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OP-Journal 2019; 35(03): 274-282
DOI: 10.1055/a-0898-6681
Fachwissen
Georg Thieme Verlag KG Stuttgart · New York

Pseudarthrosen und schlecht heilende Frakturen am Humerusschaft und am distalen Humerus

Nonunions and Delayed Unions at the Shaft and Distal End of the Humerus
Michael Plecko
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Publication History

Publication Date:
19 November 2019 (online)

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Zusammenfassung

Frakturen am Humerusschaft werden häufig konservativ im Brace behandelt und werden allgemein als benigne Frakturen mit hoher Heilungspotenz eingestuft. Dennoch kommt es, je nach Abschnitt, in 12 – 24% zur Ausbildung einer Pseudarthrose. Meist ist die Funktionalität des Armes so gestört, dass eine operative Behandlung notwendig wird. Eine exakte Analyse ist für den Erfolg der Therapie unumgänglich. Die Plattenosteosynthese, bevorzugt mit interfragmentärer Kompression und Anlagerung autologer Knochenspäne, führt in der überwiegenden Mehrzahl der Fälle zu einer raschen und soliden Heilung und ermöglich gleichzeitig die Korrektur relevanter Fehlstellungen. Bei atrophen Pseudarthrosen sind zusätzlich Maßnahmen zur Verbesserung der lokalen Biologie notwendig. Am distalen Humerus ist häufiger die suprakondyläre Region betroffen. Hier steht die Einstauchung und Kompression der Knochenenden gegeneinander sowie die Defektauffüllung mit autologen Knochenspänen im Vordergrund. Eine Doppelplattenosteosynthese sorgt für ausreichende Stabilität. Ein ausgedehntes Kapselrelease verhindert eine erhöhte Belastung der Frakturzone und verhindert eine zu starke postoperative Bewegungseinschränkung. Bei Fällen, die nicht stabil rekonstruierbar sind, stellt die Ellbogentotalendoprothese eine sehr gute Rettungsoperation dar.

Abstract

Fractures of the humeral shaft are treated with reduction and functional bracing in the majority of cases. Although the humerus shaft has a high potential to heal, depending on the different shaft areas there is a nonunion rate between 12 and 24%. A precise analysis of each case is mandatory for successful treatment. Compression plating and additional autologous bone graft has proven to be successful in the majority of cases, leading to solid bony healing and correction of malalignment. In atrophic situations methods like decortication are necessary to improve biologic environment. At the distal humerus more often the supracondylar region is affected. Impaction and interfragmentary compression after debridement as well as autologous bone graft and stable double plating technique is leading to improved stability. As there is nearly always severe joint stiffness, an extended capsular release is necessary to minimize the load at the fracture side. If a stable and adequate reconstruction is impossible, a semiconstrained total elbow prosthesis may be a perfect salvage procedure.

 

  • Literatur

  • 1 Sarmiento A, Kinman PB, Heckman JD. et al. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977; 59: 596-601
    CrossrefPubMedGoogle Scholar
  • 2 Zagorski JB, Latta LL, Zych GA. et al. Diaphyseal fractures of the humerus. Treatment with prefabricated braces. J Bone Joint Surg Am 1988; 70: 607-610
    CrossrefPubMedGoogle Scholar
  • 3 Athwal G. Distal Humerus Fractures. In: Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta III P, McKee MD. eds. Rockwood and Greenʼs Fractures in Adults. 8th ed. Vol. 1. Philadelphia: Wolters Kluwer Health; 2015: 1229-1286
    Google Scholar
  • 4 Jupiter JB, von Deck M. Ununited humeral diaphysis. J Shoulder Elbow Surg 1998; 7: 644-653
    CrossrefPubMedGoogle Scholar
  • 5 Ali E, Griffith D, Obi N. et al. Nonoperative treatment of humeral shaft fractures revisited. J Shoulder Elbow Surg 2015; 24: 210-214
    CrossrefPubMedGoogle Scholar
  • 6 Denard jr. A, Richards JE, Obremskey WT. et al. Outcome of nonoperative vs. operative treatment of humeral shaft fractures: a retrospective study of 213 patients. Orthopedics 2010; DOI: 10.3928/01477447-20100625-16.
    CrossrefPubMedGoogle Scholar
  • 7 Matsunaga FT, Tamaoki MJ, Matsumotot MH. et al. Minimally invasive osteosynthesis with bridge plate versus a functional brace for humeral shaft fractures: a randomized controlled trial. J Bone Joint Surg Am 2017; 99: 583-592
    CrossrefPubMedGoogle Scholar
  • 8 Harkin FE, Large RJ. Humeral shaft fractures: union outcomes in a large cohort. J Shoulder Elbow Surg 2017; 26: 1881-1888
    CrossrefPubMedGoogle Scholar
  • 9 Papasoulis E, Drosos GI, Ververidis AN. et al. Functional bracing of humeral shaft fractures: a review of clinical studies. Injury 2010; 41: e21-e27
    CrossrefPubMedGoogle Scholar
  • 10 Giannoudis PV, Einhorn TA, Marsh D. Fracture healing: the diamond concept. Injury 2007; 38 (Suppl. 04) S3-S6
    PubMedGoogle Scholar
  • 11 Miska M, Findeisen S, Tanner M. et al. Treatment of nonunions in fractures of the humeral shaft according to the Diamond Concept. Bone Joint J 2016; 98-B: 81-87
    PubMedGoogle Scholar
  • 12 Willems A, van der Jagt OP, Meuffels DE. extracorporal shock wave treatment for delayed union and nonunion fractures: a systematic review. J Orthop Trauma 2019; 33: 97-103
    CrossrefPubMedGoogle Scholar
  • 13 Crespo AM, Konda SR, De Paolis A. et al. Posttraumatic malalignment of the humeral shaft: challenging the existing paradigm. J Orthop Trauma 2016; 30: e48-e52
    CrossrefPubMedGoogle Scholar
  • 14 Nickel BT, Klement MR, Richard MJ. et al. Closing the gap: a noval technique for humeral shaft nonunions using cup and cone reamers. Injury 2016; 47 (Suppl. 07) S40-S43
    PubMedGoogle Scholar
  • 15 Prasarn ML, Achor T, Paul O. et al. Management of nonunions of the proximal humeral diaphysis. Injury 2010; 41: 1244-1248
    CrossrefPubMedGoogle Scholar
  • 16 Rubel IF, Kloen P, Campbell D. et al. Open reduction and internal fixation of humeral nonunions: a biomechanical and clinical study. J Bone Joint Surg Am 2002; 84: 1315-1322
    CrossrefPubMedGoogle Scholar
  • 17 Metikala S, Bhogadi P. Orthogonal double plating and autologous bone grafting of postoperative humeral shaft nonunion – a rare case report and review of literature. J Orthop Case Rep 2015; 5: 50-53
    PubMedGoogle Scholar
  • 18 Lin CL, Fang CK, Chiu FY. et al. Revision with dynamic compression plate and cancellous bone graft for aseptic nonunion after surgical treatment of humeral shaft fracture. J Trauma 2009; 67: 1393-1396
    CrossrefPubMedGoogle Scholar
  • 19 Lin J, Chiang H, Hou SM. et al. Open exchange locked nailing in humeral nonunions after intramedullary nailing. Clin Orthop Relat Res 2003; (411) 260-268
    PubMedGoogle Scholar
  • 20 Mc Kee MD, Miranda MA, Riemer BL. et al. Management of humeral nonunion after the failure of locking intramedullary nails. J Orthop Trauma 1996; 10: 492-499
    CrossrefPubMedGoogle Scholar
  • 21 Flinkkila T, Ristiniemi J, Hamalainen M. Nonunion after intramedullary nailing of humeral shaft fractures. J Trauma 2001; 50: 540-544
    CrossrefPubMedGoogle Scholar
  • 22 Gessmann J, Königshausen M, Coulibaly MO. et al. Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing. Arch Orthop Trauma Surg 2016; 136: 631-638
    CrossrefPubMedGoogle Scholar
  • 23 Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010; 41: 27-37
    CrossrefPubMedGoogle Scholar
  • 24 Taylor BC, French BG, Fowler TT. et al. Induced membrane technique for reconstruction to manage bone loss. J Am Acad Orthop Surg 2012; 20: 142-150
    CrossrefPubMedGoogle Scholar
  • 25 Kiran M, Jee R. Ilizarovʼs method for treatment of nonunion of diaphseal fractures of the humerus. Indian J Orthop 2010; 44: 444-447
    CrossrefPubMedGoogle Scholar
  • 26 Vidyadhara S, Vamsi K, Rao SK. et al. Use of intramedullary fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion. Int Orthop 2009; 33: 1009-1014
    CrossrefPubMedGoogle Scholar
  • 27 Muramatsu K, Doi K, Ihara K. et al. Recalcitrant posttraumatic nonunion of the humerus. 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand 2003; 74: 95-97
    CrossrefPubMedGoogle Scholar
  • 28 Kaminiski A, Bürger H, Müller EJ. Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity. Acta Orthop Belg 2008; 74: 235-239
    PubMedGoogle Scholar
  • 29 Peters RM, Claessen FM, Doornberg JN. et al. Union rate after operative treatment of humeral shaft nonunion – a systematic review. Injury 2015; 46: 2314-2324
    CrossrefPubMedGoogle Scholar
  • 30 Babhulkar S, Babhulkar S, Vasudev A. Recalcitrant aseptic atrophic non-union of the shaft of the humerus after failure of surgical treatment: management by excision of non-union, bone grafting and stabilization by LCP in different modes. Injury 2017; 48 (Suppl. 02) S33-S43
    CrossrefPubMedGoogle Scholar
  • 31 Sanchez-Sotelo J. Nonunion and Malunion of distal Humerus Fractures. In: Morrey BF, Sanchez-Sotelo J, Morrey ME. eds. The Elbow and its Disorders. Philadelphia: Elsevier; 2018: 501-509
    Google Scholar
  • 32 Donders JCE, Lorich DG, Helfet DL. et al. Surgical technique: treatment of distal humerus nonunion. HSS J 2017; 13: 282-291
    CrossrefPubMedGoogle Scholar
  • 33 Helfet DL, Kloen P, Anand N. et al. Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg Am 2003; 85: 33-40
    PubMedGoogle Scholar
  • 34 Ring D, Gulotta L, Jupiter JB. Unstable nonunion of the distal part of the humerus. J Bone Joint Surg Am 2003; 85: 1040-1046
    CrossrefPubMedGoogle Scholar
  • 35 Sanchez-Sotelo J, Morrey BF. Linked elbow replacement: a salvage procedure for distal humeral nonunion. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl. 02) S200-S212
    CrossrefPubMedGoogle Scholar
  • 36 Cil A, Veillette CJ, Sanchez-Sotelo J. et al. Linked elbow replacement: a salvage procedure for distal humeral nonunion. J Bone Joint Surg Am 2008; 90: 1939-1950
    CrossrefPubMedGoogle Scholar