Wertigkeit der MRT in der präoperativen Diagnostik proximaler Humerusfrakturen vs. CT und konventionelles Röntgen

A Comprehensive Review of Proximal Humerus Fractures: From Epidemiology to Treatment Strategies

This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.

Advanced Preoperative Planning Techniques in the Management of Complex Proximal Humerus Fractures

This review evaluates the current literature on the recent advances of preoperative planning in the management of complex proximal humerus fractures (PHF). PHFs can pose a considerable challenge for orthopaedic surgeons due to their diversity in presentation and complexity. Poor preoperative planning can lead to prolonged operations, increased blood loss, higher risk of complications, and increased stress on the surgical team. Recent advances have seen the evolution of preoperative planning from conventional methods to computer-assisted virtual surgical technology (CAVST) and three-dimensional (3D) printing, which have been highlighted as transformative tools for improving preoperative planning and postoperative outcomes. CAVST allows the creation of 3D renderings of patient-specific anatomy, clearly demonstrating fracture patterns and facilitating detailed planning for arthroplasty or surgical fixation. The early studies show promising outcomes however the literature calls for more high-quality randomised controlled trials. Using 3D printing for high-fidelity simulation involving patient-specific physical models offers an immersive experience for surgical planning. Preoperative planning with 3D printing reduces operative time, blood loss and use of fluoroscopy. The technology's potential to produce customisable surgical implants further improves its versatility. There is a need for a cost analysis for the use of these technologies within the orthopaedic field, particularly considering the high expense of 3D printing materials and extended hospital stays until the printed models are available. CAVST and 3D printing also show promising applications within high-fidelity simulation surgical training, with CAVST offering possibilities in virtual reality and haptic-enhanced simulations and 3D printing providing physical models for trainee surgeons to hone their skills. Moving forward, a reduction in the cost of 3D printing and the advancement of CAVST using artificial intelligence would lead to future improvement. In conclusion, preoperative planning supported by these innovative technologies will play a pivotal role in improving surgical outcomes and training for complex PHF cases.

Intraoperative 3D imaging in plate osteosynthesis of proximal humerus fractures

INTRODUCTION

Proximal humerus fractures are common and often associated with osteoporosis in the elderly. Unfortunately, the complication and revision rate for joint-preserving surgical treatment using locking plate osteosynthesis is still high. Problems include insufficient fracture reduction and implant misplacement. Using conventional intraoperative two dimensional (2D) X-ray imaging control in only two planes, a completely error-free assessment is not possible.

MATERIALS AND METHODS

The feasibility of intraoperative three-dimensional (3D) imaging control for locking plate osteosynthesis with screw tip cement augmentation of proximal humerus fractures was retrospectively studied in 14 cases with an isocentric mobile C-arm image intensifier set up parasagittal to the patients.

RESULTS

The intraoperative digital volume tomography (DVT) scans were feasible in all cases and showed excellent image quality. One patient showed inadequate fracture reduction in the imaging control, which then could be corrected. In another patient, a protruding head screw was detected, which could be replaced before augmentation. Cement distribution in the humeral head was consistent around the screw tips with no leakage into the joint.

CONCLUSION

This study shows that insufficient fracture reduction and implant misplacement can be easily and reliably detected by intraoperative DVT scan with an isocentric mobile C-arm set up in the usual parasagittal position to the patient.

Bilateral Posterior Fracture-Dislocation of the Shoulders Secondary to Uremic Encephalopathy

Bilateral posterior fracture-dislocation of the shoulder is an uncommon injury pattern usually caused by epileptic seizures. The cause of the seizure activity remains unknown in most cases, although the injury has been associated with several conditions. A 59-year-old man with uncontrolled hypertension presented with new-onset generalized tonic-clonic seizures. He was diagnosed with uremic encephalopathy and bilateral posterior fracture-dislocation of his shoulders. His medical condition required stabilization leading to a delay in definitive surgery and a subsequent poor outcome. This case highlights the previously unknown association between bilateral fracture-dislocation of the shoulders and seizures caused by uremic encephalopathy. In these complex situations with competing clinical priorities, it is important to initiate prompt treatment of the cause in any new-onset seizures, to facilitate expedient surgical management of the orthopaedic injury.

[Multiplanar reconstruction with mobile 3D image intensifier. Surgical treatment of proximal humerus fractures]

PURPOSE

The aim of this study was to analyze the applicability and advantages of the intraoperative use of a mobile 3D C-arm with multiplanar imaging for surgery of acute proximal humerus fractures.

MATERIALS AND METHODS

In this study 20 patients (11 female, 9 male, median age 70 years, range 35-91 years) with dislocated proximal humerus fractures (6 with 2 segments, 10 with 3 segments and 4 with 4 segments) were included. Preoperatively 3D scanning was performed and a reevaluation of the fracture in comparison to the plain radiographs was performed. After operative treatment another scan was performed to evaluate technical complications.

RESULTS

In comparison to the multiplanar reconstructions fracture morphology could not be correctly detected in 5 out of the 20 cases with plain radiographs. The preoperative image quality of the multiplanar reconstructions showed a significantly better assessment in comparison to the image quality with osteosynthesis (p < 0.05). The screws had to be replaced in 5 of the 20 patients.

CONCLUSION

Intraoperative 3D imaging with mobile image intensifier enables an accurate analysis of fracture morphology. Furthermore a quasi real time preoperative planning, evaluation of reduction and implant position with immediate operative relevance can be realized.

Lack of fifth anchoring point and violation of the insertion of the rotator cuff during antegrade humeral nailing: pitfalls in straight antegrade humeral nailing

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as 'critical types', due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation. We therefore emphasise the need for 'fastidious' pre-operative planning to minimise this risk.

[Arthroscopic fracture management in proximal humeral fractures]

Arthroscopy has become increasingly more established in the treatment of proximal humeral fractures. In addition to the known advantages of minimally invasive surgery fracture and implant positioning can be optimized and controlled arthroscopically and relevant intra-articular concomitant pathologies (e.g. biceps tendon complex and rotator cuff) can be diagnosed and treated. Arthroscopic techniques have proven to be advantageous in the treatment of various entities of greater tuberosity fractures, lesser tuberosity fractures (suture bridging technique) and subcapital humeral fractures (arthroscopic nailing). This article presents an overview on innovative arthroscopic modalities for treating proximal humeral fractures, describes the surgical techniques and the advantages compared to open procedures as well as initial clinical results.

Open reduction internal fixation of proximal humerus fractures

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.

All-arthroscopic intramedullary nailing of 2- and 3-part proximal humeral fractures: a new arthroscopic technique and preliminary results

PURPOSE

The most criticism of antegrade humeral nailing is the potentially deleterious effect on the shoulder function, which is caused by the trauma to the M. supraspinatus (SSP) at the nail insertion site. We describe a new technique of all-arthroscopical intramedullary nailing, which preserves the rotator cuff, and compare it with the conventional open procedure.

METHODS

From 11/2009 to 12/2010 82 patients with unstable, displaced proximal humeral fractures were treated surgically. Twenty-one of these patients received an intramedullary nailing. Sixteen of 21 met the inclusion criteria. Based on the surgeon's arthroscopic experience, patients were assigned to the arthroscopic (group I, n = 8) or open group (group II, n = 8). Both groups were compared due to the replacement results, complications, time of surgery and fluoroscopy. Concomitant intraarticular pathologies were assessed (group I). First clinical results after a median follow-up of 13 months (group I) and 14 months (group II) were reported.

RESULTS

Between group I and II, no significant differences were seen in patients age [77 years (range 45-90 years) vs. 76 years (range 65-92 years)], gender (6 female/2 male vs. 5 female/3 male) and fracture pattern (six 2-/two 3-part fractures vs. five 2-/three 3-part fractures). The reduction was evaluated by the caput-diaphysis-angle, which was median 137° (range 120-147°) in group I and 132° (range 120-158°) in group II (p = 0.959). Postoperatively, group I showed one varus-, group II two varus- and valgus deformities. Median time of surgery was 75 min (range 45-182 min) versus 70 min (range 40-146 min) (p = 0.442), fluoroscopy time 1.5 min (range, 0.6-3.7 min) versus 1.2 min (range 0.3-2.2 min) in group I and II (p = 0.336). Concomitant pathologies like one traumatic bicipital tendon-lesion and three partial lesions of the SSP were observed and treated in group I. Constant Scores and Visual Analogue Scale did not differ significantly between both groups at the time of follow-up.

CONCLUSIONS

All-arthroscopical humeral nailing is possible, preserves the rotator cuff and provides equal replacement and functional results like the open technique. An arthroscopically visualized optimal nail insertion point provides less frequent head deformities. Level of evidence Level III.

[Humeral head fracture and cuff]

During the past decade the evaluation of the rotator cuff in the management of proximal humeral fractures has received increasing attention. Different studies have investigated the pathomorphology, prevalence and impact of rotator cuff lesions on the outcome of non-operative or surgical treatment of proximal humeral fractures. Tendon defects, either chronic or trauma related, are observed mainly in the anterosuperior or posterosuperior aspect of the rotator cuff and present as partial- or full-thickness tears. Structural changes of the rotator cuff muscles including atrophy and fatty infiltration in the context of proximal humeral fractures have been inadequately investigated. The prevalence of coexisting rotator cuff pathology varies between 5 and greater than 50% depending on the method of evaluation, the fracture morphology and the age of the patient. The influence of a concomitant rotator cuff tear on the clinical outcome has not been conclusively investigated. However, different studies indicate that some lesions can be a source of persistent pain and functional deficit after conservative or surgical management of proximal humeral fractures. Therefore, a simultaneous repair of the rotator cuff defect during surgical reconstruction of the proximal humerus is indicated.