nach oben

Current Reviews in Musculoskeletal Medicine

Erschienen in:

01.03.2013 | Shoulder (JS Dines, Section editor)

Open reduction internal fixation of proximal humerus fractures

verfasst von: Marschall B. Berkes, Milton T. M. Little, Dean G. Lorich

Erschienen in: Current Reviews in Musculoskeletal Medicine | Ausgabe 1/2013

Einloggen, um Zugang zu erhalten

Abstract

The treatment of proximal humerus fractures continues to evolve. While the many of these injuries can be managed nonoperatively, a certain percentage require operative treatment. Open reduction internal fixation can offer excellent outcomes when performed in the appropriate patient and utilizing proper techniques. This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes.

Rockwood CA, Green DP, Bucholz RW, Heckman JD. Rockwood and green's fractures in adults. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001.

Hepp P, Theopold J, Osterhoff G, et al. Bone quality measured by the radiogrammetric parameter "cortical index" and reoperations after locking plate osteosynthesis in patients sustaining proximal humerus fractures. Arch Orthop Trauma Surg. 2009;129(9):1251–9.PubMedCrossRef

Bahrs C, Rolauffs B, Sudkamp NP, et al. Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: A comparative study of plain radiography and computed tomography. BMC Musculoskelet Disord. 2009;10:33.PubMedCrossRef

Brunner A, Honigmann P, Treumann T, Babst R. The impact of stereo-visualisation of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and Neer classifications in the assessment of fractures of the proximal humerus. J Bone Joint Surg Br. 2009;91(6):766–71.

Edelson G, Saffuri H, Obid E, Vigder F. The three-dimensional anatomy of proximal humeral fractures. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2009;18(4):535–44.CrossRef

Foroohar A, Tosti R, Richmond JM, et al. Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience. J Orthop Surg Res. 2011;6:38.PubMedCrossRef

Gumina S, Giannicola G, Albino P, et al. Comparison between two classifications of humeral head fractures: Neer and AO-ASIF. Acta Orthop Belg. 2011;77(6):751–7.PubMed

Voigt C, Ewig M, Vosshenrich R, Lill H. Value of MRI in preoperative diagnostics of proximal humeral fractures compared to CT and conventional radiography. [Wertigkeit der MRT in der praoperativen Diagnostik proximaler Humerusfrakturen vs. CT und konventionelles Rontgen]. Der Unfallchirurg. 2010;113(5):378–85.PubMedCrossRef

Neer 2nd CS. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Br Vol. 1970;52(6):1077–89.

10.

Brien H, Noftall F, MacMaster S, et al. Neer's classification system: a critical appraisal. J Trauma. 1995;38(2):257–60.PubMedCrossRef

11.

Brorson S, Bagger J, Sylvest A, Hrobjartsson A. Improved interobserver variation after training of doctors in the neer system. A randomised trial. J Bone Jt Surg Br Vol. 2002;84(7):950–4.CrossRef

12.

Kristiansen B, Andersen UL, Olsen CA, Varmarken JE. The neer classification of fractures of the proximal humerus. an assessment of interobserver variation. Skelet Radiol. 1988;17(6):420–2.CrossRef

13.

Sidor ML, Zuckerman JD, Lyon T, et al. The neer classification system for proximal humeral fractures. an assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am Vol. 1993;75(12):1745–50.

14.

Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am Vol. 1993;75(12):1751–5.

15.

Bernstein J, Adler LM, Blank JE, et al. Evaluation of the neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg Am Vol. 1996;78(9):1371–5.

16.

Sjoden GO, Movin T, Guntner P, et al. Poor reproducibility of classification of proximal humeral fractures. additional CT of minor value. Acta Orthop Scand. 1997;68(3):239–42.PubMedCrossRef

17.

Brunner A, Honigmann P, Treumann T, Babst R. The impact of stereo-visualisation of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and neer classifications in the assessment of fractures of the proximal humerus. J Bone Joint Surg Br Vol. 2009;91(6):766–71.CrossRef

18.

Sjoden GO, Movin T, Aspelin P, et al. 3D-radiographic analysis does not improve the neer and AO classifications of proximal humeral fractures. Acta Orthop Scand. 1999;70(4):325–8.PubMedCrossRef

19.

Tamai K, Ishige N, Kuroda S, et al. Four-segment classification of proximal humeral fractures revisited: A multicenter study on 509 cases. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2009;18(6):845–50.CrossRef

20.

• Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23(2):113–9. Comparison of two cohorts of fractures presenting with varus (24) or valgus (27) preoperative coronal displacement in three- and four-part fractures. Constant scores were significantly higher for the valgus group (71 vs. 63) at final follow-up. Overall complication rate, including AVN, screw perforation, loss of fixation, and displacement, was 79 % in the varus group, as compared with 19 % in the valgus group. Initial fracture pattern is prognostic for postoperative outcomes.PubMedCrossRef

21.

Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am Vol. 2009;91(7):1689–97.CrossRef

22.

Spross C, Platz A, Rufibach K, et al. The PHILOS plate for proximal humeral fractures-risk factors for complications at one year. J Trauma Acute Care Surg. 2012;72(3):783–92.PubMedCrossRef

23.

Yang H, Li Z, Zhou F, et al. A prospective clinical study of proximal humerus fractures treated with a locking proximal humerus plate. J Orthop Trauma. 2011;25(1):11–7.PubMedCrossRef

24.

Brorson S, Bagger J, Sylvest A, Hrobjartsson A. Low agreement among 24 doctors using the neer-classification; only moderate agreement on displacement, even between specialists. Int Orthop. 2002;26(5):271–3.PubMedCrossRef

25.

Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007;21(3):185–91.PubMedCrossRef

26.

Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22(3):195–200.PubMedCrossRef

27.

Russo R, Cautiero F, Della Rotonda G. The classification of complex 4-part humeral fractures revisited: the missing fifth fragment and indications for surgery. Musculoskelet Surg. 2012;96 Suppl 1:S13–9.PubMedCrossRef

28.

Sudkamp NP, Audige L, Lambert S, Hertel R, et al. Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2011;20(8):1207–16.CrossRef

29.

Guy P, Slobogean GP, McCormack RG. Treatment preferences for displaced three- and four-part proximal humerus fractures. J Orthop Trauma. 2010;24(4):250–4.PubMedCrossRef

30.

Robinson CM, Amin AK, Godley KC, et al. Modern perspectives of open reduction and plate fixation of proximal humerus fractures. J Orthop Trauma. 2011;25(10):618–29.PubMedCrossRef

31.

Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Am Vol. 2006;88(4):502–8.CrossRef

32.

Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2004;13(4):427–33.CrossRef

33.

•• Neviaser AS, Hettrich CM, Beamer BS, et al. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011;469(12):3300–6. This is one of the first clinical studies to examine the clinical effects and complications associated with endosteal strut augmentation of proximal humeral locking plates. No episodes of intra-articular screw penetration or cutout were reported in this series of 38 patients. One episode of partial AVN and one patient with loss of reduction were reported. The mean DASH score was 15, and the mean Constant score was 87.PubMedCrossRef

34.

• Neviaser AS, Hettrich CM, Dines JS, Lorich DG. Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant. Arch Orthop Trauma Surg. 2011;131(12):1617–22. Evaluation of rate of AVN following proximal humerus fractures treated with endosteal augmentation and proximal humeral locking plates. Thirty-four patients were followed up at a mean of 66 weeks. There was a 0 % rate of complete AVN and a 2.8 % rate of partial AVN without collapse. Length of posteromedial hinge was not found to be predictive of AVN in this patient series.PubMedCrossRef

35.

Crosby LA, Finnan RP, Anderson CG, et al. Tetracycline labeling as a measure of humeral head viability after 3- or 4-part proximal humerus fracture. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2009;18(6):851–8.CrossRef

36.

Bastian JD, Hertel R. Initial post-fracture humeral head ischemia does not predict development of necrosis. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2008;17(1):2–8.CrossRef

37.

Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. an anatomical study. J Bone Joint Surg Am Vol. 1990;72(10):1486–94.

38.

•• Hettrich CM, Boraiah S, Dyke JP, et al. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am Vol. 2010;92(4):943–8. This anatomic cadaver study was performed to reevaluate the vascular supply to the proximal humerus with the assistance of latex injection, as well as MRI imaging with the assistance of gadolinium. The posterior humeral circumflex artery displayed a dominant pattern, supplying approximately 64 % of the humeral head. This lies in contrast to the findings of Gerber et al., who reported the anterior humerual cirumflex as the dominant artery. This finding may help explain why AVN is not seen as frequently as expected in cases in which the anterior humeral circumflex artery is disrupted.CrossRef

39.

• Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008;22(2):132–7. This article provides a detailed description of the anterolateral approach to the proximal humerus. The technique and benefits of the surgical approach are highlighted.PubMedCrossRef

40.

Hettrich CM, Paul O, Neviaser AS, et al. The anterolateral approach to the proximal humerus for nonunions and delayed unions. Int J Should Surg. 2011;5(1):21–5.CrossRef

41.

Gavaskar AS, Muthukumar S, Chowdary N. Biological osteosynthesis of complex proximal humerus fractures: surgical technique and results from a prospective single center trial. Arch Orthop Trauma Surg. 2010;130(5):667–72.PubMedCrossRef

42.

Gardner MJ, Griffith MH, Dines JS, Lorich DG. A minimally invasive approach for plate fixation of the proximal humerus. Bull Hosp Jt Dis (New York NY). 2004;62(1-2):18–23.

43.

Gardner MJ, Griffith MH, Dines JS, et al. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;434:123–9.PubMedCrossRef

44.

Gardner MJ, Voos JE, Wanich T, et al. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20(9):602–7.PubMedCrossRef

45.

Roderer G, Erhardt J, Graf M, et al. Clinical results for minimally invasive locked plating of proximal humerus fractures. J Orthop Trauma. 2010;24(7):400–6.PubMedCrossRef

46.

Ruchholtz S, Hauk C, Lewan U, et al. Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. J Traumatol. 2011;71(6):1737–44.

47.

Robinson CM, Murray IR. The extended deltoid-splitting approach to the proximal humerus: variations and extensions. J Bone Joint Surg Am Vol. 2011;93(3):387–92.CrossRef

48.

Khan LA, Robinson CM, Will E, Whittaker R. Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach. Injury. 2009;40(2):181–5.PubMedCrossRef

49.

Gardner MJ, Griffith MH, Lorich DG. Helical plating of the proximal humerus. Injury. 2005;36(10):1197–200.PubMedCrossRef

50.

• Wu CH, Ma CH, Yeh JJ, et al. Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71(5):1364–70. Retrospective study comparing outcomes of proximal humerus fracture operative treatment utilizing either the anterolateral or the deltopectoral approach. No statistically significant differences in outcome were found. However, all three cases of AVN were seen in the deltopectoral group.PubMedCrossRef

51.

• Osterhoff G, Baumgartner D, Favre P, et al. Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2011;20(5):740–6. Biomechanical study with synthetic bone fixed with an angular stable locking plate with or without and endosteal fibular strut as a medial support. The models with the endosteal fibular strut had five times lower intercylcic motion, two times lower fragment migration, and two times less residual plastic deformation, as compared with the models without a fibular strut.CrossRef

52.

Osterhoff G, Ossendorf C, Wanner GA, et al. The calcar screw in angular stable plate fixation of proximal humeral fractures–a case study. J Orthop Surg Res. 2011;6:50.PubMedCrossRef

53.

•• Erhardt JB, Stoffel K, Kampshoff J, et al. The position and number of screws influence screw perforation of the humeral head in modern locking plates: a cadaver study. J Orthop Trauma. 2012;26(10):e188–92. Biomechanical study in cadavers. A key finding was that more screws correlated with increasing load to failure. Additionally, the inferomedial screw (the calcar screw) was found to be biomechanically the most important.PubMedCrossRef

54.

Lescheid J, Zdero R, Shah S, et al. The biomechanics of locked plating for repairing proximal humerus fractures with or without medial cortical support. J Trauma. 2010;69(5):1235–42.PubMedCrossRef

55.

Ockert B, Braunstein V, Kirchhoff C, et al. Monoaxial versus polyaxial screw insertion in angular stable plate fixation of proximal humeral fractures: Radiographic analysis of a prospective randomized study. J Trauma. 2010;69(6):1545–51.PubMedCrossRef

56.

Shi HF, Xiong J, Chen YX, et al. Management of proximal humeral fractures in elderly patients with uni- or polyaxial locking osteosynthesis system. Arch Orthop Trauma Surg. 2011;131(4):541–7.PubMedCrossRef

57.

Voigt C, Geisler A, Hepp P, et al. Are polyaxially locked screws advantageous in the plate osteosynthesis of proximal humeral fractures in the elderly? A prospective randomized clinical observational study. J Orthop Trauma. 2011;25(10):596–602.PubMedCrossRef

58.

Liew AS, Johnson JA, Patterson SD, et al. Effect of screw placement on fixation in the huemral head. J Shoulder Elbow Surg. 2000;9(5):423–6.

59.

Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. Surgical technique. J Bone Joint Surg Am Vol. 2009;91(Suppl 2 Pt 1):8–21.

60.

Bae JH, Oh JK, Chon CS, et al. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Am Vol. 2011;93(7):937–41.CrossRef

61.

Chow RM, Begum F, Beaupre LA, et al. Proximal humeral fracture fixation: locking plate construct +/- intramedullary fibular allograft. J Should Elb Surg. 2012;21(7):894–901.CrossRef

62.

Mathison C, Chaudhary R, Beaupre L, et al. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech (Bristol, Avon). 2010;25(7):642–6.CrossRef

63.

• Hettrich CM, Neviaser A, Beamer BS, et al. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012;26(4):212–5. Study examining outcomes of geriatric patients treated with ORIF using endosteal fibular strut. In these 27 patients, all older than 70 years, only one case experienced a loss of reduction. No cases experienced screw penetration or AVN. This demonstrates the utility of the endosteal support, even in older individuals with poorer bone quality.PubMedCrossRef

64.

Aksu N, Gogus A, Kara AN, Isiklar ZU. Complications encountered in proximal humerus fractures treated with locking plate fixation. Acta Orthop Traumatol Turc. 2010;44(2):89–96.PubMedCrossRef

65.

Faraj D, Kooistra BW, Vd Stappen WA, Werre AJ. Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. Eur J Orthop Surg Traumatol Orthop Traumatol. 2011;21(1):7–12.CrossRef

66.

Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors fro functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury. 2012;43(2):153–8.

67.

Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2011;20(5):747–55.CrossRef

68.

Konigshausen M, Kubler L, Godry H, et al. Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system? Injury. 2012;43(2):223–31.PubMedCrossRef

69.

Lee CW, Shin SJ. Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2009;18(1):83–8.CrossRef

70.

Badman B, Frankle M, Keating C, Henderson L, et al. Results of proximal humeral locked plating with supplemental suture fixation of rotator cuff. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2011;20(4):616–24.CrossRef

71.

Brunner F, Sommer C, Bahrs C, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23(3):163–72.PubMedCrossRef

72.

Duralde XA, Leddy LR. The results of ORIF of displaced unstable proximal humeral fractures using a locking plate. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2010;19(4):480–8.CrossRef

73.

Schliemann B, Siemoneit J, Theisen C, et al. Complex fractures of the proximal humerus in the elderly-outcome and complications after locking plate fixation. Musculoskelet Surg. 2012;96 Suppl 1:S3–S11.PubMedCrossRef

74.

Schulte LM, Matteini LE, Neviaser RJ. Proximal periarticular locking plates in proximal humeral fractures: functional outcomes. J Should Elb Surg Am Should Elbow Surg [Et Al]. 2011;20(8):1234–40.CrossRef

75.

Siwach R, Singh R, Rohilla RK, et al. Internal fixation of proximal humeral fractures with locking proximal humeral plate (LPHP) in elderly patients with osteoporosis. J Orthop Traumatol Off J Ital Soc Orthop Traumatol. 2008;9(3):149–53.CrossRef

76.

Sudkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am Vol. 2009;91(6):1320–8.CrossRef

77.

Zhang L, Zheng J, Wang W, et al. The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study. Int Orthop. 2011;35(11):1655–61.PubMedCrossRef

Titel: Open reduction internal fixation of proximal humerus fractures
verfasst von: Marschall B. Berkes
Milton T. M. Little
Dean G. Lorich
Publikationsdatum: 01.03.2013
Verlag: Current Science Inc.
Erschienen in: Current Reviews in Musculoskeletal Medicine / Ausgabe 1/2013
Elektronische ISSN: 1935-9748
DOI: https://doi.org/10.1007/s12178-012-9150-y

Arthropedia

Grundlagenwissen der Arthroskopie und Gelenkchirurgie. Erweitert durch Fallbeispiele, Videos und Abbildungen.
» Jetzt entdecken

Neu im Fachgebiet Orthopädie und Unfallchirurgie

18.04.2024 | Wirbelsäulenmetastase | Nachrichten

Update Orthopädie und Unfallchirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

Open reduction internal fixation of proximal humerus fractures

Abstract

Arthropedia

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Stereotaktische Radiatio schlägt konventionelle Bestrahlung

Vorsicht mit hohen NSAR-Dosen bei ankylosierender Spondylitis!

Brustkrebs in der Vorgeschichte macht Gelenkersatz komplikationsträchtiger

Zwei neue Alternativen zu TNF-Inhibitoren bei axSpA

Update Orthopädie und Unfallchirurgie

Live-Webinar: Aktuelle Leitlinien bei Herz-Kreislauf-Erkrankungen

Springer Medizin

Abstract

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 1/2013

Hemiarthroplasty for proximal humerus fractures

Trapeziometacarpal joint arthritis

Sports injuries of the wrist

Management of proximal humerus fractures utilizing reverse total shoulder arthroplasty

Acromioclavicular joint separations

Current concepts in Dupuytren’s disease

Arthropedia

Neu im Fachgebiet Orthopädie und Unfallchirurgie

Stereotaktische Radiatio schlägt konventionelle Bestrahlung

Vorsicht mit hohen NSAR-Dosen bei ankylosierender Spondylitis!

Brustkrebs in der Vorgeschichte macht Gelenkersatz komplikationsträchtiger

Zwei neue Alternativen zu TNF-Inhibitoren bei axSpA

Update Orthopädie und Unfallchirurgie