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Manoukov Y, Le Hanneur M, Kany J, Grimberg J. Traumatic avulsion of the subscapularis tendon in adolescents: Return to sport after surgical repair. Orthop Traumatol Surg Res 2024; 110:103823. [PMID: 38278345 DOI: 10.1016/j.otsr.2024.103823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 11/13/2023] [Accepted: 12/04/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Traumatic complete rotator cuff tears are rare in the pediatric population. These injuries might be a result of shoulder dislocation or direct trauma experienced during contact sports (i.e., rugby, judo). The purpose of this study was to identify the epidemiologic and clinical characteristics of these injuries and assess the medium- and long-term outcomes following surgery, with return to sport as the primary endpoint. MATERIALS AND METHODS An electronic questionnaire was sent to all surgeons who were members of the French Shoulder and Elbow Society (SOFEC) and/or the French Society of Arthroscopy (SFA), asking if they ever had to surgically treat a traumatic complete tear of 1 or more rotator cuff tendons in a child or adolescent. Ninety (38.6%) of the 233 surgeons members of the SOFEC and/or the SFA responded to our questionnaire. We then contacted the 15 surgeons who answered affirmatively to collect the complete medical records of their patient(s). RESULTS We reviewed the records of 17 children and adolescents who underwent surgery for a traumatic complete rotator cuff tear. The mean age at surgery was 15.2 years (range, 12-17). Glenohumeral dislocation during contact sports (n=7/17) was a frequent mechanism of injury (41%). All of these cases involved at least the subscapularis muscle with an avulsed bony insertion. The injury involved other rotator cuff tendons in 29% of cases (5/17). The bone and tendon repair was either performed as open surgery (n=5/17) or arthroscopically (n=12/17). At a median follow-up of 24 months and a mean follow-up of 50 months, 82.4% of patients had returned to sport at their preinjury level. Three patients presented neurologic complications resulting from the traumatic event, but only 1 of them required nerve grafting with a favorable outcome. We also reported 3 cases of nonunion of the lesser tuberosity that required revision surgery with good outcomes. Only 1 patient out of all those with at least 1 episode of dislocation presented a recurrent anterior shoulder instability that required a bone block-type procedure 7 years after the initial surgery. CONCLUSION Traumatic complete rotator cuff tears are rare in children and adolescents. They often occur during contact sports. These types of injuries are diagnosed by clinical examination and confirmed by cross-sectional imaging, ideally magnetic resonance imaging. Tendon injuries mainly involve the subscapularis but can also affect other cuff tendons. Return to preinjury activity levels after surgical management was possible in more than 80% of cases. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Yvan Manoukov
- Hôpital Saint-Antoine, Assistance publique-Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France.
| | - Malo Le Hanneur
- Centre Main Épaule Méditerranée (CMEM), clinique Bouchard, 77, rue du Dr Escat, 13006 Marseille, France
| | - Jean Kany
- Clinique de l'Union, groupe Ramsay GDS, boulevard Ratalens, 31240 Saint-Jean, France
| | - Jean Grimberg
- Clinique Jouvenet, groupe Ramsay GDS, 6, square Jouvenet, 75016 Paris, France
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2
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Walters T, Barnes L. Open reduction and internal fixation using suture anchors for an isolated lesser tuberosity fracture: description of technique and a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:431-437. [PMID: 39157228 PMCID: PMC11329003 DOI: 10.1016/j.xrrt.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Affiliation(s)
- Taylor Walters
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Leslie Barnes
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA, USA
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3
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Caldaria A, Giovannetti de Sanctis E, Palumbo A, Franceschi F, Maffulli N. Rotator Cuff Repair in Pediatric and Adolescent Athletes: Indications and Outcomes. Sports Med Arthrosc Rev 2023; 31:62-66. [PMID: 37976126 DOI: 10.1097/jsa.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Rotator cuff (RC) tears in pediatric and adolescent athletes are rare events. In these patients, RC tears are more likely to be traumatic or related to overuse among overhead. Repeated movements of abduction and external rotation are frequent mechanisms of injury. The supraspinatus is the most commonly involved tendon and the articular-sided tears are more common than the bursal side. Magnetic resonance imaging is considered the gold standard for diagnosing RC tears. Conservative treatment, arthroscopic, and open repair are all effective treatment methods depending on the type of injury. The risk of growth plate injury in these patients should be always considered when planning surgical interventions. Return to sport for competitive-level throwing athletes represents the greatest challenge in the treatment of these injuries.
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Affiliation(s)
- Antonio Caldaria
- Department of Orthopedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital
| | - Edoardo Giovannetti de Sanctis
- Department of Orthopedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital
- UniCamillus-Saint Camillus International University of Health Sciences
| | - Alessio Palumbo
- Department of Orthopedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital
- UniCamillus-Saint Camillus International University of Health Sciences
| | - Francesco Franceschi
- Department of Orthopedic and Trauma Surgery, San Pietro Fatebenefratelli Hospital
- UniCamillus-Saint Camillus International University of Health Sciences
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Università of Rome 'La Sapienza', Rome, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London
- School of Pharmacy and Bioengineering, keele University School of Medicine, London, UK
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4
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Garbis NG, Walsh DJ. Delayed Repair of a Lesser Tuberosity Avulsion Fracture in an Adolescent 3 Years After Initial Injury. Orthopedics 2022; 46:e189-e192. [PMID: 36067048 DOI: 10.3928/01477447-20220831-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.].
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5
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Lesser Tuberosity Avulsion Fracture in an 11-Year-Old Baseball Player due to Batting. Case Rep Orthop 2021; 2021:2396200. [PMID: 34824874 PMCID: PMC8610693 DOI: 10.1155/2021/2396200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 11/18/2022] Open
Abstract
Case We report an 11-year-old male who sustained a lesser tuberosity avulsion fracture of the proximal humerus upon making contact with a baseball during an at-bat. This injury was neglected for 14 months and was eventually detected by an axillary radiograph and subsequent MRI. He successfully underwent an open surgical repair and regained full range of motion and level of activity at 1-year follow-up. Conclusion In pediatric baseball players, lesser tuberosity avulsion fractures may occur upon striking a baseball with a bat. Even after being neglected for several months, these injuries can be treated successfully with an open surgical repair.
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6
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Spek RW, Schoolmeesters BJ, den Haan C, Jaarsma RL, Doornberg JN, van den Bekerom MP. What are the patient-reported outcomes, functional limitations, and complications after lesser tuberosity fractures? a systematic review of 172 patients. JSES Int 2021; 5:754-764. [PMID: 34223426 PMCID: PMC8245972 DOI: 10.1016/j.jseint.2021.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Reinier W.A. Spek
- Medical Doctor, Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
| | | | | | - Ruurd L. Jaarsma
- Orthopaedic Trauma Surgeon, Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Job N. Doornberg
- Orthopaedic Trauma Surgeon, Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Michel P.J. van den Bekerom
- Orthopaedic Surgeon, Shoulder and Elbow Expertise Centre, Department of Orthopaedic Surgery, OLVG, Amsterdam, The Netherlands
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7
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Bedoya MA, Barrera CA, Bencardino JT, Ho-Fung V. Humeral lesser tuberosity avulsion fractures - magnetic resonance imaging characteristics in the pediatric population. Pediatr Radiol 2021; 51:1421-1430. [PMID: 33666731 DOI: 10.1007/s00247-021-04988-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/15/2020] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Maria A Bedoya
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, 19104, USA. .,Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Christian A Barrera
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jenny T Bencardino
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Ho-Fung
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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8
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Davey MS, Hurley ET, Scanlon JP, Gaafar M, Pauzenberger L, Mullett H. Excellent Clinical Outcomes and Rates of Return to Play After Arthroscopic Rotator Cuff Repair for Traumatic Tears in Athletes Aged 30 Years or Less. Arthrosc Sports Med Rehabil 2021; 3:e667-e672. [PMID: 34195630 PMCID: PMC8220565 DOI: 10.1016/j.asmr.2021.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/12/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To evaluate clinical outcomes and rate of return to play (RTP) among athletes aged 30 years or younger who have undergone an arthroscopic rotator cuff repair (ARCR) after trauma. Methods We performed a retrospective review of patients who underwent an ARCR with a minimum of 12 months’ follow-up between 2012 and 2019. Patients were followed up to assess the American Shoulder and Elbow Surgeons score, Subjective Shoulder Value, visual analog scale score, and satisfaction level. Whether patients were able to RTP was reported, in addition to the timing of return and the level to which they returned. Results Our study included 20 athletes (20 shoulders), with a mean follow-up period of 31.8 months. All patients were satisfied with their surgical procedure, and all would opt to undergo surgery again. Overall, 85% returned to sport and 50.0% returned to the same level or a higher level. The overall mean American Shoulder and Elbow Surgeons score was 92.4; mean Subjective Shoulder Value, 87.0; and mean visual analog scale score, 0.7. At final follow-up, only 1 patient (5.0%) had undergone a revision procedure. Of the 15 patients who played collision sports, 93.3% returned to sport but only 60.0% returned to the same level or a higher level. Conclusions After ARCR, athletes aged 30 years or younger show excellent functional outcomes with high rates of patient satisfaction and RTP after the procedure. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Martin S Davey
- Sports Surgery Clinic, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eoghan T Hurley
- Sports Surgery Clinic, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland.,National University of Ireland, Galway, Galway, Ireland
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9
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de Casas R, Novoa B, Cobelo E, Cidoncha M. Reconstruction of a massive avulsion fracture of the lesser tuberosity using the arthroscopic tension band technique: a case report and brief review of the literature. JSES Int 2020; 4:730-733. [PMID: 33345207 PMCID: PMC7738591 DOI: 10.1016/j.jseint.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ricardo de Casas
- Department of Orthopedic Surgery, Clinica Traumacor, A Coruna, Spain
| | - Benedicto Novoa
- Department of Orthopedic Surgery, Clinica Traumacor, A Coruna, Spain
| | - Elisa Cobelo
- Department of Orthopedic Surgery, Clinica Traumacor, A Coruna, Spain
| | - Myriam Cidoncha
- Department of Physical Medicine, Clinica Traumacor, A Coruna, Spain
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10
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Chen J, Xu C, Zhao J. Arthroscopic treatment of isolated subscapularis avulsion fracture: a case report and literature review. JSES Int 2020; 4:347-351. [PMID: 32490424 PMCID: PMC7256808 DOI: 10.1016/j.jseint.2019.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jiebo Chen
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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11
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Park SG, Shim BJ, Seok HG. Isolated avulsion fracture of the lesser tuberosity of the humerus in an adolescent amateur boxer. JSES Int 2020; 4:759-764. [PMID: 33345212 PMCID: PMC7738451 DOI: 10.1016/j.jseint.2020.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sam-Guk Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Bum-Jin Shim
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Hyun-Gyu Seok
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Daegu, Republic of Korea
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12
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Agarwalla A, Puzzitiello RN, Leong NL, Allison B, Romeo AA, Forsythe B. Primary Arthroscopic Repair of a Traumatic Isolated Subscapularis Tendon Rupture in an Adolescent Patient. Orthopedics 2020; 43:e182-e186. [PMID: 32003841 DOI: 10.3928/01477447-20200129-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/14/2019] [Indexed: 02/05/2023]
Abstract
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.].
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13
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Mizrahi DJ, Averill LW, Blumer SL, Meyers AB. Chronic lesser tuberosity avulsion in an adolescent with an associated biceps pulley injury. Pediatr Radiol 2018; 48:749-753. [PMID: 29103066 DOI: 10.1007/s00247-017-4016-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/26/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
We report a case of a 15-year-old boy with chronic intermittent left shoulder pain due to an undiagnosed lesser tuberosity avulsion fracture, an associated biceps pulley injury and intra-articular dislocation of the long head of the biceps tendon. Lesser tuberosity avulsion fractures are rare injuries that are difficult to detect on clinical exam and radiographically, which may lead to delayed diagnosis and chronic shoulder instability. Few reports describe dislocations or subluxations of the biceps tendon in association with lesser tuberosity avulsions in children. We utilize this case to emphasize the importance of MR not only in detecting lesser tuberosity avulsions, but also in evaluating biceps pulley injuries, which are a rarely reported, but clinically important, association.
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Affiliation(s)
- Daniel J Mizrahi
- Department of Medical Imaging, Nemours Children's Health System, A. I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Lauren W Averill
- Department of Medical Imaging, Nemours Children's Health System, A. I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Steven L Blumer
- Department of Medical Imaging, Nemours Children's Health System, A. I. duPont Hospital for Children, Wilmington, DE, USA.,Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Arthur B Meyers
- Department of Medical Imaging, Nemours Children's Health System, Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA.
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Azzam MG, Dugas JR, Andrews JR, Goldstein SR, Emblom BA, Cain EL. Rotator Cuff Repair in Adolescent Athletes. Am J Sports Med 2018; 46:1084-1090. [PMID: 29438628 DOI: 10.1177/0363546517752919] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tears are rare injuries in adolescents but cause significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with few data to guide treatment. HYPOTHESIS Adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair but would have some difficulty with returning to overhead sports. STUDY DESIGN Case series; Level of evidence 4. METHODS A retrospective search of the practice's billing records identified all patients participating in at least 1 sport who underwent rotator cuff repair between 2006 and 2014 with an age <18 years at the time of surgery and a minimum follow-up of 2 years. Clinical records were evaluated for demographic information, and telephone follow-up was obtained regarding return to play, performance, other surgery and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index. RESULTS Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range, 13.2-17.9 years) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event, and 27 of these patients (93%) had no symptoms before the trauma. The most common single tendon injury was to the supraspinatus (21 patients, 66%), of which 2 were complete tendon tears, 1 was a bony avulsion of the tendon, and 18 were high-grade partial tears. Fourteen patients (56%) underwent single-row repair of their rotator cuff tear, and 11 (44%) underwent double-row repair. All subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically. Twenty-seven patients (84%) completed the outcome questionnaires at a mean 6.2 years after surgery (range, 2-10 years). The mean ASES score was 93 (range, 65-100; SD = 9); mean Western Ontario Rotator Cuff Index, 89% (range, 60%-100%; SD = 13%); and mean numeric pain rating, 0.3 (range, 0-3; SD = 0.8). Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) were forced to change positions. There were no surgical complications, but 2 patients did undergo a subsequent operation. CONCLUSION Surgical repair of high-grade partial-thickness and complete rotator cuff tears yielded successful outcomes among adolescents, with excellent functional outcomes at midterm follow-up. However, overhead athletes may have difficulty playing the same position after surgery.
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Affiliation(s)
- Michael G Azzam
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - James R Andrews
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA.,Andrews Research and Education Foundation, Gulf Breeze, Florida, USA
| | - Samuel R Goldstein
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
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15
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Ono Y, Sakai T, Carroll MJ, Lo IK. Tears of the Subscapularis Tendon. JBJS Rev 2017; 5:01874474-201703000-00001. [DOI: 10.2106/jbjs.rvw.16.00054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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16
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Aagaard KE, Lunsjö K. Occult fracture of the lesser tuberosity in a 9-year-old female swimmer. J Surg Case Rep 2017; 2017:rjw238. [PMID: 28122897 PMCID: PMC5266086 DOI: 10.1093/jscr/rjw238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The adolescent avulsion of the lesser tuberosity of the humerus has historically been considered as very rare. The youngest patient reported in the literature is 11 years old. We report a case of a 9-year-old girl who suffered a subscapularis tendon tear with an occult avulsion of the lesser tuberosity. Late repair restored function. Despite that late repair in this present case resulted in excellent outcome, we strongly recommend the additional axillary lateral view of the plain radiographs, as well as proper physical examination to facilitate early diagnosis.
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Affiliation(s)
- K E Aagaard
- Department of Orthopedics, Skånevård Sund, Region Skåne, Sweden .,Department of Clinical Sciences Lund - Orthopedics, Lund University, Lund, Sweden
| | - K Lunsjö
- Department of Orthopedics, Skånevård Sund, Region Skåne, Sweden
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Vavken P, Bae DS, Waters PM, Flutie B, Kramer DE. Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review. Arthroscopy 2016; 32:919-28. [PMID: 26786826 DOI: 10.1016/j.arthro.2015.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 08/10/2015] [Accepted: 10/27/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Patrick Vavken
- alphaclinic Zurich, Zurich, Switzerland; Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A..
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Peter M Waters
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Brett Flutie
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Dennis E Kramer
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
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Koper MC, Jakma TSC. Case report of a proximal humeral fracture with an avulsion fracture of the lesser tuberosity in an adolescent girl. J Shoulder Elbow Surg 2015; 24:e260-3. [PMID: 26187137 DOI: 10.1016/j.jse.2015.05.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 02/01/2023]
Affiliation(s)
- Maarten C Koper
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
| | - Tijs S C Jakma
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Gornitzky AL, Potty AGR, Carey JL, Ganley TJ. Repair of Acute-on-Chronic Subscapularis Insufficiency in an Adolescent Athlete. Orthopedics 2015; 38:e844-8. [PMID: 26375545 DOI: 10.3928/01477447-20150902-90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/03/2015] [Indexed: 02/03/2023]
Abstract
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.
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LaMont LE, Green DW, Altchek DW, Warren RF, Wickiewicz TL. Subscapularis tears and lesser tuberosity avulsion fractures in the pediatric patient. Sports Health 2015; 7:110-4. [PMID: 25984255 PMCID: PMC4332639 DOI: 10.1177/1941738114533657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
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.
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Nardo L, Ma BC, Steinbach LS. Lesser tuberosity avulsions in adolescents. HSS J 2014; 10:201-7. [PMID: 25264435 PMCID: PMC4171444 DOI: 10.1007/s11420-014-9400-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 04/28/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Lorenzo Nardo
- />Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus, San Francisco, CA 94143-0628 USA
| | - Benjamin C. Ma
- />Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143 USA
| | - Lynne S. Steinbach
- />Radiology and Orthopaedic Surgery, University of California, San Francisco, 505 Parnassus, Suite M392, San Francisco, CA 94143-0628 USA
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Saltzman BM, Chalmers PN, Mascarenhas R, Cole BJ, Romeo AA. Upper extremity physeal injury in young baseball pitchers. PHYSICIAN SPORTSMED 2014; 42:100-11. [PMID: 25295772 DOI: 10.3810/psm.2014.09.2081] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Bryan M Saltzman
- Resident, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL.
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Paxinos O, Karavasili A, Manolarakis M, Paxinos T, Papavasiliou A. Neglected lesser tuberosity avulsion in an adolescent elite gymnast. Shoulder Elbow 2014; 6:178-81. [PMID: 27582934 PMCID: PMC4935056 DOI: 10.1177/1758573214531413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Accepted: 03/03/2014] [Indexed: 11/17/2022]
Abstract
We report the case of a 16-year-old elite gymnast who presented with recurring pain in the left shoulder after training. The athlete recalled an injury to the shoulder 2 years ago. Clinically a localized tenderness to the anterior shoulder and loss of strength and range of motion was noted. Imaging investigation suggested a neglected lesser tuberosity avulsion. The athlete was treated with open excision of the deformed tuberosity and direct repair of the subscapularis to the humeral head. Following a careful postoperative rehabilitation protocol the athlete was able to return to unrestricted gymnastics after 6 months. After surgery the athlete followed a intense rehabilitation program that allowed him to return to sports at 6 months. At 5-years follow-up, the athlete was asymptomatic and competing at an international level. Avulsion fractures of the lesser tuberosity are extremely rare injuries with significant shoulder disability if left untreated. Anatomic repair can yield excellent results, even in neglected cases.
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Affiliation(s)
- Odysseas Paxinos
- Orthopedic Department, 251 Hellenic Air Force
Hospital, Athens, Greece,Hellenic Gymnastics Federation Medical Team,
Athens, Greece,Odysseas Paxinos, 251 Hellenic Air Force Hospital,
Athens, Greece 3 P. Kanellopoulou Street, Athens, 11525, Greece. E-mail:
Tel: +30-210-7464903; Fax: +30-210-7781104
| | | | | | - Thrasivoulos Paxinos
- Hellenic Army Academy, Faculty of Physical and
Cultural Education, Vari, Attiki, Greece
| | - Athanasios Papavasiliou
- Department of Physical Education and Sport
Science, Aristotle University of Thessaloniki, Greece
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Neogi DS, Bejjanki N, Ahrens PM. The consequences of delayed presentation of lesser tuberosity avulsion fractures in adolescents after repetitive injury. J Shoulder Elbow Surg 2013; 22:e1-5. [PMID: 23415817 DOI: 10.1016/j.jse.2012.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 11/28/2012] [Accepted: 12/02/2012] [Indexed: 02/01/2023]
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Abstract
BACKGROUND Lesser tuberosity avulsion fractures in adolescents occur infrequently. Perhaps because of their rarity, many cases are missed on initial physical exam, imaging studies, and even diagnostic arthroscopy, leading to delay in diagnosis. Without operative intervention, these injuries may cause significant morbidity, whereas operative fixation has predictably good results. We review 6 cases and compare them to a review of the previous published cases. METHODS All cases of isolated lesser tuberosity avulsions in skeletally immature patients treated by the senior author (MTB) at a pediatric referral center were included. The mean follow-up was over 4 years (range, 2 to 7 y). Operative treatment consisted of a diagnostic arthroscopy to evaluate for concomitant pathology, followed by an open reattachment of the tuberosity through an incision in line with the anterior axillary fold. A lasso technique using suture anchors and sutures to loop over and hold down the fragment is our preferred method as it decreases the risk of fracture seen with fixation using screws or sutures through drill holes in the tuberosity. RESULTS Even with a frequent delay in diagnosis, all patients had a predictably good outcome with an average American Shoulder and Elbow Surgeons score of 97 (range, 88 to 100) and a Western Ontario Shoulder Instability Index of 94 (range, 84 to 100). The patient history, symptoms, and physical exam findings were consistent across the published cases. The prototypical patient is a male, age 13, who sustains an abduction and extension injury during sports. Anterior shoulder pain, positive belly press, and lift-off signs are frequent findings. CONCLUSIONS A high index of suspicion is needed to recognize this uncommon injury. History, physical exam for subscapularis function, and magnetic resonance imaging should be diagnostic. Operative treatment with a suture anchor lasso technique leads to predictably good results. LEVEL OF EVIDENCE Level IV therapeutic study.
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e31826b35c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients. J Shoulder Elbow Surg 2012; 21:e6-e11. [PMID: 22572400 DOI: 10.1016/j.jse.2012.01.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 01/12/2012] [Accepted: 01/15/2012] [Indexed: 02/01/2023]
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