Skip to main content
SpringerLink
Log in

Posttraumatische Fehlstellungen und Pseudarthrosen des proximalen Humerus

Möglichkeiten und Grenzen der Korrekturosteotomie

Posttraumatic nonunions and malunions of the proximal humerus

Possibilities and limitations of corrective osteotomy

  • Leitthema
  • Published:
Der Unfallchirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Aufgrund der demographischen Entwicklung ist zukünftig mit einer deutlichen Zunahme der Inzidenz proximaler Humerusfrakturen und konsekutiv posttraumatischer Fehlstellungen und Pseudarthrosen zu rechnen.

Fragestellung

Diese Übersichtsarbeit stellt Indikation, Technik und Ergebnisse von Korrekturosteotomien für Patienten mit posttraumatischer Fehlstellung oder Pseudarthrose nach proximaler Humerusfraktur dar.

Methoden

Es erfolgte eine selektive Literaturrecherche unter Berücksichtigung eigener Erfahrungen.

Ergebnisse

Fehlstellungen des proximalen Humerus können nach konservativer und operativer Therapie entstehen. Aufgrund der komplexen Geometrie des proximalen Humerus muss die Analyse der Fehlstellung systematisch erfolgen (epi-, metaphysär). In einem nächsten Schritt muss evaluiert werden, inwieweit die objektivierte Fehlstellung für die vom Patienten berichteten Beschwerden verantwortlich gemacht werden kann. Die benachbarten Weichteilstrukturen (glenohumeraler Kapsel-Band-Apparat, lange Bizepssehne, Rotatorenmanschette, an der Metaphyse inserierende Muskulatur) können unabhängig von der Fehlstellung zu Beschwerden führen und müssen als solche identifiziert werden.

Schlussfolgerungen

In Abhängigkeit von der Lokalisation und dem Ausmaß der posttraumatischen Fehlstellung kommen prinzipiell diverse Korrekturverfahren als Option in Frage. Die hier vorgestellte Single-cut-Osteotomie stellt eine elegante Möglichkeit zur Korrektur mehrdimensionaler Fehlstellungen am proximalen Humerus dar. Pseudarthrosen des proximalen Humerus können durch eine Spongiosaplastik und winkelstabile Plattenosteosynthese in der Vielzahl der Fälle erfolgreich saniert werden.

Abstract

Background

According to the future demographic trends the incidence of proximal humeral fractures and subsequent posttraumatic malunions and nonunions of the proximal humerus are expected to substantially increase.

Objectives

This article reviews the indications, techniques and outcomes of corrective osteotomy for the treatment of posttraumatic nounions and malunions of the proximal humerus.

Methods

A selective literature search was performed and personal surgical experiences are reported.

Results

Malunions of the proximal humerus can occur after both surgical and conservative management of fractures. Due to the complex anatomy of the proximal humerus, malunions have to be systematically assessed regarding epiphyseal and metaphyseal malpositioning. Furthermore, the objective anatomical disorder has to be completely correlated with the subjective patient complaints. The associated soft tissue structures, such as the glenohumeral joint capsule and ligaments, long head of the biceps tendon, rotator cuff and muscles inserting in the metaphysis, can independently cause discomfort to the patient and need to be meticulously identified as such.

Conclusion

A variety of corrective surgical strategies are available, which are indicated depending on the location and extent of the malunion. The depicted single-cut osteotomy technique represents an elegant therapeutic option for multidimensional deformities of the proximal humerus. Nonunions of the proximal humerus can usually be successfully managed with autologous cancellous bone grafting and locking plate osteosynthesis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Allende C, Allende BT (2009) The use of a new locking 90 degree blade plate in the treatment of atrophic proximal humerus nonunions. Int Orthop 33(6):1649–1654

    Article  PubMed Central  PubMed  Google Scholar 

  2. Aoki SK, Anderson LA, Marchese JW (2011) Recession wedge osteotomy of the greater tuberosity for proximal humeral varus. Orthopedics 34(5):398

    PubMed  Google Scholar 

  3. As’ad M, Thet MM, Chambler AF (2007) Arthroscopic treatment for malunion of a head-splitting proximal humeral fracture: the need for adequate initial radiologic investigation. J Shoulder Elbow Surg 16(4):e1–e2

    Article  PubMed  Google Scholar 

  4. Badman BL, Mighell M, Kalandiak SP, Prasarn M (2009) Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft. J Orthop Trauma 23(3):173–179

    Article  PubMed  Google Scholar 

  5. Bahrs C, Badke A, Rolauffs B et al (2010) Long-term results after non-plate head-preserving fixation of proximal humeral fractures. Int Orthop 34(6):883–889

    Article  PubMed Central  PubMed  Google Scholar 

  6. Benegas E, Zoppi Filho A, Ferreira Filho AA et al (2007) Surgical treatment of varus malunion of the proximal humerus with valgus osteotomy. J Shoulder Elbow Surg 16(1):55–59

    Article  PubMed  Google Scholar 

  7. Beredjiklian PK, Iannotti JP, Norris TR, Williams GR (1998) Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am 80(10):1484–1497

    CAS  PubMed  Google Scholar 

  8. Boileau P, Walch G (1997) The three-dimensional geometry of the proximal humerus. Implications for surgical technique and prosthetic design. J Bone Joint Surg Br 79(5):857–865

    Article  CAS  PubMed  Google Scholar 

  9. Boileau P, Trojani C, Walch G, Krishnan SG, Romeo A, Sinnerton R (2001) Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 10(4):299–308

    Article  CAS  PubMed  Google Scholar 

  10. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C (2006) Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res 442:121–130

    Article  PubMed  Google Scholar 

  11. Bono CM, Renard R, Levine RG, Levy AS (2001) Effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder. J Bone Joint Surg Br 83(7):1056–1062

    Article  CAS  PubMed  Google Scholar 

  12. Brostrom LA, Kronberg M, Soderlund V (1993) Surgical and methodologic aspects of proximal humeral osteotomy for stabilization of the shoulder joint. J Shoulder Elbow Surg 2(2):93–98

    Article  CAS  PubMed  Google Scholar 

  13. Brunner U, Kohler S (2007) [Shoulder arthroplasty for treatment of the sequelae of proximal humerus fractures]. Orthopade 36(11):1037–1049

    Article  CAS  PubMed  Google Scholar 

  14. Burkhart SS, De Beer JF (2000) Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16(7):677–694

    Article  CAS  PubMed  Google Scholar 

  15. Burkhart KJ, Dietz SO, Bastian L, Thelen U, Hoffmann R, Muller LP (2013) The treatment of proximal humeral fracture in adults. Dtsch Arztebl Int 110(35–36):591–597

    PubMed Central  PubMed  Google Scholar 

  16. Cadet ER, Yin B, Schulz B, Ahmad CS, Rosenwasser MP (2013) Proximal humerus and humeral shaft nonunions. J Am Acad Orthop Surg 21(9):538–547

    Article  PubMed  Google Scholar 

  17. Cheung EV, Sperling JW (2008) Management of proximal humeral nonunions and malunions. Orthop Clin North Am 39(4):475–482, vii

    Article  PubMed  Google Scholar 

  18. Constant CR (1997) An evaluation of the Constant-Murley shoulder assessment. J Bone Joint Surg Br 79(4):695–696

    CAS  PubMed  Google Scholar 

  19. Court-Brown CM, McQueen MM (2008) Nonunions of the proximal humerus: their prevalence and functional outcome. J Trauma 64(6):1517–1521

    Article  PubMed  Google Scholar 

  20. Duparc F (2013) Malunion of the proximal humerus. Orthop Traumatol Surg Res 99(1 Suppl):S1–S11

    Article  CAS  PubMed  Google Scholar 

  21. Erasmo R, Guerra G, Guerra L (2014) Fractures and fracture-dislocations of the proximal humerus: a retrospective analysis of 82 cases treated with the Philos((R)) locking plate. Injury 45(Suppl 6):S43–S48

    Article  PubMed  Google Scholar 

  22. Fischer LP, Carret JP, Gonon GP, Dimnet J (1977) [Cinematic study of the movements of the scapulo-humeral (articulatio humeri) joint]. Rev Chir Orthop Reparatrice Appar Mot 63(Suppl 2):108–115

    PubMed  Google Scholar 

  23. Georgiadis GM, Georgiadis AG (2013) Proximal humeral nonunion treated with an intramedullary tantalum cylinder. Orthopedics 36(12):e1555–e1558

    Article  PubMed  Google Scholar 

  24. Gilbart MK, Gerber C (2007) Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 16(6):717–721

    Article  PubMed  Google Scholar 

  25. Gill TJ, Waters P (1997) Valgus osteotomy of the humeral neck: a technique for the treatment of humerus varus. J Shoulder Elbow Surg 6(3):306–310

    Article  CAS  PubMed  Google Scholar 

  26. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC (1994) Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 304:78–83

    PubMed  Google Scholar 

  27. Gurke L, Strecker W, Martinoli S (1999) [Graphical analysis and operative technique of single-cut osteotomy for complex femur deformities]. Unfallchirurg 102(9):684–690

    Article  CAS  PubMed  Google Scholar 

  28. Habermeyer P, Schweiberer L (1992) [Corrective interventions subsequent to humeral head fractures]. Orthopade 21(2):148–157

    CAS  PubMed  Google Scholar 

  29. Hinov V, Wilson F, Adams G (2002) Arthroscopically treated proximal humeral fracture malunion. Arthroscopy 18(9):1020–1023

    Article  PubMed  Google Scholar 

  30. Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S (1992) The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am 74(4):491–500

    CAS  PubMed  Google Scholar 

  31. Krettek C, Wiebking U (2011) [Proximal humerus fracture: is fixed-angle plate osteosynthesis superior to conservative treatment?] Unfallchirurg 114(12):1059–1067

    Article  CAS  PubMed  Google Scholar 

  32. Kronberg M, Brostrom LA (1995) Rotation osteotomy of the proximal humerus to stabilise the shoulder. Five years’ experience. J Bone Joint Surg Br 77(6):924–927

    CAS  PubMed  Google Scholar 

  33. Kumar S, Chopra RK, Kashyap A, Arora S (2013) Missed posterior shoulder dislocation with malunited proximal humerus fracture. Chin J Traumatol 16(6):375–378

    PubMed  Google Scholar 

  34. Ladermann A, Denard PJ, Burkhart SS (2012) Arthroscopic management of proximal humerus malunion with tuberoplasty and rotator cuff retensioning. Arthroscopy 28(9):1220–1229

    Article  PubMed  Google Scholar 

  35. Lill H, Voigt C, Jensen G, Warnhoff M, Katthagen JC (2015) [Corrective osteosynthesis of proximal humeral fractures. Technique and prospective results]. Unfallchirurg 118(1):18–28

    Article  CAS  PubMed  Google Scholar 

  36. Maier D, Jaeger M, Izadpanah K, Strohm PC, Suedkamp NP (2014) Proximal humeral fracture treatment in adults. J Bone Joint Surg Am 96(3):251–261

    Article  PubMed  Google Scholar 

  37. Martinez AA, Calvo A, Domingo J, Cuenca J, Herrera A (2010) Arthroscopic treatment for malunions of the proximal humeral greater tuberosity. Int Orthop 34(8):1207–1211

    Article  PubMed Central  PubMed  Google Scholar 

  38. Paavolainen P, Bjorkenheim JM, Slatis P, Paukku P (1983) Operative treatment of severe proximal humeral fractures. Acta Orthop Scand 54(3):374–379

    Article  CAS  PubMed  Google Scholar 

  39. Palvanen M, Kannus P, Niemi S, Parkkari J (2006) Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 442:87–92

    Article  PubMed  Google Scholar 

  40. Pentek M, Horvath C, Boncz I et al (2008) Epidemiology of osteoporosis related fractures in Hungary from the nationwide health insurance database, 1999–2003. Osteoporos Int 19(2):243–249

    Article  CAS  PubMed  Google Scholar 

  41. Pinkas D, Wanich TS, DePalma AA, Gruson KI (2014) Management of malunion of the proximal humerus: current concepts. J Am Acad Orthop Surg 22(8):491–502

    Article  PubMed  Google Scholar 

  42. Russo R, Vernaglia Lombardi L, Giudice G, Ciccarelli M, Cautiero F (2005) Surgical treatment of sequelae of fractures of the proximal third of the humerus. The role of osteotomies. Chir Organi Mov 90(2):159–169

    CAS  PubMed  Google Scholar 

  43. Siegel JA, Dines DM (2000) Proximal humerus malunions. Orthop Clin North Am 31(1):35–50

    Article  CAS  PubMed  Google Scholar 

  44. Soliman OA, Koptan WM (2013) Four-part fracture dislocations of the proximal humerus in young adults: results of fixation. Injury 44(4):442–447

    Article  PubMed  Google Scholar 

  45. Solonen KA, Vastamaki M (1985) Osteotomy of the neck of the humerus for traumatic varus deformity. Acta Orthop Scand 56(1):79–80

    Article  CAS  PubMed  Google Scholar 

  46. Voigt C, Kreienborg S, Megatli O, Schulz AP, Lill H, Hurschler C (2011) How does a varus deformity of the humeral head affect elevation forces and shoulder function? A biomechanical study with human shoulder specimens. J Orthop Trauma 25(7):399–405

    Article  PubMed  Google Scholar 

  47. Walch G, Badet R, Nove-Josserand L, Levigne C (1996) Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elbow Surg 5(3):161–168

    Article  CAS  PubMed  Google Scholar 

  48. Wirth MA (2003) Late sequelae of proximal humerus fractures. Instr Course Lect 52:13–16

    PubMed  Google Scholar 

  49. Yamane S, Suenaga N, Oizumi N, Minami A (2008) Interlocking intramedullary nailing for nonunion of the proximal humerus with the Straight Nail System. J Shoulder Elbow Surg 17(5):755–759

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland

    R. Meller, N. Hawi, U. Schmiddem,  M. Petri & C. Krettek

  2. Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, 81657, Vail, CO, USA

    P.J. Millett &  M. Petri

  3. The Steadman Clinic, 181 West Meadow Drive, 81657, Vail, CO, USA

    P.J. Millett &  M. Petri

Authors
  1. R. Meller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. N. Hawi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. U. Schmiddem
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P.J. Millett
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. Petri
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. C. Krettek
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Petri.

Ethics declarations

Interessenkonflikt

M. Petri ist derzeit Angestellter des Steadman Philippon Research Instituts, und sein AGA-Fellowship-Programm wird von Arthrex gesponsort. P.J. Millett ist als beratender Arzt für Arthrex und Myos tätig und Aktieninhaber bei GameReady and VuMedi. Das Steadman Philippon Research Institute ist ein non-profit Forschungsinstitut und erhält Forschungsförderung von Smith & Nephew, Arthrex, Ossur und Siemens. R. Meller, N. Hawi, C. Krettek, U. Schmiddem geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Additional information

Redaktion

C. Krettek, Hannover

R. Meller, Hannover

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Meller, R., Hawi, N., Schmiddem, U. et al. Posttraumatische Fehlstellungen und Pseudarthrosen des proximalen Humerus. Unfallchirurg 118, 577–585 (2015). https://doi.org/10.1007/s00113-015-0032-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00113-015-0032-9

Schlüsselwörter

Keywords

Search

Navigation