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OP-Journal 2017; 33(03): 236-246
DOI: 10.1055/s-0043-119261
Fachwissen
Georg Thieme Verlag KG Stuttgart · New York

Die proximale Humerusfraktur des geriatrischen Patienten

Proximal Humerus Fracture in the Geriatric Patient
Michael Plecko
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Publication History

Publication Date:
17 January 2018 (online)

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Zusammenfassung

Frakturen am proximalen Humerus stellen beim alten Patienten mit erheblicher Osteoporose auch heute noch, trotz der stark verbesserten Implantate und der verfeinerten Operationstechnik, eine große Herausforderung dar. In Abhängigkeit von den persönlichen Bedürfnissen eines geriatrischen Patienten, der Erwartungshaltung, dem Aktivitätsniveau, den kognitiven Fähigkeiten sowie der Frakturform, der Knochendurchblutung, dem Grad der Osteoporose, dem Zustand der Rotatorenmanschette und dem Grad der Arthrose ist heute ein individuell angepasstes Behandlungskonzept zu favorisieren. Dabei spielt auch die konservative Therapie eine zunehmende Rolle, da bei manchen Patienten weniger die weitgehende Wiederherstellung der Beweglichkeit als vielmehr die Schmerzfreiheit im Vordergrund steht. Es ist also eine individuelle Nutzen-Risiko-Abwägung notwendig und das Behandlungsziel und die notwendige Behandlungsstrategie mit dem Patienten bzw. seinen Angehörigen zu diskutieren und festzulegen. Die winkelstabile Plattenosteosynthese sollte im Bedarfsfall mit Zusatzmaßnahmen wie einer Zementaugmentation oder einem Knochengraft kombiniert werden, um ein sekundäres Nachsinken mit sekundärer Schraubenperforation zu vermeiden. Bei nicht sinnvoll rekonstruierbaren Frakturen hat die inverse Schulterprothese im geriatrischen Patientengut die Frakturhemiprothese weitgehend abgelöst und bietet eine gute Möglichkeit, rasch Schmerzfreiheit und eine brauchbare Alltagsfunktion zu erreichen.

Abstract

Fractures of the proximal humerus in the geriatric population with severe osteoporosis are still challenging to treat, although there has been significant improvement in implants and increasing experience with the critical details of meticulous surgical techniques. The personal needs and expectations of the patient, the activity level, fitness and health status must all be considered. The fracture pattern, the local bone quality, the blood supply of the fragments as well as the integrity of the rotator cuff and the grade of degenerative changes also influence the decision. We are in favour of an individual, patient-specific treatment approach. During the last decade, conservative treatment has gained more importance in this group of patients, as in the very old fragile patient minimal or freedom from pain is the goal and range of movement may be less important. An individual risk-benefit comparison is mandatory and must be discussed with the patient and his or her family. If angle-stable plating is the treatment of choice, screw augmentation or an additional fibula graft may improve stability in poor bone quality, in order to avoid loss of reduction and secondary screw perforation. If the fracture is not reconstructable, hemiprosthesis has been replaced by reverse shoulder prosthesis in this geriatric population, leading to good pain relief and satisfactory function.

 

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