腕骨通穎骨折 29例について手術、保存の治療成績を比較 保存の方法は 先行研究 1971,aug に牽引をかけた徒手整復を追加 
    結果 粉砕骨折以外は保存で良好な結果が得られた

    (先行研究 1964)
    Comminuted Fractures of the Distal End of the Humerus in the Adult.
    Journal of Bone & Joint Surgery - American Volume: April 1964

    手術と保存を比較 手術で肘屈伸total 111度 保存で47度 よって手術の方が望ましい

    Wrist mobilization following volar plate fixation of fractures of the distal part of the radius.
    J Bone Joint Surg Am. 2008 Jun;90(6):1297-304. doi: 10.2106/JBJS.G.01368.

    colles fx 後 volar plate 固定した患者60人 の可動域訓練開始時期を ①早期(平均術後8日) ②6週後(平均49日) の2群に分けて治療効果を比較 6か月後の治療効果に有意差なし
    結論 可動域訓練開始時期を遅らせても、治療効果は変わらない

    Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study.
    J Bone Joint Surg Am. 2014 Oct 1;96(19):1621-30.

    colles fx 後 volar plate 固定した患者81人 の可動域訓練+筋トレ開始時期を ①2週 ②6週 の2群に分けて治療効果を比較 6か月後の治療効果は早期群で有意に改善
    結論 早期介入群( 術後2週でGrip , wrist isometric 4週で wrist isotonic、スプリントオフ  6週 heavy なgrip )治療効果は標準のプロトコルより優れていた 再骨折等の副作用もなかった。

    South Bay Hand Surgery Center protocol 

    1-6週 指のpassive,activeROM 指の動きが悪ければスプリントで矯正
    6-8週 キャストオフ、愛護的ROM開始
    8-10週 軽度の筋トレ開始 手関節の動きが悪ければスプリントで矯正
    10週ー 筋力強化開始 必要に応じてスプリント

    キャストはMPjt freeに 手根管症候群の兆候が出れば外すか、巻きなおし

    ・掌側傾斜( Palmar tilt )30度以上または背側傾斜(radial angulation )10度以上 は伸筋腱への影響大
    ・背側傾斜(radial angulation )10度以上  痛み、握力低下が長期に続く
    ・橈骨短縮10mm以上 回内障害47% 回外障害27%発生

    No difference between two types of exercise after proximal phalangeal fracture fixation: a randomised trial
    Journal of Physiotherapy, Volume 62, Number 1, 2016, pp. 12-19(8)

    基節骨骨折患者66名の 術後のリハビリ方法について 術後1週より ①wrist free のgutter splint MP flex 70 固定 ,splint 装着によるエクササイズ指導↓
    ダウンロード (2)

    ②splint 作らずFinger exercize=active ROM 指導 ↓


    結果 12週後の治療効果変わらず
    結論 術後1週よりgutter splintによるエクササイズを開始しても副作用が無く、高いリハビリ効果が期待できる