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Minimal-invasive Plattenosteosynthese proximaler Humerusschaftfrakturen mittels langer PHILOS-Platte

Minimally invasive plating osteosynthesis of proximal humeral shaft fractures with long PHILOS plates

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Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Zusammenfassung

Operationsziel

Geschlossene Reposition und minimal-invasive Stabilisation proximaler Humerusschaftfrakturen mittels langer PHILOS-Platte. Die präsentierte Technik ermöglicht eine stabile extramedulläre Frakturfixation ohne Alteration der dabei zu unterfahrenden Nerven.

Indikationen

Proximale Humerusschaftfrakturen, die aufgrund eines engen, deformierten oder durch Implantate besetzten Markkanals oder offener Epiphysenfugen nicht für eine Marknagelosteosynthese geeignet sind.

Kontraindikationen

Frakturen, bei denen eine geschlossene Reposition durch Traktion oder eine direkte perkutane Reposition nicht möglich ist. Frakturen mit verzögerter Heilung („delayed union“) oder Pseudarthrosen („non-union“), die durch indirekte oder direkte perkutane Maßnahmen nicht adäquat therapiert werden können.

Operationstechnik

Über einen anterolateralen Deltasplit-Zugang wird von proximal nach distal ein epiperiostaler Tunnel präpariert. Nachfolgend wird distal auf Höhe des lateralen Rands des M. biceps brachii eingegangen. Der M. brachialis wird längs durchtrennt. Die PHILOS-Platte wird torquiert, sodass der proximale Teil lateral und der distale Teil anterolateral des Humerus zu liegen kommt. Danach wird die Platte von proximal nach distal in den epiperiostalen Tunnel eingeführt und die Plattenlöcher werden perkutan besetzt.

Postoperative Behandlung

Ruhigstellung des operierten Arms in einem Gilchrist-Verband oder Schultergurt bis zur gesicherten Wundheilung. Ab dem 1. postoperativen Tag aktiv-assistive physiotherapeutische Mobilisation ohne Belastung. Beginn mit aktiver Mobilisation 8–12 Wochen postoperativ. Metallentfernung bei störendem Osteosynthesematerial 1 Jahr postoperativ.

Ergebnisse

Zwischen 2005 und 2011 wurden 16 Patienten (8 Frauen, 8 Männer, Durchschnittsalter 61 Jahre) mit der beschriebenen Technik versorgt. Entsprechend der AO-Klassifikation wurden 5 Frakturen als Typ A, 8 als Typ B und 3 als Typ C klassifiziert. Alle Patienten konnten nach durchschnittlich 24 Monaten (12–38 Monate) klinisch und radiologisch nachuntersucht werden. Zum Zeitpunkt der letzten Nachuntersuchung zeigten alle Frakturen eine vollständige knöcherne Konsolidation. Der durchschnittliche Constant-Murley-Score ergab 81 Punkte, dies entsprach 84% des Constant-Murley-Scores der gesunden Gegenseite. Der durchschnittliche DASH-Score betrug 33 Punkte und der mittlere SF-36-Wert 85 Punkte.

Abstract

Objective

Closed reduction and minimally invasive stabilization of proximal humeral shaft fractures with long PHILOS plates. The presented technique enables stable extramedullary fixation of the fractures without affecting surrounding nerves.

Indications

Proximal humeral shaft fractures that may not be fixed by intramedullary nailing because of a narrow, deformed or occupied intramedullary canal or because of open growth plates.

Contraindications

Fractures that may not be reduced adequately by traction or with percutaneous techniques. Furthermore, fractures with delayed or nonunion and pseudarthrosis should not be treated with this technique.

Surgical technique

An anterolateral delta split approach is used to create an epiperiosteal tunnel along the humeral shaft from proximally to distally. A second incision is made distally at the lateral border of the biceps muscle. The brachialis muscle is dissected longitudinally. The PHILOS plate is twisted so that the proximal part of the plate can be placed laterally and the distal part anterolaterally at the humeral shaft. The plate is inserted into the epiperiostal tunnel and fixed with percutaneous screws.

Postoperative management

The arm is immobilized in a Gilchrest bandage until wounds are healed. Active-assisted physiotherapeutic mobilization without loading starts on the first postoperative day. Active mobilization starts 8–12 weeks postoperatively. In cases of soft tissue irritation the PHILOS plate may be removed after 1 year.

Results

Between 2005 and 2011 a total of 16 patients (8 women and 8 men) were treated with the presented technique. The patients mean age was 61 years. According to the AO classification, five fractures were classified as type A, eight as type B and three fractures as type C. All patients had clinical and radiological follow-up examinations after a mean of 24 months (12–38 months). All fractures showed complete bony consolidation at the final follow-up. The mean Constant-Murley score was 81 points representing 84% of the Constant-Murley score of the healthy contralateral shoulder. The average DASH score was 33 points and the mean SF36 was 85 points.

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  1. Klinik für Unfallchirurgie, Chirurgische Klinik Luzern, Luzerner Kantonsspital, Spitalstr., 6000, Luzern 16, Schweiz

    A. Brunner &  R. Babst

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  1. A. Brunner
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  2. S. Thormann
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  3. R. Babst
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Correspondence to R. Babst.

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Brunner, A., Thormann, S. & Babst, R. Minimal-invasive Plattenosteosynthese proximaler Humerusschaftfrakturen mittels langer PHILOS-Platte. Oper Orthop Traumatol 24, 302–311 (2012). https://doi.org/10.1007/s00064-012-0176-5

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  • DOI: https://doi.org/10.1007/s00064-012-0176-5

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