Fig. 12.1
(a) Single large fragment of greater tuberosity fracture: X-ray. (b) Arthroscopic treatment with two cannulated screws. (c) Postoperative X-ray
Where there are several small or poor-quality fragments, fixation with transosseous nonabsorbable sutures should be preferred, through direct repair of the rotator cuff [1]. Even in this case various techniques have been adopted: Park et al. and Flatow et al. [11, 12] reported good results using transosseous sutures in a figure-of-eight pattern placing the fragments back into the fracture bed and thereby minimizing potential hardware mobilization problems.
Transosseous fixation can also be achieved by using small anchors : Bhatia et al. [27] reported excellent long-term results with a double row of suture anchors: the sutures arranged in this way buttress the fragments against the fracture surface. We currently prefer open surgery to fix these fractures with transosseous sutures using a new device (SharcFT®) that allows for the creation of transosseous tunnels even in conditions of poor bone stock [28] (Fig. 12.2).
Fig. 12.2
(a) Several fragments of greater tuberosity fracture-dislocation: X-ray. (b) 3D-CT fracture view. (c) Open fixation with transosseous system, the SharcFT®. (d) Final suture configuration. (e) Postoperative X-ray
Arthroscopic fixation is more recent and offers many advantages: considerably less trauma to soft tissue; possibility of having a comprehensive view of associated lesions, together with the opportunity to treat them; better visualization of the fixation obtained; and unscathed deltoid muscle [4, 10]. There are, however, also disadvantages: greater difficulty in obtaining a stable fixation, complex conversion to open surgery, higher cost, and longer learning curve [29].
The literature contains few case series concerning arthroscopic treatment of greater tuberosity fractures: Taverna et al. [30] reported excellent results with the described technique in which the posterior portal is placed superiorly and laterally to improve visualization of the tuberosity fragment. After debridement of the fracture site, the greater tuberosity is reduced and temporarily stabilized using K-wires, with subsequent definitive fixation using cannulated screws with the aid of fluoroscopy.
In the presence of multifragmented fractures, one often has to handle smaller fragments with the cuff inserted, predominantly supraspinatus or supra-infraspinatus. In such cases the fracture may be treated as a rotator cuff tear using the technique described by Bhatia et al. [27], which addresses the fixation of the tuberosity fragments indirectly by repairing the rotator cuff with anchors (Fig. 12.3).
Fig. 12.3
(a) Several small fragments of greater tuberosity fracture: X-ray. (b) 3D-CT fracture view. (c) Arthroscopic indirectly fixation with transosseous equivalent technique (suture bridge) as a rotator cuff tear repair: postoperative X-ray
Other authors such as Ji et al. [31, 32] and Song et al. [33] reported direct rotator cuff repair by using double-row and suture-bridge techniques to reduce and fix the tuberosity fragments, especially when comminuted, with good or excellent results. A 2012 cadaveric biomechanical study by Lin et al. [34] demonstrated that in greater tuberosity fractures, fixation techniques relying on anchors last longer than those relying on screws.
A fundamental aspect is the correct choice of indication for arthroscopic fixation: isolated greater tuberosity fractures or those associated with reduced glenohumeral dislocation; single fragment of 2–3 cm with minimal displacement, preferably treated with 1–2 cannulated screws; and comminuted fractures or with a main fragment of 1–2 cm if displaced posterosuperiorly and associated with rotator cuff tears [1, 35] to be treated with double-row sutures of suture-bridge technique only if bone quality is good. Arthroscopic treatment also has some limitations: multifragmented fractures; fragments larger than 3 cm or than 2 cm but severely displaced, owing to the difficulty achieving a good anatomic reduction and a stable fixation; valgus impacted fractures; and presence of severe osteoporosis (where the transosseous system with SharcFT® device could overcome the problem).
As regards postoperative treatment of both open and arthroscopic fixation, we prefer to use a shoulder sling at 10–15° of abduction and neutral rotation for 4 weeks. Passive mobilization is allowed at 1 week even with the help of mechanical aids, whereas active mobilization is recommended at 4–6 weeks, alternating exercise on land and in water with a maximum of three sessions a week.
12.2.4 Conclusions
Greater tuberosity fractures form a distinct disease entity within the spectrum of fractures of the proximal humeral epiphysis. Current classifications are inadequate both for diagnostic interpretation and for providing the correct indication for treatment. The clinical and rehabilitation course after operative and nonoperative treatment is often more complex than expected or communicated to the patient. When indicated, arthroscopic fixation may play a crucial role in the technical result and the postoperative course.
12.3 Lesser Tuberosity
Fractures of the lesser tuberosity are even rarer than those affecting the greater tuberosity, accounting for approximately 2 % of all proximal humeral fractures [36].
From the point of view of demographics, pathological anatomy, etiology, and pathogenesis, we can distinguish two types of lesion: fractures-avulsions in the adolescent and fractures in the adult.
Fractures-avulsions of the adolescent are relatively rare but increasing in frequency: a recent review of the literature published in 2012 [37] reports on a study of 33 cases among patients aged 11–20 years, predominantly males, with a mean age of 13 years. The growing incidence reported by some authors [38] is related to the increasingly earlier and more intense engagement of adolescents in high-level contact or overhead sports. Another peculiarity of these lesions is the delay in diagnosis and treatment relative to the traumatic event. Vezeridis et al. [39] reported a mean time from trauma to diagnosis of 6.5 weeks, and Levine et al. [40] in a review of 32 cases confirmed a delay of over 6 months in 50 % of cases. The reported traumatic mechanisms are basically two: forced and resisted abduction-external rotation during a throwing action, a backward fall with extended and externally rotated shoulder. In both cases there is an eccentric contraction of the subscapularis which opposes the forced external rotation. The third mechanism, specific to sports like baseball or fishing, is related to repetitive abduction-external rotation that can cause microtraumatic detachment of the lesser tuberosity (little league shoulder). In terms of pathological anatomy, fracture-avulsion of the lesser tuberosity cannot be defined as either epiphyseal detachment or apophysitis in the rare cases of little league shoulder, since the ossification center of the lesser tuberosity fuses with the humeral head between the ages of 7 and 11 years. Because a relative weakness of the lesser tuberosity-head transition zone is thought to persist between the ages of 12 and 16–17 years, the lesion can be defined as a transitional fracture or a lesser tuberosity stress lesion.
The clinical examination of these patients reveals anterior shoulder pain which is put in relation to a precise traumatic event in some cases only; in the majority of patients, no precise traumatic event can be identified. For this reason, the first clinical suspicion is anterior instability, though careful assessment will reveal a limitation and weakness in internal rotation-retropulsion, positive belly-press test and lift-off test, and in some cases increased external rotation at ER1 (external rotation with elbow close to trunk). In cases in which the time from traumatic event to diagnosis exceeds 6–12 months, there may be an anterior bony mass due to exostotic callus formation.
Standard radiography often does not allow for a precise diagnosis with even the axillary view not permitting a diagnosis in over 50 % of patients [41] since the detached fragment is mostly cartilaginous. Only in patients undergoing assessment a long time after the traumatic event does the development of an exostosis visible on the axillary view allow the diagnosis.
MRI is specific and sensitive for this type of lesion and is therefore indicated in anterior shoulder pain in 11–17-year-old adolescents with a history of trauma during abduction-external rotation and backward fall during external rotation or in young athletes with repeated throwing action. In some cases MRI will allow visualization of the associated capsular detachment and/or medial displacement of the long head of the biceps.
Conservative treatment is reserved for cases in which the pathogenetic mechanism is repetitive throwing in abduction-external rotation (e.g., baseball) and in which investigations reveal an undisplaced stress lesion. Follow-up at 2 years shows complete recovery of function. Persistence of symptoms or imaging evidence of fragment displacement constitutes an indication for reduction and fixation [38].
Open surgical reduction and fixation via deltopectoral approach is instead warranted for all other posttraumatic cases to avoid short- and long-term sequelae. Goeminne and Debeer [37] report two severe sequelae in two patients aged 37 and 39 years who had sustained trauma as adolescents and required complex surgical procedures to restore function.
The lesser tuberosity fragment, which is usually small, can be reinserted through transosseous tunnels starting at the bicipital groove or with the aid of paracartilaginous medial anchors at the tendon-bone junction and lateral-row anchors (suture-bridge construct). In the event of biceps dislocation, tenodesis is performed within the bony groove.
Vezeridis et al. [39], in a series of eight patients treated between 2000 and 2010, report return to sport after an average of 4.5 months, with a mean limitation to external rotation of 13° in only 3/8 patients at 2-year follow-up.
Lesser tuberosity fractures in the adult may be isolated or associated with posterior glenohumeral dislocation; in either case they are relatively rare with an incidence ranging from 0.46 per 100,000 persons/year to 110 per 100,000 persons/year [42]. Given the peculiarity of fractures associated with posterior dislocation, these will not be discussed.
There are considerable variations in the reported age and sex of patients at risk of this type of fracture, but most of them are males aged 40–50 years. These fractures are caused by high-energy traumatic events such as a fall down the stairs or a fall from a horse or bicycle, which entail a forceful contraction of the subscapularis when the arm is forced into external rotation and extension. In cases associated with posterior dislocation, detachment of the lesser tuberosity appears as a propagation of the anterior osteochondral fracture of the humeral head. As with fractures-avulsions in adolescents, the clinical and radiological diagnosis is not always straightforward. Patients are mostly victims of high-energy traumas and therefore they are seen in the emergency department where, on the one hand, the intense pain of acute injury precludes a thorough clinical assessment and, on the other, it is difficult to obtain a correct axillary projection which would facilitate the diagnosis. In the AP view, these fractures appear as an altered bone profile medially to the bicipital groove or, where the groove is involved, an altered profile of the groove itself. Such radiographic changes associated with a history of a fall with extended or externally rotated arm, with intense pain and complete functional disability, should prompt the performance of an emergent CT scan.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
