Therapie von Humerusschaftfrakturen

Frakturen des Humerusschaftes sind seltene Verletzungen der oberen Extremität. Die Wahl der individuell besten Versorgungsstrategie stellt im klinischen Alltag mitunter weiterhin eine Herausforderung dar. Patientenspezifische Faktoren sollten neben der Frakturmorphologie, dem Entstehungsmechanismus und möglichen Begleitverletzungen (u. a. vorliegende neurologische oder Weichteilschädigung) die Grundlage dieser Entscheidungsfindung bilden.

Abstract

Humeral shaft fractures are a rare but challenging entity of injuries of the upper extremity. Despite all advances in the past decades – including improved imaging, adjusted surgical techniques and new implant designs – the treatment of humeral shaft fractures and especially the treatment choice remains challenging. Treatment options need to be evaluated individually under consideration of fracture morphology, soft tissue and potential neurological damage as well as patient-specific factors (i.e., age, comorbidities). Moreover, the risk of common complications such as radial nerve palsy, infection, non-union and malrotation needs to be evaluated in order to facilitate the best possible therapy for each patient. The regular available treatment options include conservative (cast, brace, etc.) and surgical measures (ante- and retrograde nailing, angle-stable plate osteosynthesis). Furthermore, (temporary) external fixation remains an option in emergency and complicative cases. However, none of the aforementioned options have proven a superior gold standard. This review evaluates the currently available treatment options and their individual advantages as well as the probability of possible complications and is aiming to supply a guide for individual treatment choice.

Kernaussagen

• Humerusschaftfrakturen sind vergleichsweise seltene Verletzungen, die jedoch nach einem klaren diagnostischen und therapeutischen Therapiealgorithmus versorgt werden.

• Für die Therapie von Humerusschaftfrakturen stehen konservative sowie operative (intramedullär/Marknägel vs. extramedullär/Plattenosteosynthesen) Verfahren zur Verfügung, wobei für kein Verfahren eine deutliche Überlegenheit nachgewiesen werden konnte.

• Die Wahl der Therapie sollte unter Berücksichtigung patientenindividueller (Alter, Komorbiditäten, Compliance etc.) und frakturmorphologischer (Hochrasanztrauma, Weichteilschaden, Kettenverletzung, einfache oder mehrfragmentäre Fraktur, Radialisläsion etc.) Faktoren getroffen werden.

• Die häufigsten Komplikationen nach Humerusschaftfrakturen sind Achs-/Rotationsfehlstellungen, Pseudarthrosen, Infekte und sekundäre (iatrogene) Radialisparesen.

• Im Fall einer primären Radialisparese muss nicht zwingend die offene Darstellung des Nervs erfolgen, da auch ohne operative Therapie hohe spontane Remissionsraten berichtet werden. Bei Anzeichen einer Nervendurchtrennung oder -einklemmung sollte jedoch entweder simultan zur Osteosynthese (vor allem Marknagelversorgung) die minimalinvasive Liberation und Freilegung erwogen bzw. zeitnah die chirurgische Intervention/Rekonstruktion angestrebt werden.

• Im Falle komplikativer Verläufe bietet der Fixateur externe oder auch der funktionelle Brace eine mögliche Rückzugsoption. In Einzelfällen kann eine Ausheilung auch mit einem dieser Verfahren erwogen werden.

Schlüsselwörter

Frakturbehandlung - Plattenosteosythese - Nagelosteosynthese - obere Extremität - Radialisnervläsion

Keywords

fracture treatment - plate osteosynthesis - nailing - upper extremity - radial nerve palsy

Publication History

Article published online:
28 July 2023

• Literatur

• 1 Ekholm R, Adami J, Tidermark J. et al. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br 2006; 88: 1469-1473
• 2 Lotzien S, Hoberg C, Hoffmann MF. et al. Standards: Humerusschaftfraktur. Trauma Berufskrankh 2017; 19: 216-221
• 3 Böhler L. Gegen die operative Behandlung von frischen Oberarmbrüchen. Arch f klin Chir 1964; 308: 465-476
• 4 Clement ND. Management of humeral shaft fractures; non-operative versus operative. Arch Trauma Res 2015; 4: e28013
• 5 Sarmiento A, Zagorski JB, Zych GA. et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000; 82: 478-486
• 6 Schoch BS, Padegimas EM, Maltenfort M. et al. Humeral shaft fractures: national trends in management. J Orthop Traumatol 2017; 18: 259-263
• 7 Kim JW, Oh CW, Byun YS. et al. A prospective randomized study of operative treatment for noncomminuted humeral shaft fractures: conventional open plating versus minimal invasive plate osteosynthesis. J Orthop Trauma 2015; 29: 189-194
• 8 Biber R, Bail HJ, Geßlein M. Humeral shaft fractures. Unfallchirurg 2018; 121: 747-758
• 9 Hegeman EM, Polmear M, Scanaliato JP. et al. Incidence and management of radial nerve palsies in humeral shaft fractures: a systematic review. Cureus 2020; 12: e11490
• 10 Meinberg EG, Agel J, Roberts CS. et al. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018; 32 (Suppl. 01) S1-S170
• 11 Humerus. J Orthop Trauma [Anonym]. 2018; 32 (Suppl. 01) S11-S20
• 12 Oestern HJ, Tscherne H. Pathophysiologie und Klassifizierung des Weichteilschadens bei Frakturen [Pathophysiology and classification of soft tissue damage in fractures]. Orthopade 1983; 12: 2-8
• 13 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24: 742-746
• 14 Kehtari S, Gallusser N, Vauclair F. Update on humeral shaft fractures. Rev Med Suisse 2021; 16: 2421-2425
• 15 Sarmiento A, Kinman PB, Galvin EG. et al. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am 1977; 59: 596-601
• 16 Yiğit Ş. What should be the timing of surgical treatment of humeral shaft fractures?. Medicine 2020; 99: e19858
• 17 Schwab TR, Stillhard PF, Schibli S. et al. Radial nerve palsy in humeral shaft fractures with internal fixation: analysis of management and outcome. Eur J Trauma Emerg Surg 2018; 44: 235-243
• 18 Papasoulis E, Drosos GI, Ververidis AN. et al. Functional bracing of humeral shaft fractures. A review of clinical studies. Injury 2010; 4: e21-e27
• 19 Rosenberg N, Soudry M. Shoulder impairment following treatment of diaphysial fractures of humerus by functional brace. Arch Orthop Trauma Surg 2006; 126: 437-440
• 20 van de Wall BJM, Ochen Y, Beeres FJP. et al. Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. J Shoulder Elbow Surg 2020; 29: 1493-1504
• 21 Westrick E, Hamilton B, Toogood P. et al. Humeral shaft fractures: results of operative and non-operative treatment. Int Orthop 2017; 41: 385-395
• 22 Kapil Mani KC, Gopal Sagar DC, Rijal L. et al. Study on outcome of fracture shaft of the humerus treated non-operatively with a functional brace. Eur J Orthop Surg Traumatol 2013; 23: 323-328
• 23 Sargeant HW, Farrow L, Barker S. et al. Operative versus non-operative treatment of humeral shaft fractures: a systematic review. Shoulder Elbow 2020; 12: 229-242
• 24 Denard 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; 33
• 25 Lode I, Nordviste V, Erichsen JL. et al. Operative versus nonoperative treatment of humeral shaft fractures: a systematic review and meta-analysis. J Shoulder Elbow Surg 2020; 29: 2495-2504
• 26 Matsunaga FT, Tamaoki MJS, Matsumoto MH. et al. Minimally invasive osteosynthesis with a bridge plate versus a functional brace for humeral shaft fractures: a randomized controlled trial. J Bone Joint Surg Am 2017; 99: 583-592
• 27 Smolle MA, Bösmüller S, Puchwein P. et al. Complications in humeral shaft fractures – non-union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis. EFORT Open Rev 2022; 7: 95
• 28 Schoch BS, Padegimas EM, Maltenfort M. et al. Humeral shaft fractures: national trends in management. J Orthop Traumatol 2017; 18: 259
• 29 Chapman JR, Henley MB, Agel J. et al. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma 2000; 14: 162-166
• 30 Kulkarni VS, Kulkarni MS, Kulkarni GS. et al. Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures. Injury 2017; 48 (Suppl. 02) S8-S13
• 31 Zhang R, Yin Y, Li S. et al. Intramedullary nailing versus a locking compression plate for humeral shaft fracture (AO/OTA 12-A and B): a retrospective study. Orthop Traumatol Surg Res 2020; 106: 1391-1397
• 32 Patino JM, Ramella JC, Michelini AE. et al. Plates vs. nails in humeral shaft fractures: do plates lead to a better shoulder function?. JSES Int 2021; 5: 765-768
• 33 Furuhata R, Kamata Y, Kono A. et al. Influence of timing on surgical outcomes for acute humeral shaft fractures. Adv Orthop 2021; 2021: 8977630
• 34 Hessmann MH, Mittlmeier T. Antegrade and retrograde nailing of humeral shaft fractures. Oper Orthop Traumatol 2021; 33: 139-159
• 35 Schratz W, Wörsdörfer O, Klöckner C. et al. Behandlung der Oberarmschaftfraktur mit intramedullären Verfahren (Seidel-Nagel, Marchetti-Vicenzi-Nagel, Prevot-Pins) [Treatment of humeral shaft fracture with intramedullary procedures (Seidel nail, Marchetti-Vicenzi nail, Prevot pins)].. Unfallchirurg 1998; 101: 12-17
• 36 Pidhorz L. Acute and chronic humeral shaft fractures in adults. Orthop Traumatol Surg Res 2015; 101: S41-S49
• 37 Li Y, Wang C, Wang M. et al. Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing. J Shoulder Elbow Surg 2011; 20: 947-954
• 38 Wen H, Zhu S, Li C. et al. Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: an update meta-analysis. Medicine 2019; 98: e17952
• 39 Culemann U. Schaft- und distale Humerusfrakturen. Trauma Berufskr 2016; 18: 468-473
• 40 Studier-Fischer S, Moghaddam A, Wagner C. et al. Marknagelung bei der Humerusschaftfraktur. Trauma Berufskr 2005; 7: 97-102
• 41 Zhao JG, Wang J, Meng XH. et al. Surgical interventions to treat humerus shaft fractures: a network meta-analysis of randomized controlled trials. PLoS One 2017; 12: e0173634
• 42 Henley MB, Monroe M, Tencer AF. Biomechanical comparison of methods of fixation of a midshaft osteotomy of the humerus. J Orthop Trauma 1991; 5: 14-20
• 43 Blum J, Machemer H, Högner M. et al. Biomechanik der Verriegelungsmarknagelung bei Oberarmschaftfrakturen. Vergleichsuntersuchungen zweier Marknagelsysteme und des Effekts der interfragmentären Kompression bei unaufgebohrtem Humerusnagel. Unfallchirurg 2000; 103: 183-190
• 44 Dalton JE, Salkeld SL, Satterwhite YE. et al. A biomechanical comparison of intramedullary nailing systems for the humerus. J Orthop Trauma 1993; 7: 367-374
• 45 Schopfer A, Hearn TC, Malisano L. et al. Comparison of torsional strength of humeral intramedullary nailing: a cadaveric study. J Orthop Trauma 1994; 8: 414-421
• 46 An Z, He X, Zeng B. [A comparative study on open reduction and plating osteosynthesis and minimal invasive plating osteosynthesis in treating mid-distal humeral shaft fractures]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2009; 23: 41-44
• 47 Keshav K, Baghel A, Kumar V. et al. Is minimally invasive plating osteosynthesis better than conventional open plating for humeral shaft fractures? A systematic review and meta-analysis of comparative studies. Indian J Orthop 2021; 55 (Suppl. 02) S283-S303
• 48 Kuner EH, Bonnaire F, Schaefer DJ. Die Plattenosteosynthese bei der Humerusschaftfraktur. Chirurg 1995; 66: 1085-1091
• 49 Hu X, Xu S, Lu H. et al. Minimally invasive plate osteosynthesis vs conventional fixation techniques for surgically treated humeral shaft fractures: a meta-analysis. J Orthop Surg Res 2016; 11: 59
• 50 Hoyen H, Papendrea R. Exposures of the shoulder and upper humerus. Hand Clin 2014; 30: 391-399
• 51 Zlotolow DA, Catalano LW, Barron OA. et al. Surgical exposures of the humerus. J Am Acad Orthop Surg 2006; 14: 754-765
• 52 Concha JM, Sandoval A, Streubel PN. Minimally invasive plate osteosynthesis for humeral shaft fractures: are results reproducible?. Int Orthop 2010; 34: 1297-1305
• 53 Beeres FJ, Diwersi N, Houwert MR. et al. ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. Injury 2021; 52: 653-663
• 54 Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report. Injury 2005; 36: 530-538
• 55 Livani B, Belangero W, Andrade K. et al. Is MIPO in humeral shaft fractures really safe? Postoperative ultrasonographic evaluation. Int Orthop 2009; 33: 1719-1723
• 56 Marsh JL, Mahoney CR, Steinbronn D. External fixation of open humerus fractures. Iowa Orthop J 1999; 19: 35-42
• 57 Salar M, Dougherty PJ. Infections associated with temporary external fixation. J Surg Orthop Adv 2020; 29: 73-76
• 58 Bassiony AA, Almoatasem AM, Abdelhady AM. et al. Infected non-union of the humerus after failure of surgical treatment: management using the Orthofix external fixator. Ann Acad Med Singap 2009; 38: 1090-1094
• 59 Lenoble E, Terracher R, Kessi H. et al. [Treatment of fractures of the humeral shaft using Hoffman’s external fixator]. Rev Chir Orthop Reparatrice Appar Mot 1993; 79: 606-614
• 60 Simpson AHRW, Robiati L, Jalal MMK. et al. Non-union: indications for external fixation. Injury 2019; 50 (Suppl. 01) S73-S78
• 61 Mostafavi HR, Tornetta P. Open fractures of the humerus treated with external fixation. Clin Orthop Relat Res 1997; (337) 187-197
• 62 Bilir M, Tekin SB. Evaluation of complications in patients with open fractures of the upper and lower extremity treated with internal fixation after the external fixation. Ulus Travma Acil Cerrahi Derg 2020; 26: 865-869
• 63 Shao YC, Harwood P, Grotz MRW. et al. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br 2005; 87: 1647-1652
• 64 Ristic S, Strauch RJ, Rosenwasser MP. The assessment and treatment of nerve dysfunction after trauma around the elbow. Clin Orthop Relat Res 2000; (370) 138-153
• 65 Alnot J, Osman N, Masmejean E. et al. Les lésions du nerf radial dans les fractures de la diaphyse humérale. A propos de 62 cas [Lesions of the radial nerve in fractures of the humeral diaphysis. Apropos of 62 cases]. Rev Chir Orthop Reparatrice Appar Mot 2000; 86: 143-150
• 66 Altintas AA, Altintas MA, Gazyakan E. et al. Long-term results and the disabilities of the arm, shoulder, and hand score analysis after modified Brooks and D’Aubigne tendon transfer for radial nerve palsy. J Hand Surg Am 2009; 34: 474-478
• 67 Benz D, Balogh ZJ. Damage control surgery: current state and future directions. Curr Opin Crit Care 2017; 23: 491-497
• 68 Taeger G, Ruchholtz S, Zettl R. et al. Primärer Fixateur externe mit konsekutivem Verfahrenswechsel beim Polytrauma. Unfallchirurg 2002; 105: 315-321
• 69 Höntzsch D. Fixateur-externe-Osteosynthese. Orthopäde 2010; 39: 192-200
• 70 Crespo AM, Konda SR, Egol KA. Set it and forget it: diaphyseal fractures of the humerus undergo minimal change in angulation after functional brace application. Iowa Orthop J 2018; 38: 73-77
• 71 Shields E, Sundem L, Childs S. et al. The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures. Injury 2016; 47: 914-918
• 72 Wang C, Ma X, Liu Q. et al. Postoperative malrotation of humerus shaft fracture causes degeneration of rotator cuff and cartilage. Sci Rep 2021; 11: 18596
• 73 Ekegren CL, Edwards ER, de Steiger R. et al. Incidence, costs and predictors of non-union, delayed union and mal-union following long bone fracture. Int J Environ Res Public Health 2018; 15: 2845
• 74 Beeres FJ, Diwersi N, Houwert MR. et al. ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. Injury 2021; 52: 653-663
• 75 van de Wall BJM, Baumgärtner R, Houwert RM. et al. MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg 2022; 48: 47-59
• 76 Olson JJ, Entezari V, Vallier HA. Risk factors for nonunion after traumatic humeral shaft fractures in adults. JSES Int 2020; 4: 734-738
• 77 Gerlach U-J. Infizierte Plattenosteosynthese. OP-Journal 2017; 33: 108-112
• 78 Trampuz A, Zimmerli W. Diagnosis and treatment of infections associated with fracture-fixation devices. Injury 2006; 37: S59-S66