BACKGROUND: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.
METHODS: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.
RESULTS: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).
CONCLUSIONS: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.
UNASSIGNED: HINTERGRUND: Die proximale Humerusfraktur ist mit 0,45–2 % aller Frakturen eine relativ häufige Verletzung im Kindes- und im Jugendalter [2, 18]. Die Behandlung ist meistens konservativ, aber immer noch Gegenstand der wissenschaftlichen Diskussion [9, 12]. Neben der S1-LL gibt es unterschiedliche Empfehlungen zu Diagnostik und Behandlung dieser Fraktur in der Literatur.
METHODS: Im Rahmen des 10. Wissenschaftstreffens der SKT in der DGU wurden die vorhandenen Empfehlungen und die relevante bzw. aktuelle Literatur kritisch von einem Expertengremium diskutiert und ein Konsens formuliert. In diesen wurde ein Algorithmus zu Diagnostik, Therapie und Behandlung integriert.
UNASSIGNED: Die Messung der Achsabweichung und Abkippung ist nicht „interobserver“ und „intraobserver reliable“ [3]. Die Altersgrenze, bis zu der eine vollständige Korrektur möglich ist, wurde auf 10 Jahre festgelegt, da sich ca. um dieses Alter das Korrekturpotenzial ändert. Zur Diagnostik wird die gut zentrierte Röntgenaufnahme in 2 Ebenen (true a.-p.- und Y‑Aufnahme ohne Thoraxanteile) als Standard festgelegt. Im Alter unter 10 Jahren kann jegliche Fehlstellung konservativ mittels Gilchrist-Verband für 2 bis 3 Wochen behandelt werden. Nur in Einzelfällen kann eine Operation z. B. bei starken Schmerzen oder notwendiger rascher Belastbarkeit indiziert sein. Über 10 Jahren sollte ein Ad-latus-Versatz über halbe Schaftbreite nicht toleriert werden. Aufgrund der Varianz der Messergebnisse kann eine Empfehlung zur operativen Versorgung in Abhängigkeit vom Ausmaß der Ad-axim-Dislokation nicht benannt werden. Orientierend gilt: Je größer die Dislokation und je näher das Kind am Fugenschluss ist, desto eher ist die operative Therapie indiziert. Die Entwicklung ist hier einzubeziehen. Den Goldstandard stellt die retrograde, radiale und unilaterale ESIN-Osteosynthese mittels 2 intramedullären Nägeln dar. Die Osteosynthese erfordert keine Ruhigstellung. Ein Verlaufsröntgen ist bei instabilen Frakturen ohne Osteosynthese nach einer Woche, sonst optional zur Dokumentation der Konsolidierung nach 4 (bis 6) Wochen, wenn z. B. die Sportfreigabe erteilt werden soll, sowie vor der Metallentfernung (12 Wochen) vorgesehen.
UNASSIGNED: Empfehlungen zur Operationsindikation auf der Grundlage des Ausmaßes der Abkippung sind nicht reproduzierbar und erscheinen in Anbetracht der aktuellen Literatur schwierig [3, 9, 12]. Sinnvoller ist ein pragmatisches Vorgehen. Die Prognose der Fraktur erscheint unter Beachtung des erstellten Algorithmus so gut zu sein, dass in den meisten Fällen die Restitutio ad integrum erwartet werden kann.

BACKGROUND: Hitherto, the decision-making process for treatment of proximal humerus fractures (PHF) remains controversial, with no established or commonly used treatment regimens. Identifying fracture- and patient-related factors that influence treatment decisions is crucial for the development of such treatment algorithms. The objective of this study was to define a Delphi consensus of clinically relevant fracture- and patient-related factors of PHF for clinical application and scientific research.
METHODS: An online survey was conducted among an international panel of preselected experienced shoulder surgeons. An evidence-based list of fracture-related and patient-related factors affecting treatment outcome after PHF was generated and reviewed by the members of the committee through online surveys. The proposed factors were revised for definitions, and suggestions from the first round mentioned in the free text were included as possible factors in the second round of surveys. Consensus was defined as having at least a two-thirds majority agreement.
RESULTS: The Delphi consensus panel consisted of 18 shoulder surgeons who completed 2 rounds of online surveys. There was an agreement of more than two-thirds of the panel for three fracture-related factors affecting treatment decision in the case of PHF: head-split fracture, dislocated tuberosities, and fracture dislocation. Of all patient-related factors, a two-thirds consensus was reached for two factors: age and rotator cuff tear arthropathy.
CONCLUSIONS: This study successfully conducted a Delphi consensus on factors influencing decision-making in the treatment of proximal humeral fractures. The documented factors will be useful for clinical evaluation and scientific validation in future studies.

BACKGROUND: Proximal humerus fractures (PHF) should be subject to standardized monitoring during treatment, whether non-operative or operative, to document and adequately assess bone healing. The purpose of this study was to develop a standardized protocol for an image-based monitoring of PHF for joint-preserving treatment options, including a minimum set of descriptors or definitions of features of radiographic images, to be applied in clinical routine practice and studies.
METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons self-selected after invitation of all AO Trauma members. Using open questions participants recommended the type and timing of desired diagnostic images, and formulated definitions for the imaging parameters they considered most important. Formulated recommendations for the type and timing of radiological fracture monitoring and clarification of the definitions of the proposed radiological parameter set were subjected to further survey. Consensus for each factor was considered to have been reached when there was at least a two-thirds agreement in the survey participants.
RESULTS: Response rates of 231 interested surgeons were 66% and 44% for the first and second survey respectively. Sixty percent of participants to the first survey responded to the second (131/219). 93% of respondents considered radiographic monitoring to be an important part of fracture care. 92% of respondents to the first survey considered that \'malreduction\' should be assessed, and 165 of 189 respondents provided a suggestion for a definition for this parameter. 88% of respondents to the second survey agreed on a redefinition of the term \'malreduction\' as \'non-anatomical fracture reduction\'. There was substantial agreement about the radiographic views and orientation of radiographs to be recorded (80%) and the timing of radiological reviews (67- 78% for time points during follow up). Just over half of respondents recommended cessation of radiological review when fracture healing was considered to have occurred by radiological evaluation.
CONCLUSIONS: Our work confirmed the need for clear definitions of radiological features that should be considered in the follow-up of proximal humeral fractures. It has resulted in the development of an international consensus monitoring protocol for PHF treatment with a structured core set of radiological parameters. Clinical application and validation of the monitoring process are needed.

BACKGROUND: Proximal humerus fracture (PHF) complications, whether following surgery or nonoperative management, require standardization of definitions and documentation for consistent reporting. We aimed to define an international consensus core event set (CES) of clinically-relevant unfavorable events of PHF to be documented in clinical routine practice and research.
METHODS: A Delphi exercise was implemented with an international panel of experienced shoulder trauma surgeons selected by survey invitation of AO Trauma members. An organized list of PHF events after nonoperative or operative management was developed and reviewed by panel members using on-line surveys. The proposed core set was revised regarding event groups along with definitions, specifications and timing of occurrence. Consensus was reached with at least a two-third agreement.
RESULTS: The PHF consensus panel was composed of 231 clinicians worldwide who responded to at least one of two completed surveys. There was 93% final agreement about three intraoperative local event groups (device, osteochondral, soft tissue). Postoperative or nonoperative event terms and definitions organized into eight groups (device, osteochondral, shoulder instability, fracture-related infection, peripheral neurological, vascular, superficial soft tissue, deep soft tissue) were approved with 96 to 98% agreement. The time period for documentation ranged from 30 days to 24 months after PHF treatment depending on the event group and specification. The resulting consensus was presented on a paper-based PHF CES documentation form.
CONCLUSIONS: International consensus was achieved on a core set of local unfavorable events of PHF to foster standardization of complication reporting in clinical research and register documentation.
BACKGROUND: Not applicable.

BACKGROUND: Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached.
METHODS: This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level.
RESULTS: Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles.
CONCLUSIONS: Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

暂无摘要。

The humeral heads of whole body cadaveric shoulders underwent fluoroscopic evaluation with the head divided into three zones on both anteroposterior (AP) and axillary views creating nine zones. Five AP and three axillary fluoroscopic images in different rotational positions were assessed for pin penetration. All images were evaluated for pin penetration and the AP view was evaluated for lesser tuberosity location. Pins placed appropriately below the subchondral bone did not appear to penetrate the joint on any fluoroscopic image. Pins placed 2 mm beyond the articular surface were appropriately viewed exiting the head on most views (64%) but falsely appeared within the head on several others (36%). Pins perforating the posterior head were problematic for accurate detection on AP views (missed in 87%), but this was avoided by externally rotating the humerus to 60 degrees. Articular penetration cannot always be appreciated radiographically and special efforts are necessary to avoid this problem including the use of various rotational views as well as the use of appropriate landmarks for orientation such as the lesser tuberosity position.

暂无摘要。