Maier D, Jäger M, Strohm P C, Südkamp N P
Universitätsklinikum Freiburg, Dept. Orthopädie und Traumatologie, Klinik für Traumatologie Freiburg im Breisgau, Germany.
Acta Chir Orthop Traumatol Cech. 2012;79(4):307-16.
Fractures of the proximal humerus commonly affect elderly patients. The vast majority of proximal humeral fractures result from low-energy trauma in presence of osteoporosis. Incidence of proximal humeral fractures dramatically increased over the last decades. Recent epidemiological studies expect a rather stagnant incidence. Diversity of fracture types attenuates reliability of available classification systems. Even though, predictive morphologic criteria have been detected enabling a prognostic assessment. A short or absent metaphyseal head extension and disruption of the medial periosteal hinge reliably predict ischemia of the humeral head fragment. Still, humeral head necrosis may be prevented in early reduction and fixation. The range of treatment options consists of non-operative therapy, minimal-invasive osteosynthesis, open reduction and plate fixation, intramedullary nailing and primary arthroplasty. Most proximal humeral fractures in the elderly are stable injuries and can be successfully treated by non-operative means. Operative treatment of displaced, unstable fractures should resort to the least invasive procedure providing adequate reduction and fixation stability. To date, open reduction and locking plate osteosynthesis represents the standard operative procedure in displaced three- and four-part fractures. However, a number of risk factors may promote fixation failure or impair functional outcome, most important low local bone mineral density, residual varus displacement of the humeral head, insufficient restoration of medial calcar support, humeral head ischemia and insufficient fracture reduction. Innovation of fixation techniques (e. g. angular stable locking systems and bone augmentation) will further expand indications for operative fracture treatment. Outcome of hemiarthroplasty is closely related to anatomical tuberosity healing and restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients, rotator cuff dysfunction or failure of first-line treatment. Choice of treatment should be individualized and base on careful evaluation of patient-specific, fracture-specific and surgeon-specific aspects.
肱骨近端骨折常见于老年患者。绝大多数肱骨近端骨折是在骨质疏松的情况下由低能量创伤引起的。在过去几十年中，肱骨近端骨折的发生率急剧上升。最近的流行病学研究预计发生率将相当稳定。骨折类型的多样性削弱了现有分类系统的可靠性。尽管如此，已经发现了一些预测形态学标准，能够进行预后评估。干骺端头部延伸短或缺失以及内侧骨膜铰链中断可可靠地预测肱骨头碎片的缺血情况。不过，通过早期复位和固定可预防肱骨头坏死。治疗选择包括非手术治疗、微创接骨术、切开复位钢板固定、髓内钉固定和一期关节成形术。老年人的大多数肱骨近端骨折为稳定损伤，可通过非手术方法成功治疗。对于移位的不稳定骨折，手术治疗应采用侵入性最小的方法，以提供足够的复位和固定稳定性。迄今为止，切开复位锁定钢板接骨术是移位的三部分和四部分骨折的标准手术方法。然而，一些危险因素可能会导致固定失败或影响功能结果，其中最重要的是局部骨密度低、肱骨头残留内翻移位、内侧距支撑恢复不足、肱骨头缺血以及骨折复位不充分。固定技术的创新（如角度稳定锁定系统和骨增强）将进一步扩大手术治疗骨折的适应症。半关节成形术的结果与解剖学结节愈合和肩袖功能恢复密切相关。反肩关节置换术可为老年患者、肩袖功能障碍或一线治疗失败的患者提供满意的肩部功能。治疗选择应个体化，并基于对患者特异性、骨折特异性和外科医生特异性方面的仔细评估。
