体育相关的英文文献

HindawiPublishingCorporationAdvancesinOrthopedicsVolume2012,ArticleID861598,10pagesdoi:10.1155/2012/861598ReviewArticleEvaluationandManagementofProximalHumerusFracturesEkaterinaKhmelnitskaya,LaurenE.Lamont,SamuelA.Taylor,DeanG.Lorich,DavidM.Dines,andJoshuaS.DinesSportsMedicineandShoulderService,OrthopaedicTraumaService,HospitalforSpecialSurgery,535East70thStreet,NewYork,NY10021,USACorrespondenceshouldbeaddressedtoEkaterinaKhmelnitskaya,[e-mail]28August2012;Revised12November2012;Accepted12November2012AcademicEditor:RobertGillespieCopyright©2012EkaterinaKhmelnitskayaetal.ThisisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.Proximalhumerusfracturesarecommoninjuries,especiallyamongolderosteoporoticwomen.Restorationoffunctionrequiresathoroughunderstandingoftheneurovascular,musculotendinous,andbonyanatomy.Thispaperaddressestherelevantanatomyandhighlightsvariousmanagementoptions,includingindicationforarthroplasty.Inthevastmajorityofcases,proximalhumerusfracturesmaybetreatednonoperatively.Inthecaseofdisplacedfractures,whensurgicalinterventionmaybepursued,numerousconstructshavebeeninvestigated.Ofthese,theproximalhumeruslockingplateisthemostwidelyused.Arthroplastyisgenerallyreservedforcomminuted4-partfractures,head-splitfractures,orfractureswithsignificantunderlyingarthriticchanges.Reversetotalshoulderarthroplastyisreservedforpatientswithadeficientrotatorcuff,orhighlycomminutedtuberosities.1.IntroductionProximalhumerusfracturesarecommonlyencounteredfracturesingeneralorthopaedicpractices.Treatmentshouldfocusonmaximizingapatient’sfunctionaloutcomeandminimizingpain.Understandingthefunctionalanatomyoftheproximalhumerusasitrelatestofractureisparamounttoachievingthesegoals.Interventionoptionsrangefromnonoperativemodalitiestoosteosynthesis,andinselectcasesarthroplasty.Thispaperwillreviewrelevantanatomy,commonfixationconstructs,appropriateindicationsforprostheticreplacement,andtheauthors’preferredtreatmentalgorithm.2.AnatomyTheglenohumeraljointisthemostmobilejointinthebody,resultingfromaseriesofcomplexinteractionsamongbone,muscle,andsofttissueforces.Anappreciationforthisanatomyenablesthesurgeontoeffectivelyrestorefunctioninthesettingoffracture.Theproximalhumerusincludesthehumeralhead,greatertuberosity,lessertuberosity,andthehumeralshaft.Inthesagittalplane,thehumeralheadisretrovertedanaverageof30degreesrelativetothehumeralshaft[1].Inthecoronalplane,itisangled130to150degreescephaladrelativetothediaphysis.Fracturesthroughtheanatomicneckcanresultinsignificantvascularcompromisetohumeralheadleadingtoavascularnecrosis[2].Inneutralrotation,thegreatertuberosityformsthelateralborderoftheproximalhumerus.Thelessertuberosity,whichsitsdirectlyanteriorinthisposition,becomesprofiledmediallywhenthehumerusisinternallyrotated—thiscreatesaroundedsilhouette“lightbulbsign”onradiograph.Thelongheadofthebicepspassesbetweenthetwotuberosi-tiesintheintertuberculargroove,approximately1cmlateraltothemidlineofthehumerus,anditsrelationshipisanimportantlandmarkduringfracturereduction[2].Whenfractured,thegreaterandlessertuberositiesaredeformedbytheirmusculotendinousrotatorcuffattach-ments(Figure1)[2,3].Thesupraspinatusmuscle,innervatedbythesupras-capularnerve,attachestothesuperiorfacetofthegreatertuberositywithaforcevectorthatpullspredominantlyinamedialdirection.Theinfraspinatusmuscle,alsoinnervatedbythesuprascapularnerve,insertsonthemiddlefacetof2AdvancesinOrthopedicsABCDEFigure1:Thisdrawingdemonstratesthedeformingforcesontheproximalhumerusinthesettingoffracture.Thesupraspinatus(A)exertsaforceposteromedially.Theinfraspinatusandteresminor(B)pullposteromediallyandexternallyrotate.Thesubscapularis(C)exertsananteromediallydirectedforceonthelessertuberosity.Thepectoralismajor(D)internallyrotatesandadducts,whilethedeltoid(E)pullssuperiorlyonthemetadiaphysisofthehumerus.(ReprintedwithpermissionfromGrusonetal.[4]).thegreatertuberosity.Theteresminormuscle,innervatedbytheaxillarynerve,attachestotheinferiorfacet.Together,thesethreeexternallyrotateandyieldaposteromediallydirecteddeformingforce.Therefore,ifthegreatertuberosityisfractured,itisdisplacedposteromedially.Ifitremainsintact,andthereisasurgicalneckfracture,theresultingdeformityistypicallyvarusandexternalrotation.Anteriorly,thesubscapularis,innervatedbytheupperandlowersub-scapularnerves,attachestothelessertuberosity,resultinginanteromedialdisplacementofthisosseousfragmentiffractured[2,3].Thepectoralismajortendoninsertionisanimportantlandmark,especiallyduringhemiarthroplasty.Murachovskyetal.showedthattheaveragedistancefromthepectoralismajortendoninsertiontothetangenttothehumeralheadwas5.6cm(Figure2)[5].Torrensandcolleaguesconfirmedthisrelationshipandaddedthathemiarthroplastyrotationcouldalsobeestimatedbasedontheinsertionofthistendon[6].Specifically,theauthorsfoundthattheanatomyoftheproximalhumeruscanberestoredbyplacingtheprosthesis5.6cmabovetheupperinsertionofthepectorali