Omuz Çevresi Kırıkları
Özet
Gençlerde yüksek enerjili travmalarla, yaşlılarda ise düşük enerjili düşmelerle sıkça karşılaşılan omuz çevresi kırıkları (humerus üst uç, skapula ve klavikula) üst ekstremitenin cerrahisi zor yaralanmaları arasındadır. Humerus üst uç kırıkları toplumda ve özellikle kadınlarda sık görülmekte olup tanısal süreçte altın standart olan radyografi yetersiz kaldığında BT veya MR kullanılmaktadır. Tedavide hastanın yaşı, kırık tipi ve parça sayısı (Neer sınıflandırmasına göre) kritik rol oynar; ayrışmamış stabil kırıklar için %75 oranında konservatif tedavi (kol askısı, egzersizler) tercih edilirken, 1 cm'den fazla yer değiştirme veya 45 dereceden fazla açılanma içeren deplese durumlarda cerrahi (açık/kapalı redüksiyon, kilitli plak veya ters omuz protezi) uygulanmaktadır. Tüm kemik kırıklarının küçük bir kısmını oluşturan skapula kırıkları genellikle politravmalara eşlik eder; gövde kırıkları çoğunlukla konservatif takip edilirken, belirgin deplasman veya açısal bozukluk gösteren boyun ve glenoid kırıklarında anatomik kilitli plaklarla cerrahi sabitleme gerekmektedir. Genç popülasyonda ve spor yaralanmalarında sık gözlenen klavikula kırıklarında ise 2 cm'den fazla kısalık veya deplasman, çok parçalı veya açık kırık varlığı kesin cerrahi (açık redüksiyon ve plak) endikasyonudur. Konservatif yaklaşımlar yüksek kaynamama riskine, kas güçsüzlüğüne ve hareket kaybına yol açabildiğinden, uygun cerrahi kriterleri taşıyan klavikula kırıklarında cerrahi tedavi üstün kaynama ve fonksiyonel başarı sunmaktadır.
Shoulder girdle fractures (proximal humerus, scapula, and clavicle), frequently encountered due to high-energy traumas in young populations and low-energy falls in the elderly, represent complex upper extremity injuries with high surgical risks. Proximal humerus fractures are common in society, particularly among women, and while radiography is the gold standard for diagnosis, CT or MRI is utilized when plain films are insufficient. Patient age, fracture type, and fragment count (based on Neer classification) crucially guide the management; stable, undisplaced fractures are treated conservatively in 75% of cases using shoulder slings and exercises, whereas displaced fractures with over 1 cm separation or 45-degree angulation require surgical intervention via open/closed reduction, locked plating, or reverse shoulder arthroplasty. Scapula fractures, accounting for a minor percentage of all fractures, typically accompany polytraumas; while scapular body fractures are mostly managed conservatively, neck and glenoid fractures exhibiting significant displacement or angulation necessitate surgical fixation with anatomical locked plates. For clavicle fractures, highly prevalent in young individuals and sports injuries, a displacement or shortening exceeding 2 cm, or the presence of comminuted or open fractures, constitutes definitive surgical indications using open reduction and plating. Since conservative approaches can result in high nonunion rates, muscle weakness, and loss of motion, surgical treatment offers superior union rates and functional success for clavicle fractures meeting the appropriate surgical criteria.
Referanslar
Gorschewsky, O., et al. The treatment of proximal humeral fractures with intramedullary titanium helix wire by 97 patients. Archives of orthopaedic and trauma surgery, 2005, 125.10: 670-675.
Krıstiansen, B., et al. The Neer classification of fractures of the proximal humerus. Skeletal radiology, 1988, 17.6: 420-422.
Neer,C.S. 2nd. Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-89.
Hertel, R., Hempfing, A., Stiehler, M., Leunig, M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13:427-3
Wild, J.R., DeMers, A., French, R., et al: Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures, Orthopedics 34:e629, 2011.
Corbacho, B., Duarte, A., Keding, A., et al: Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial, Bone Joint J 98B:152, 2016.
Perez, E. A., (2017). Campbell’s Operatıve Orthopaedıcs. (13th edition). Copyright © by Elsevier, Inc. All rights reserved.
Solberg, B. D., Moon, C. N., Franco, D. P., & Paiement, G. D.Surgical Treatment of Three and Four-Part Proximal Humeral Fractures. The Journal of Bone and Joint Surgery-American (2009). Volume 91(7), 1689–1697. doi:10.2106/jbjs.h.00133
Jawa, A., & Burnikel, D. Treatment of Proximal Humeral Fractures. JBJS Reviews, (2016). 4(1), e31–e39. doi:10.2106/jbjs.rvw.o.00003
Mease, S. J., et al. Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures. JBJS, 2021, 103.9: 829-836.
Demirtaş, M., Aydın, M. Humerus üst kırıklarında kilitli plak ile tespit ve minimal invaziv cerrahi uygulamalar. Totbid Dergisi , 2012, 11.1: 20-27.
Court-Brown, Ch., McQueen, M.M., Tornetta, P. Trauma (shoulder girdle). Philadelphia, PA: Lippincott Williams & Wilkins; 2006:68–88.
Bartonicek, J.(2015). Rockwood and Green’s Fractures in Adults. (8th edition). Copyright © 2015 Wolters Kluwer Health.
Harris, R.D., Harris, J.H., Jr. The prevalence and significanceof missed scapular fractures in bluntchest trauma. Am J Roentgenol 1998; 151: 743
Anavian, J., Conflitti, J.M., Khanna, G., et al: A reliable radiographic measurement technique for extra-articular scapular fractures, Clin Orthop Relat Res 469:3371, 2011.
Cole, P.A., Gauger, E.M., Schroder, L.K. Management of scapular fractures, J Am Acad Orthop Surg 20:130, 2012.
Anavian, J., Gauger, E.M., Schroder, L.K., et al: Surgical and functional outcomes after operative management of comples and displaced intra-articular glenoid fractures, J Bone Joint Surg 94:645,
McKee MD.(2015) Clavicle fractures. Rockwood and Green’s fractures in adults (7th ed). Copyright © 2015 Wolters Kluwer Health
Neer CS. Fractures of the distal clavicle with detachment of the coracoclavicular ligaments in adults. J Trauma. 1963;3:99–110.
Zlowodzki M, Zelle BA, Cole PA, et al: Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures. On behalf of the Evidence-Based Orthopaedic Trauma Working Group, J Orthop Trauma 19:504, 2005
Canadian Orthopaedic Trauma Society: Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter,randomized clinical trial, J Bone Joint Surg 89A:1, 2007.)
Brinker MR, Edwards TB, O’Connor DP. Letter to the editor. J Bone Joint Surg Am. 2005;87 A(3):677–678.
Hill JM, McGuire MH, Crosby LA. Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br. 1997;79(4):537–539.
Robinson CM, Court-Brown CM, McQueen MM, et al. Estimating the risk of nonunion following nonoperative treatment of a clavicle fracture. J Bone Joint Surg Am. 2004;86- A(7):1359–1365.
McKee MD, Pedersen EM, Jones C, et al. Deficits following nonoperative treatment of displaced midshaft clavicular fractures. J Bone Joint Surg Am. 2006;88(1):35–40.
