Skip to main content

Posttraumatische Humeruskopfnekrose – Endoprothese oder Gelenkerhalt

Post-traumatic necrosis of the humeral head—Endoprosthesis or joint preservation

Zusammenfassung

Hintergrund

Proximale Humeruskopffrakturen spielen im klinischen Alltag und in der Alterstraumatologie aufgrund ihrer hohen Inzidenz eine große Rolle, wobei die posttraumatische Humeruskopfnekrose bei gelenkerhaltender Therapie eine häufig beobachtete Langzeitkomplikation ist.

Fragestellung

In der vorliegenden Arbeit werden Daten zur Epidemiologie und Kausalität der Humeruskopfnekrose übersichtlich dargestellt. Eine große Bedeutung kommt hierbei der Anatomie, der Frakturform und assoziierten Risikofaktoren zu.

Material und Methoden

Es erfolgt eine Aufarbeitung der aktuellen Literatur zum Thema und die kritische Darstellung der Therapieoptionen.

Ergebnisse

Humeruskopffrakturen sind die siebthäufigste Fraktur des Menschen. Trotz moderner Implantate und Operationstechniken liegt die Komplikationsrate weiterhin bei bis zu 40 %. Innerhalb der fehlgeschlagenen Behandlungen stellt die posttraumatische Nekroserate mit 34 % eine der häufigsten Komplikationen dar und führt zu Revisionsraten von bis zu 19 %.

Fazit

Bei der Therapie der Humeruskopffraktur müssen zahlreiche Variablen berücksichtigt werden. Hierbei gilt es, die individuelle Frakturform und individuelle Faktoren mit in die Wahl des Osteosyntheseverfahrens einzubeziehen. Nach Daten der aktuellen wissenschaftlichen Literatur sollten insbesondere moderne winkelstabile Implantate verwendet werden und stets der endoprothetische Gelenkersatz kritisch abgewägt werden. Hierbei spielt die Erwartungshaltung des Patienten an das postoperative Aktivitätsniveau eine große Rolle.

Abstract

Background

Humerus fractures play a major role in daily clinical routine, and subsequent osteonecrosis is common after osteosyntheses.

Objectives

The current paper highlights the incidence and cause of osteonecrosis after proximal humerus fractures, with respect to presentation of anatomy and risk factors.

Methods

Display of the literature and therapy options for humerus fracture and subsequent necrosis.

Results

Humerus fractures are the seventh most frequent fractures in humans. The complication rate is 40%, and the described rate of necrosis is up to 34%. Accordingly, the surgical revision rate is at 19% according to recent literature.

Conclusion

The treatment of humerus head fracture must consider numerous variables. The individual type of fracture and the current individual situation of the patient must be included in the process of choosing the right treatment. Modern implants with screw locking features should be used, and for certain circumstances the direct implantation of a prosthesis should be considered. Thereby the expectations of the patient with respect to the postoperative activity level play a major role.

This is a preview of subscription content, access via your institution.

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5

Literatur

  1. Iglesias-Rodriguez S et al (2021) Epidemiology of proximal humerus fractures. J Orthop Surg Res 16(1):402

    PubMed  PubMed Central  Article  Google Scholar 

  2. Passaretti D et al (2017) Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg 26(12):2117–2124

    PubMed  Article  Google Scholar 

  3. Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury 37(8):691–697

    PubMed  Article  Google Scholar 

  4. Launonen AP et al (2015) Epidemiology of proximal humerus fractures. Arch Osteoporos 10:209

    PubMed  Article  Google Scholar 

  5. Hemmann P et al (2020) Trends in fracture development of the upper extremity in Germany—a population-based description of the past 15 years. J Orthop Surg Res 15(1):65

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  6. Taskesen A et al (2020) Effect of osteoporosis on proximal humerus fractures. Geriatr Orthop Surg Rehabil 11:2151459320985399

    PubMed  PubMed Central  Article  Google Scholar 

  7. Clavert P et al (2010) Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elbow Surg 19(4):489–494

    PubMed  Article  Google Scholar 

  8. Plecko M, Kraus A (2005) Internal fixation of proximal humerus fractures using the locking proximal humerus plate. Oper Orthop Traumatol 17(1):25–50

    PubMed  Article  Google Scholar 

  9. Schliemann B et al (2012) Complex fractures of the proximal humerus in the elderly—outcome and complications after locking plate fixation. Musculoskelet Surg 96(Suppl 1):S3–S11

    PubMed  Article  Google Scholar 

  10. Sproul RC et al (2011) A systematic review of locking plate fixation of proximal humerus fractures. Injury 42(4):408–413

    PubMed  Article  Google Scholar 

  11. Sudkamp N et al (2009) 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 91(6):1320–1328

    CAS  PubMed  Article  Google Scholar 

  12. Voigt C et al (2011) 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 25(10):596–602

    PubMed  Article  Google Scholar 

  13. Large TM et al (2019) Posttraumatic avascular necrosis after proximal femur, proximal humerus, talar neck, and scaphoid fractures. J Am Acad Orthop Surg 27(21):794–805

    PubMed  Article  Google Scholar 

  14. Shah KN et al (2015) Pathophysiology and risk factors for osteonecrosis. Curr Rev Musculoskelet Med 8(3):201–209

    PubMed  PubMed Central  Article  Google Scholar 

  15. Larsen CF, Brondum V, Skov O (1992) Epidemiology of scaphoid fractures in Odense, Denmark. Acta Orthop Scand 63(2):216–218

    CAS  PubMed  Article  Google Scholar 

  16. Fortin PT, Balazsy JE (2001) Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 9(2):114–127

    CAS  PubMed  Article  Google Scholar 

  17. Hettrich CM et al (2010) Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am 92(4):943–948

    PubMed  Article  Google Scholar 

  18. Cruess RL (1978) Experience with steroid-induced avascular necrosis of the shoulder and etiologic considerations regarding osteonecrosis of the hip. Clin Orthop Relat Res 130:86–93

    Google Scholar 

  19. Hertel R et al (2004) Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 13(4):427–433

    CAS  PubMed  Article  Google Scholar 

  20. Bastian JD, Hertel R (2008) Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg 17(1):2–8

    PubMed  Article  Google Scholar 

  21. Robinson CM, Khan LA, Akhtar MA (2006) Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br 88(4):502–508

    CAS  PubMed  Article  Google Scholar 

  22. Xu J, Zhang C, Wang T (2014) Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. J Orthop Surg Res 9:31

    PubMed  PubMed Central  Article  Google Scholar 

  23. Gerber C, Hersche O, Berberat C (1998) The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg 7(6):586–590

    CAS  PubMed  Article  Google Scholar 

  24. Schnetzke M et al (2016) Quality of reduction influences outcome after locked-plate fixation of proximal humeral type‑C fractures. J Bone Joint Surg Am 98(21):1777–1785

    PubMed  Article  Google Scholar 

  25. Belayneh R et al (2018) Osteonecrosis after surgically repaired proximal humerus fractures is a predictor of poor outcomes. J Orthop Trauma 32(10):e387–e393

    PubMed  Article  Google Scholar 

  26. Hattrup SJ, Cofield RH (1999) Osteonecrosis of the humeral head: relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 8(6):559–564

    CAS  PubMed  Article  Google Scholar 

  27. Greiner S et al (2009) Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury 40(2):186–191

    CAS  PubMed  Article  Google Scholar 

  28. Soudy K et al (2017) Results and limitations of humeral head resurfacing: 105 cases at a mean follow-up of 5 years. Orthop Traumatol Surg Res 103(3):415–420

    CAS  PubMed  Article  Google Scholar 

  29. Roderer G et al (2011) Second generation locked plating of proximal humerus fractures—a prospective multicentre observational study. Int Orthop 35(3):425–432

    PubMed  Article  Google Scholar 

  30. Boileau P et al (1999) Sequelae of fractures of the proximal humerus: surgical classification and limits of shoulder arthroplasty. In: Walch G, Boileau P (Hrsg) Shoulder arthroplasty. Springer, Berlin, Heidelberg

    Google Scholar 

  31. Tauber M et al (2007) Shoulder arthroplasty for traumatic avascular necrosis: predictors of outcome. Clin Orthop Relat Res 465:208–214

    PubMed  Article  Google Scholar 

  32. Pape G et al (2010) Humeral surface replacement for the sequelae of fractures of the proximal humerus. J Bone Joint Surg Br 92(10):1403–1409

    CAS  PubMed  Article  Google Scholar 

  33. Raiss P et al (2009) Treatment of osteonecrosis of the humeral head with cementless surface replacement arthroplasty. J Bone Joint Surg Am 91(2):340–349

    PubMed  Article  Google Scholar 

  34. Boileau P et al (2001) Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 10(4):299–308

    CAS  PubMed  Article  Google Scholar 

  35. Raiss P et al (2009) Humeral head resurfacing for fixed anterior glenohumeral dislocation. Int Orthop 33(2):451–456

    CAS  PubMed  Article  Google Scholar 

  36. Moosmayer S et al (2009) Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br 91(2):196–200

    CAS  PubMed  Article  Google Scholar 

  37. Valenti P et al (2012) Mid-term outcome of reverse shoulder prostheses in complex proximal humeral fractures. Acta Orthop Belg 78(4):442–449

    PubMed  Google Scholar 

  38. Szerlip BW, Morris BJ, Edwards TB (2016) Reverse shoulder arthroplasty for trauma: when, where, and how. Instr Course Lect 65:171–179

    PubMed  Google Scholar 

  39. Choo A et al (2014) Prevalence of rotator cuff tears in operative proximal humerus fractures. Orthopedics 37(11):e968–e974

    PubMed  Article  Google Scholar 

  40. Stechel A et al (2010) Reversed shoulder arthroplasty in cuff tear arthritis, fracture sequelae, and revision arthroplasty. Acta Orthop 81(3):367–372

    PubMed  PubMed Central  Article  Google Scholar 

  41. Boileau P et al (2006) Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 15(5):527–540

    PubMed  Article  Google Scholar 

  42. Neviaser AS et al (2011) Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant. Arch Orthop Trauma Surg 131(12):1617–1622

    PubMed  Article  Google Scholar 

  43. Wu CH et al (2011) Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches. J Trauma 71(5):1364–1370

    PubMed  Google Scholar 

  44. Padegimas EM et al (2017) Defining optimal calcar screw positioning in proximal humerus fracture fixation. J Shoulder Elbow Surg 26(11):1931–1937

    PubMed  Article  Google Scholar 

  45. Matassi F et al (2012) Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus. Injury 43(11):1939–1942

    PubMed  Article  Google Scholar 

  46. Tillmann BN (2010) Atlas der Anatomie. Springer, Berlin, Heidelberg, S 430

    Google Scholar 

  47. Panayiotou Charalambous C (2019) Avascular necrosis of the humeral head. In: The shoulder made easy. Springer, Cham, S 381–388 https://doi.org/10.1007/978-3-319-98908-2_29

    Chapter  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to A. Wegner.

Ethics declarations

Interessenkonflikt

A. Wegner, D. Wassenaar, A. Busch, M. Stanjek, C. Mayer und M. Jäger geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Additional information

figure qr

QR-Code scannen & Beitrag online lesen

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wegner, A., Wassenaar, D., Busch, A. et al. Posttraumatische Humeruskopfnekrose – Endoprothese oder Gelenkerhalt. Orthopädie 51, 822–828 (2022). https://doi.org/10.1007/s00132-022-04307-9

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00132-022-04307-9

Schlüsselwörter

  • Knochennekrose
  • Humerus
  • Risikofaktoren
  • Schulterfrakturen
  • Schulterprothese

Keywords

  • Bone necrosis
  • Humerus
  • Risk factors
  • Shoulder fractures
  • Shoulder prosthesis