Subscapularis avulsion of the lesser tuberosity in adolescents

Evaluation and Management of Pediatric Proximal Humerus Greater and Lesser Tuberosity Avulsion Fractures

Proximal humerus fractures account for 2% of fractures in skeletally immature patients. Avulsion fractures of the lesser and greater tuberosity are a rare subset of these injuries. Lack of awareness of these fracture types and subtle radiographic findings can result in delayed diagnosis and treatment. Case reports provide most of the current literature, and thus common injury mechanisms, clinical presentation, and ideal treatment time frame and modality are still undetermined. There are limited data directly comparing outcomes with nonsurgical or surgical management leading to unclear treatment guidelines. Presently, techniques for management of these injuries continue to evolve. Although these injuries represent a subset of pediatric proximal humerus injuries, they must be considered when evaluating a child with atraumatic and traumatic shoulder pain.

Bilateral Proximal Humerus Lesser Tuberosity Avulsions in an Adolescent Patient: A Case Report

CASE

Fourteen-year-old boy presented with bilateral proximal humerus lesser tuberosity avulsions after swinging between 2 desks. Injuries were not visualized on radiographs but identified on magnetic resonance imaging. He underwent bilateral open reduction and internal fixation of the bony avulsions. Following repair, he returned to full activities, including sports, without limitations.

CONCLUSION

Lesser tuberosity avulsions are rare injuries in the pediatric population that can be missed. Our case is a low energy noncontact mechanism resulting in bilateral injury, highlighting the importance of having a high index of suspicion for this diagnosis in adolescent patients with shoulder pain with normal radiographs.

Rotator cuff injury in the pediatric population: a systematic review of patient characteristics, treatment, and outcomes

Rotator cuff injuries (RCIs), traditionally thought to be an adult-type pathology, have been reported in the pediatric population, but there remains limited evidence regarding this injury pattern in pediatric patients. The purpose of this study was to systematically review the literature to characterize the epidemiology, injury patterns, treatment modalities, and outcomes for pediatric patients with RCIs. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, reviewing Pubmed, Embase, Cochrane, and CINAHL databases. Studies reporting imaging confirmed RCIs, and treatment outcomes in patients less than 18 years of age were included. Patient demographics, mechanism, injury type, and injury location were recorded. Treatment type and patient outcomes were abstracted when available and summarized with descriptive statistics. Our search identified 28 studies published from 1994 to 2020, which included 215 total tendons injured in 185 patients. Twenty-six studies were classified as level IV evidence, whereas only two were level III. When described, the most injured tendon ( n = 184) was the supraspinatus, whereas the most described injury type ( n = 215) was a partial tear. Surgical intervention was pursued in 75.8% of injuries, with arthroscopy being more common than open repair (79.4% vs. 20.6%). Nonoperative treatment was primarily utilized for partial tears. Among the 24 studies reporting on return to sports, nonoperatively managed patients returned later than those treated operatively (mean: 10.7 vs. 7 months). Only eight studies included patient reported outcome measures (PROMs), and just five had pre- and posttreatment scores. Three complications were noted, all in operative patients. RCIs in pediatric patients have been reported in the literature with increasing frequency over the last decade, but the quality of evidence remains poor with inconsistent injury descriptions and outcome reporting. Excellent results were seen for all injury types and locations with both operative and nonoperative treatments. The literature for pediatric RCIs remains limited in guiding management decisions indicating a need for more high-quality studies to compare outcomes across injury and treatment type. Level of evidence: level III.

Delayed Repair of a Lesser Tuberosity Avulsion Fracture in an Adolescent 3 Years After Initial Injury

This case study examines an adolescent athlete who had an avulsion fracture of the lesser tuberosity of the humerus. This is a relatively rare injury, although a collection of case studies have identified an increase in this type of injury in the past 15 years. Uniquely, the patient experienced a delay in appropriate diagnosis for approximately 3 years from the time of his initial injury. This is one of the most significant delays in diagnosis and treatment in the current body of literature regarding lesser tuberosity fractures. The authors include a detailed series of imaging studies, including preoperative plain radiographs, preoperative computed tomography, intraoperative arthroscopic images, and postoperative plain radiographs. In addition, a thorough description of the patient's surgery is presented. The degree of scarring to the axillary nerve present in this patient required conversion to a full open reduction. The authors' aim is that this case can be used as a reference for future surgical decision making, particularly in pediatric patients whose injuries are highly chronic or who are actively involved in athletic physical training programs. [Orthopedics. 20XX;XX(X):xx-xx.].

Arthroscopic Fixation of Avulsion Fractures of the Lesser Tuberosity of the Humerus: Clinical Outcomes With a Mean 3.5-Year Follow-up

Background:

Avulsion fracture of the lesser tuberosity (AFLT) of the humerus has traditionally been treated with open reduction internal fixation using screw fixation. The clinical outcomes of arthroscopic repair with suture anchors remains unknown.

Hypothesis:

It was hypothesized that arthroscopic fixation with suture anchors would result in good clinical outcomes for the treatment of AFLT.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 15 patients who underwent arthroscopic repair of AFLT of the humerus between January 2014 and October 2017. All patients had 3-dimensional computed tomography scans and magnetic resonance imaging to evaluate the avulsed fracture and concomitant injuries before surgery. The arthroscopic double-row and suture-bridge techniques were used based on the morphology of the avulsion fractures. Functional outcomes were assessed with range of motion, the visual analog scale (VAS) for pain, the Subjective Shoulder Value (SSV), the American Shoulder and Elbow Surgeons (ASES) score, and the University of California, Los Angeles (UCLA) shoulder score. The bear-hug test, liftoff test, and internal rotation resistance test at 90° abduction and external rotation (IRRT 90°) were used to evaluate subscapularis tendon integrity.

Results:

The mean follow-up time was 3.5 years (range, 3-5 years). Comminuted fractures with 1 large part and ≥1 small pieces were seen in 12 cases, partial tear of the supraspinatus in 2 cases, Bankart lesion in 2 cases, and superior labrum anterior to posterior injury in 2 cases. There was a statistically significant improvement from the baseline to the final follow-up in the VAS (from 6.9 ± 1.5 to 1.1 ± 1), SSV (from 30.7 ± 5.1 to 90.5 ± 11.6), ASES (from 28.5 ± 7.7 to 92.3 ± 4.5), and UCLA (from 29.5 ± 6.3 to 94.2 ± 8.3) scores (P < .001 for all). All patients showed full range of shoulder motion and bilateral symmetric strength on physical examination with the bear-hug test, liftoff test, and IRRT 90° test.

Conclusion:

The arthroscopic repair of AFLT resulted in excellent reduction and healing of the displaced fragment. At the final follow-up, clinical and functional results were good. Associated injuries occurred in 40% of patients but did not affect outcomes.

What are the patient-reported outcomes, functional limitations, and complications after lesser tuberosity fractures? a systematic review of 172 patients

BACKGROUND

Lesser tuberosity fractures are relatively rare, with an incidence of 0.46 per 100,000 persons per year. This systematic review was performed to address patient-reported outcomes (PROMs), shoulder function, and complications after lesser tuberosity fractures in pediatric and adult patients, as well as patients with an associated posterior shoulder dislocation. Within these groups, identical outcomes were evaluated for nonoperative, surgical, acute and delayed treatment.

METHOD

A comprehensive search was carried out in multiple databases. Articles were included if patients sustained a lesser tuberosity fracture without a concomitant proximal humerus fracture. There were no restrictions on age, type of treatment, fragment displacement, time to presentation, or associated injuries.

RESULTS

One thousand six hundred forty-four records were screened for eligibility of which 71 studies were included (n = 172). Surgical treatment was provided to 50 of 62 (81%) pediatric patients, 49 of 66 (74%) adults, and 34 of 44 (77%) patients with an associated posterior shoulder dislocation. In the pediatric group, the mean of PROMs was 94 (range 70-100) and among adults 89 (range 85-100). In the posterior shoulder dislocation group, 89% did not regain full range of motion and the complication rate was 17%. In pediatric patients, surgery was associated with fewer complications (P = .021) compared to nonoperative treatment.

CONCLUSION

Pediatric patients have excellent outcomes after lesser tuberosity fractures and respond well to surgical treatment. Adults have acceptable outcomes but patients with an associated posterior shoulder dislocation have impaired range of shoulder movement and are more likely to develop complications.

Humeral lesser tuberosity avulsion fractures - magnetic resonance imaging characteristics in the pediatric population

BACKGROUND

Avulsion fractures of the humeral lesser tuberosity are rare injuries in skeletally immature patients and can pose a diagnostic challenge that often leads to delayed identification.

OBJECTIVE

To describe the demographics, mechanism of injury and magnetic resonance imaging (MRI) findings of lesser tuberosity avulsion fractures in children.

MATERIALS AND METHODS

A retrospective search of children with lesser tuberosity avulsion fractures on MRI was done. Available radiographs were evaluated. Demographics, mechanism of injury, MRI characteristics and treatment were recorded.

RESULTS

Thirteen children, all male, were included (median age: 13.8 years, range: 12.5-16.8 years). The most common mechanism was blunt, overhead or hyperextension traumatic injury related to sports. All patients were skeletally immature and 10/13 demonstrated isolated avulsion fractures at the footprint. Only one patient had associated osteochondral injury to the humeral head and labral tear. Two children demonstrated medial dislocation/subluxation of the biceps tendon. The median size of the avulsed fragment was 15 mm (range: 5-29 mm), median anteroposterior displacement was 3 mm (range: 0-6 mm) and medial displacement was 1 mm (range: 0-20 mm). There was no correlation between age and the size of the avulsed fragment (P=0.29). Common injury patterns were complete avulsion of the subscapularis footprint (6/13) and partial avulsion of inferior footprint (6/13). Two-thirds of the radiographs were initially reported as normal, but retrospectively showed two missed fractures. One of the initial radiographs raised concern for bone tumor. The best view for identifying an avulsion fragment was the axillary view. Seven patients of the 13 patients underwent internal fixation.

CONCLUSION

Avulsion fractures of the lesser tuberosity are rare, challenging to diagnose and often radiographically occult. MRI can identify the injury at the subscapularis tendon footprint with variable size and displacement. The long head of the biceps tendon is usually normal in location. Although this entity is rare, radiologists should be aware of it to allow for correct and prompt diagnosis and prevent unnecessary biopsy or contrast administration.

Primary Arthroscopic Repair of a Traumatic Isolated Subscapularis Tendon Rupture in an Adolescent Patient

Subscapularis tendon tears in the pediatric population are most commonly associated with an avulsion fracture of the lesser tuberosity. Isolated subscapularis tendon ruptures are infrequently reported. According to previous reports, the diagnosis of subscapularis tendon injuries in pediatric patients is often delayed and management is typically conservative. When operative management is indicated, an open deltopectoral approach has been used and may include concomitant open reduction and internal fixation of the lesser tuberosity. The authors report the case of a healthy 15-year-old boy who had an isolated subscapularis tendon rupture. During operative management, labral tape sutures were passed through the subscapularis tendon at the junctions of the inferior one-third and superior two-thirds, along with the superior one-third and inferior two-thirds. Both suture limbs were implanted with a 4.75-mm polyetheretherketone suture anchor within the inferior one-third and superior one-third of the lesser tuberosity footprint. A mini-open subpectoral biceps tenodesis was also performed through an axillary incision. By 8 months postoperatively, the patient exhibited normal function with full range of motion and was allowed to return to sport-related activity. [Orthopedics. 2020;43(3):e182-e186.].

Lesser Tuberosity Avulsion Fracture Repair Using Knotless Arthroscopic Fixation

Although some literature may suggest that acute nondisplaced lesser tuberosity fractures should undergo nonoperative management, there is a body of evidence that supports surgical stabilization of these injuries due to concern for fracture displacement, nonunion and malunion, anteromedial impingement, and possible biceps tendon subluxation or dislocation. In this Technical Note, we introduce a novel technique for arthroscopic fixation of lesser tuberosity avulsion fractures using a knotless repair. In the lateral decubitus position using standard arthroscopic portals, with the addition of the biceps accessory portal, 2 ULTRATAPE sutures are fixed to the avulsed fragment in luggage-tag fashion to create a secure, knotless fixation. These are used to mobilize and anatomically approximate the lesser tuberosity to the avulsion bed and are held in place with suture anchors placed immediately adjacent to the fracture bed. This technique provides good anatomic reduction with maximal surface area for bone-to-bone healing.

Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review

PURPOSE

To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries.

METHODS

We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed.

RESULTS

We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain.

CONCLUSIONS

Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity.

LEVEL OF EVIDENCE

Level IV, systematic review of low-quality studies.

Repair of Acute-on-Chronic Subscapularis Insufficiency in an Adolescent Athlete

A 13-year-old right-hand-dominant skeletally immature boy presented to the authors' clinic after being blocked during an overhead dodgeball throw and hearing an abrupt "pop" in the shoulder. He had pain in the subdeltoid region that was most prominent during sports-related activity, particularly throwing. The patient had nonoperative management of a lesser tuberosity avulsion fracture 1 year earlier after a similar injury that occurred during a basketball game. He had returned to normal sporting activity 2 months before the most recent injury. Repeat advanced imaging showed an avulsion fracture of the subscapularis tendon, with a significantly retracted 2-cm component as well as a less retracted component, suggesting acute-on-chronic injury. Given this retraction and the symptoms during throwing, the patient was counseled that surgical management would best facilitate an asymptomatic return to sports-related activity. This case showed acute-on-chronic subscapularis tendon insufficiency with avulsion of the lesser tuberosity and significant retraction of the subscapularis tendon without tearing, a rare injury pattern in adolescents. For fixation of the avulsed lesser tuberosity fracture, an open approach technique was used in which SpeedBridge (Arthrex, Naples, Florida) sutures were passed behind the bone fragment. Four anchors were placed medial and lateral to the subscapularis insertion points to create a knotless double-row footprint. Compared with the published literature, this method of subscapularis fixation offered secure anatomic repair in a time-efficient, user-friendly manner.

Subscapularis tears and lesser tuberosity avulsion fractures in the pediatric patient

Background:

Pediatric subscapularis tears are known to be rare injuries. They are often associated with an avulsion fragment of the lesser tuberosity leading to dual description in the literature of either subscapularis tear or lesser tuberosity avulsion. Historically, they were managed nonoperatively; however, outcomes have improved with operative management. Nonoperative management often led to bony overgrowth at the lesser tuberosity that limited motion. The literature is limited to case reports and a few small case series, often not restricted to pediatric patients.

Study Design:

Case series.

Level of Evidence:

Level 5.

Methods:

Radiographic and operative databases were retrospectively reviewed to identify pediatric patients with subscapularis tears or lesser tuberosity avulsions in the past 10 years.

Results:

Five cases of pediatric subscapularis tears were identified that underwent operative management. Of the 5 cases, 4 had delayed presentation. In 1 case, the lesser tuberosity fragment was initially missed on radiographic imaging. All patients underwent operative management.

Conclusion:

These cases add to the body of knowledge of a rare pediatric injury that is commonly missed or diagnosis delayed. The importance of suspicion in the adolescent male patient without instability and unrelenting shoulder pain is stressed. Additionally, the importance of early magnetic resonance imaging with suspicion as well as an axillary view of the shoulder is demonstrated. As with all rare entities, it is important to disseminate information on natural history and interventions for this injury.

Evaluation and management of pediatric proximal humerus fractures

In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.

Lesser tuberosity avulsions in adolescents

BACKGROUND

Subscapularis tendon avulsions of the lesser tuberosity are relatively rare and often missed acutely and their characteristic appearance is frequently not recognized or is misinterpreted for an osteochondroma or a neoplastic process.

QUESTIONS/PURPOSES

This report reviews our experience with six adolescents who had subscapularis tendon avulsions of the lesser tuberosity.

METHODS

Six male adolescents (12-15 years) presented with shoulder pain following history of trauma during amateur sport. Clinical notes including range of motion, strength tests, and pain assessment were reviewed along with imaging studies pre- and post treatment. Treatment consisted of either surgical or conservative measures.

RESULTS

Two of the six patients had a large avulsion that simulated an exostosis of the proximal humerus that was misdiagnosed as an osteochondroma at two different outside institutions. All six cases were diagnosed with subscapularis tendon avulsion of the lesser tuberosity following clinical and imaging evaluation at our institution. Five of the patients underwent surgical repair and fixation of the tendon and the lesser tuberosity with suture anchors. One patient was treated conservatively. All patients had a good outcome with recovery of full shoulder strength and motion upon follow-up.

CONCLUSION

Clinicians should have a high index of suspicion of lesser tuberosity avulsions in adolescents who present with loss of internal rotation and anterior shoulder pain following traumatic injuries. In addition, an osseous fragment or exostosis along the inferomedial humeral head should suggest a subscapularis tendon avulsion and also should not be confused with an osteochondroma or a neoplastic process.

Upper extremity physeal injury in young baseball pitchers

Adolescent baseball players, especially pitchers, are at increased risk for shoulder and elbow injuries as their level of competition increases. The intersection of the adolescent growth spurt with the high levels of elbow valgus and shoulder rotational torques placed upon the arm during overhand pitching predisposes the shoulder and elbow to physeal injuries. Little League shoulder and Little League elbow syndromes most commonly represent pathology at the physeal regions of the proximal and distal humerus and proximal ulna sustained from repetitive loads caused by overhead throwing. There is a growing understanding that these injuries occur on a wide spectrum from delayed physeal closure and physeal widening to acute transphyseal fracture. Although operative intervention is infrequently required, patient and parent counseling can be complex. Health care professionals who care for adolescent baseball players also can play an important role in prevention. Appropriate counseling requires a comprehensive understanding of the clinical, radiographic, and biomechanical aspects of these injuries. This review summarizes these major concepts, focusing on the best available evidence from recent biomechanical and clinical studies on shoulder and elbow injuries in adolescent baseball pitchers.