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1、CurrentConceptsReview Proximal HumeralFracture Treatmentin AdultsDirk Maier, MD, Martin Jaeger, MD, Kaywan Izadpanah, MD, Peter C. Strohm, MD, and Norbert P. Suedkamp, MDInvestigation performed at the Department of Orthopaedic and Trauma Surgery, University Medical Center Freiburg, Freiburg, Germany
2、?Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.?The treatment of displaced three and four-part fractures remains controversial and depends on a variety of un- derlying factors related to the patient (e.g., comorbidity, functio
3、nal demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).?Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.?Low local bone mineral density, humeral hea
4、d ischemia, residual varus displacement, insufficient restoration ofthe medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.?The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of ro
5、tator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function ingeriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.Challenges in the treatment of proximal humeral fractures are complex and the variety of fracture
6、patterns complicates clas-sification. To prevent failures, it is essential to choose the most suitable treatment, including nonoperative therapy, minimallyinvasive osteosynthesis, open reduction and plate fixation, intramedullary nail osteosynthesis, and primary arthroplasty. Surgical treatment requ
7、ires anatomic reduction and stablefixation, proving difficult, particularly in osteoporotic bone. In the United States, the introduction of locking plates caused a substantial rise of operative treatment1. Comparing treatment of proximal humeral fractures in the period 1999 to 2000, in- cluding 14,7
8、74 patients, with that of proximal humeral frac- tures in the period 2004 to 2005, including 16,138 patients, therate of operative treatment increased by 25.6% (p 45? or a separation of 1 cm. Complimentary tothese six groups, in his classification system, Neer defined one, two, three, and four-part
9、fractures to indicate the number of main segments affected by displacement. Neer6also pointedout that displacement was defined rather arbitrarily and theintention was not to dictate treatment. The AO/OTA classifica- tion distinguishes three basic fracture types (A, extra-articular- unifocal; B, extr
10、a-articular-bifocal; and C, articular) and comprises a total of twenty-seven subtypes7. Resch et al.8dif- ferentiated between varus and valgus fractures. The varus fracture may present as an impaction or distraction (disrup- tion) type. Valgus fractures may be impacted in straight lateral or postero
11、lateral direction (Fig. 1). Hertel et al.9introduced the binary description system based on the Codman twelve basicfracture patterns. In addition, they identified the morphologic risk factors for humeral head ischemia. Reliable predictors of ischemia were a short (2 mm. Majed et al.10found low tomod
12、erate interobserver reliabilities among classification sys- tems despite the use of three-dimensional computed tomog- raphy (CT) models. The Codman-Hertel description system achieved the highest interobserver score, followed by the Neer,Resch et al., and AO/OTA classifications.Clinical and Radiograp
13、hic Assessment Clinical assessment should involve carefully looking for soft- tissue and neurovascular injuries. Vascular injuries are more likely tooccurafterseveredisplacement and fracture-dislocation. Lesions of the axillary or brachial artery might be masked by collateral circulation. Doppler ul
14、trasound examination is useful for preliminary assessment. However,digital subtraction angiography remains the diagnostic standard. CTangiography may guide interventional treatment including endarterectomy for intimaltears, primary reconstruction, resectionwith end- to-end anastomosis, grafting for
15、more extended lesions, or embolization for false aneurysms. Stableforth11found injuries of the brachial plexus in 6.2% of eighty-one patients with four- part fractures. Visser et al.12noted electromyographic (EMG) denervation in 67% of 143 patients with displaced and non- displaced proximal humeral
16、fractures. The nerves most fre- quently affected in patients were the axillary nerve in 58% and the suprascapular nerve in 48%. Nerve lesions were found inforty-one (82%) of fifty displaced fractures compared withonly fifty-five (59%) of ninety-three non-displaced fractures12. Magnetic resonance imaging (MRI) detected at least one torn oravulsedrotatorcufftendonintwelve(40%)ofthirty patients with proximal humeral fractures13. The severity of tendon in-jury significantly correlated with increasi
