Postoperative treatment of scapula fractures
Phase 1: Injury to End of Week 3 (Inflammatory Phase)
Principle: Protect the injured (or operated) limb to enable proper healing.
Aims: Promote healing without complications while enabling early movement
External Support: Full-time use of optimal shoulder immobilisation. Traditionally, a sling is used to secure the upper arm and forearm against the chest. A simple triangular bandage tied behind the neck often provides this support by countering the weight of the arm.
Additional Support: A swath can be wrapped around the humerus and chest to further restrict shoulder movement and hold the arm securely in the sling. Commercially available devices also offer similar immobilisation, with or without this extra circumferential support.
In cases like coracoid or acromion fractures, or after rotator cuff surgery. The arm may need elevation and abduction to reduce tension, which can be achieved using an abduction brace or cushion (e.g., an aeroplane splint).
Mobilisation: It’s critical to maintain mobility in unaffected joints to reduce swelling and improve circulation. This promotes proprioception and joint health. Recommended exercises include:
- Opening and closing the hand
Squeezing a soft ball
- Wrist flexion and extension, as well as circular movements
Side-to-side hand movements
Elbow flexion and extension
- Squeezing the shoulder blades together while keeping the shoulders relaxed
- Gentle neck movements (side-to-side, forward and backward, rotation)
Physical Therapy: Active-assisted range of motion exercises should start with gravity eliminated, progressing as comfort allows. X-rays are advised if unexpected pain occurs, to rule out secondary fracture displacement.
Daily Activities: At this stage, activities should be limited to basic personal care. The patient should use the affected hand only for midline tasks (e.g., eating or toileting). Care should be taken to avoid extreme motions like reaching behind the back until fracture healing is confirmed.
Sleeping: Patients should sleep in the sling, either on their back or the non-injured side, with proper arm and shoulder support using pillows. Some may prefer a semi-reclined position.
Hygiene: Axillary hygiene is essential. Use a non-slip mat in the shower, and a long-handled sponge for difficult-to-reach areas if assistance is unavailable.
Phase 2: Week 4 to Week 6 (Early Repair Phase)
Principle: Continue protecting the injured limb while guiding tissue repair.
Aim: Strengthen the healing tissues to support antigravity function.
External Support: Full-time use of the sling continues, transitioning to part-time or no support as appropriate. Use pillows for arm support during rest or exercises.
Exercises: Continue all Phase 1 exercises while introducing active-assisted elevation to shoulder level, but avoid extreme hand-behind-back movements and across-body adduction.
Daily Activities: Basic activities from Phase 1 continue. Additional light tasks at the tabletop level, such as food preparation, are encouraged.
Radiographic Control: X-rays should confirm fracture union at this point, allowing progression to Phase 3.
Phase 3: Week 7 to Week 12 (Late Repair & Early Tissue Remodelling)
Principle: Restore proprioception in the limb.
Aim: Promote tissue normalisation and reinnervation, while preventing secondary injury.
External Support: Wean off full-time sling use. Patients may still prefer support at night or during outdoor activities.
Exercises: Continue Phase 2 exercises, progressing to actively-assisted elevation above shoulder level. Hand-behind-back and across-body adduction is now permitted to facilitate natural shoulder rotation. Begin isometric and isokinetic strengthening of the rotator cuff, deltoid, and periscapular muscles.
Shoulder Therapy Set: Devices like exercise bars and pulley assemblies can help improve passive motion. Elastic bands (therabands) can introduce resistance to build strength.
Daily Activities: Along with continuing Phase 2 tasks, introduce social and recreational activities as comfort allows.
Radiographic Control: Confirm fracture consolidation with no adverse symptoms before moving to Phase 4.
Phase 4: Week 13 Onwards (Remodelling & Reintegration)
Principle: Normalise proprioceptive function with correct biomechanics.
Aim: Ensure proper tissue structure and reinnervation through endurance training and practice.
Mobilisation: There are no movement restrictions. Sport-specific and occupational training can be introduced under supervision.
Daily Activities: Full engagement in sport and occupational activities involving resisted elevation and abduction is encouraged.
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