Abstract
Background: Fractures of the lesser tuberosity are rare injuries, and little is known of their epidemiology. Operative treatment is generally recommended for displaced fractures; however, the outcome of this method of treatment has not previously been studied. The aims of our study were to determine the approximate incidence of lesser tuberosity fractures, as well as the functional outcome following operative treatment in a consecutive series of patients.
Methods: Over an eight-year period, we studied the demographic details of a consecutive series of twenty-two adult patients who had a fracture of the lesser tuberosity. We used age and sex-specific local census data to estimate the annual incidence of this injury in our local population. Seventeen of the original cohort of twenty-two patients, who were medically fit and had a displaced (two-part) fracture, were treated with open reduction and internal fixation of the fracture. We assessed the outcome using the Short Form-36 (SF-36) general health measure, the Constant score, and the Disabilities of the Arm, Shoulder and Hand (DASH) score.
Results: The estimated annual incidence of these fractures was low at 0.46 per 100,000 population per year during the study period. There were fifteen men and seven women, with a median age of forty-three years. There was an even distribution of fractures across the age cohorts, and most fractures were sustained from a high-energy transfer mechanism. The median Constant score was 95 points at two years, and the median DASH score was 12 points at two years after the injury. Most patients regained nearly normal range of motion in the affected shoulder by three months. One patient had development of posttraumatic shoulder stiffness, which responded to arthroscopic release. All patients who were in regular employment prior to the injury returned to their jobs within six months. There were no significant differences between each component of the SF-36 at two years compared with age and sex-matched controls.
Conclusions: A lesser tuberosity fracture, without an associated humeral head or greater tuberosity fracture, is a rare injury. Open reduction and internal fixation provides excellent restoration of function and range of shoulder movement, with a low risk of complications.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Lesser tuberosity fractures usually occur in association with Neer three or four-part fractures and fracture-dislocations of the proximal end of the humerus1. Undisplaced (one-part) and displaced (two-part) lesser tuberosity fractures1 are rare, and most have been described in case reports involving a small number of patients2-11. A detailed appraisal of the epidemiology of such fractures has therefore not previously been possible. The fracture is most commonly reported as either an isolated injury3,4,8-10,12-18, due to osseous avulsion of the subscapularis insertion13,19, or in association with a posterior shoulder dislocation20-22. The large number of chronic injuries that are reported suggests that they are often missed at the time of the original injury2.
It is generally agreed that acute displaced lesser tuberosity fractures should be treated with operative reduction and internal fixation2,23. This is because failure to achieve anatomic reduction may cause functional impairment from either subscapularis weakness or secondary impingement of the malunited fracture5. However, the functional outcome and complications from operative treatment have not been quantified previously.
It has been our policy to treat all acute displaced fractures of the lesser tuberosity, which are visible on conventional radiographs, in medically fit patients with open reduction and internal fixation. All of these patients have been monitored with use of a defined research protocol during the first two years after the injury. The aims of our study were to estimate the incidence of these fractures and to determine the functional outcomes following operative treatment in a consecutive series of patients who received a standard protocol of treatment during this time period.
Patient Demographics
Over the eight-year period from January 1998 to December 2005, we studied a consecutive series of locally resident patients with an acute fracture of the lesser tuberosity without associated fracture of the greater tuberosity or anatomic or surgical neck of the humerus (three-part and four-part fractures)1. These patients were referred to our acute shoulder service after their initial assessment in our affiliated emergency department. This provides the only acute musculoskeletal trauma service for patients over thirteen years old in the local population. Our catchment area is typical of the stable urban population of most developed cities. To estimate the incidence of these fractures, we considered the twenty-two patients with an undisplaced (one-part) or displaced (two-part) fracture of the lesser tuberosity1 who presented to our unit within the eight-year period, excluding those patients who had a lesser tuberosity fracture in association with a three-part or four-part fracture.
For the functional outcome study, we considered only the acute, displaced (two-part) fractures1, which had been treated operatively. We considered acute injuries to be those seen within six weeks after the injury, and displacement of >1 cm on any of the preoperative radiographs was considered to be clinically important. No fracture was displaced <1 cm, but two patients were excluded because they had a completely undisplaced (one-part) fracture and were treated nonoperatively. An additional three patients were excluded. Two of them were excluded because they presented more than six weeks after injury, and the third, an eighty-six-year-old patient with a displaced fracture, was treated nonoperatively because he was medically unfit for anesthesia. The remaining seventeen patients included eleven men and six women with a mean age of 42.6 years (range, twenty-three to sixty-eight years) who underwent operative treatment for an acute two-part fracture at an average of thirty-eight hours (range, five to eighty-two hours) after the injury.
Initial Treatment Protocol
Standardized preoperative trauma radiographs (anteroposterior and Velpeau views24) were made prior to further interventions. Computerized tomography was adopted as a standard preoperative investigation after 2004, and was performed in six patients. Intraoperatively, one of us (C.M.R.) by protocol documented the anatomy of the injury, recording the location and extent of the key fracture lines through the humeral head and tuberosities and the extent of comminution of these fragments.
Operative Protocol
All operative procedures were performed by the senior author (C.M.R.). Under general anesthesia, the patient was positioned supine in the so-called beach-chair position, with a shoulder operating table "cut-away" to facilitate access for the image intensifier from the opposite side of the table. Routine broad-spectrum antibiotic and antithrombotic prophylaxis was used.
Two-Part Fractures without Glenohumeral Dislocation (Thirteen Patients)
A standard deltopectoral approach was used when there was a lesser tuberosity fracture and the humeral head was not dislocated. The lesser tuberosity fracture fragment and the native bed from which it had been avulsed were identified. We attempted to reduce the fracture anatomically, either using large reduction forceps or by transfixing it with Kirschner wires to achieve provisional stabilization.
In nine of the thirteen two-part fractures, there was a single fracture fragment of >2 cm in diameter. The extent of these fractures was often underestimated on conventional radiographs but was clearer on spiral computed tomography three-dimensional reconstructions (Figs. 1-A through 1-D). In six of the nine patients, the fracture included the bicipital groove, and the long head of the biceps tendon was initially dislocated medially with the fracture. Following reduction and fixation of the fragment, the biceps tendon was stable in all of these patients. In four of the nine patients, the fractured lesser tuberosity had a fragment of the adjacent articular surface attached to it. Two of these four patients had fracture fragments that involved both the bicipital groove and the articular surface. Only one fracture involved neither the bicipital groove nor the articular surface. In the patients who had articular involvement, the articular reduction was carefully confirmed under direct vision prior to definitive internal fixation. Definitive internal fixation was performed with use of two (in five patients), three (in two patients), or four (in two patients) partially threaded 3.5-mm cancellous screws, which were inserted through the lesser tuberosity in an anteroposterior direction with the arm held in 45° of external rotation. Judging accurate screw length (typically between 40 and 50 mm) was an important technical aspect of the procedure, in order to gain bicortical purchase. This was checked by making intraoperative fluoroscopic images of the shoulder to ensure that the screws were long enough to obtain adequate fixation in the relatively thin far cortex located in the posteroinferior aspect of the greater tuberosity but had not inadvertently penetrated the posterior part of the glenohumeral joint.
Of the remaining four patients with two-part fractures, two had a lesser tuberosity fragment that was =2 cm and two had comminution (more than two fragments) of a larger tuberosity fragment. In these patients, screw fixation either would have risked secondary comminution, because of the small size of the fragment, or would not have provided sufficient stability because of the presence of multiple fracture fragments. For these patients, the reduction was maintained by transosseous sutures, placed both through the tuberosity and through the bone-tendon junction, which were secured to the adjacent metaphyseal bone, with use of number-2 Ethibond (Ethicon, Somerville, New Jersey) or Orthocord sutures (DePuy Mitek, Norwood, Massachusetts). This is a modification of a technique that was previously described for fixation of fractures of the greater tuberosity25. The arm was positioned in 45° of external rotation to avoid overtightening the subscapularis tendon. None of these four fractures involved the bicipital groove or the articular surface of the humeral head.
Two-Part Posterior Fracture-Dislocations (Four Patients)
For these four fracture-dislocations, an attempt was initially made to obtain a closed reduction of the dislocation with the patient placed under anesthesia. When this was not possible an open reduction was performed through an extended deltoid-splitting approach21,26. After reduction of the shoulder had been obtained, its stability was assessed throughout a full range of internal and external rotation, both with the arm at the side and in 90° of abduction.
In three of the four patients, the shoulder was acutely unstable because of reengagement of a reverse Hill-Sachs lesion on the posterior aspect of the glenoid beyond neutral rotation. In two of these three patients, the reverse Hill-Sachs lesion was elevated and filled with bone graft, according to the technique used by Griggs et al.27. The other patient had a larger defect, and the articular surface was fragmented. To fill the lesion, we used a sculpted femoral head allograft secured with two countersunk, partially threaded cancellous screws, according to the technique described by Gerber and Lambert28. In these three patients, the lesser tuberosity was then reattached anatomically, with use of the same techniques as for other two-part fractures, with either two partially threaded cancellous screws (two patients) or transosseous sutures (one patient).
In one of the four patients, the dislocation was reduced by closed means and was stable. However, there was residual displacement of the lesser tuberosity fracture fragment, and it was repaired anatomically with partially threaded cancellous screws.
Postoperative Protocol
All patients were rested in a shoulder immobilizer sling in neutral abduction, flexion, and rotation, with the elbow flexed 90°, for four weeks after surgery. Pendulum and elbow range-of-motion exercises were commenced immediately after surgery, and active-assisted range-of-motion exercises were begun at two weeks after the operation; however, external rotation or abduction of the shoulder of >90° was avoided. Isometric rotator cuff exercises and graduated, active range-of-motion exercises under physiotherapy supervision were commenced after sling removal and were continued for at least four months after the operation.
Outcome Assessment
The two chief outcome measures in this study were the prevalence of clinically or radiographically apparent fracture-related complications and the functional outcome. These outcomes were assessed by protocol within the first two years after the injury. Our experience in the treatment of other complex shoulder fractures has previously shown that the functional recovery and the risk of fracture-related complications reach a plateau at this time29,30.
We aimed to evaluate all patients at a dedicated Shoulder Injury Clinic at one and six weeks, three and six months, and one and two years after the injury. At each visit, a standard questionnaire booklet was given to the patient by a dedicated research worker and was completed prior to the consultation. The booklet incorporated the Short Form-36 (SF-36) general health questionnaire31,32, the upper limb-specific Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire33, and the questionnaire components of the shoulder-specific Constant score34. An independent research worker then recorded whether the patient had returned to work or the normal activities of daily living and assessed the range of motion and muscle power of the patients. Specific tests for rotator cuff weakness35,36, impingement37-40, and biceps tendon dysfunction41,42 were also performed at each visit from three months after surgery by one of us (C.M.R.).
Anteroposterior and Velpeau radiographs were made at each visit. The degree of residual tuberosity displacement, in millimeters, was measured, adjusting for magnification artifact. The observer reliability of these measurements was not assessed. The nearly anatomic fracture reduction in all patients made assessment of fracture union difficult, as it was hard to assess internal callus formation. We therefore considered fractures to be united at the time when the patient reported no shoulder pain or only mild activity-related discomfort and there was no radiographic evidence of loss of the initial fracture reduction or evidence of implant loosening or breakage on the radiographs.
We used age and sex-specific local census data to determine the overall annual incidence of one-part and two-part lesser tuberosity fractures of the shoulder in our local population. The general health scores (SF-36) were individually compared with age and sex-matched control values for the normal population with use of the Mann-Whitney U test.
Source of Funding
There was no external funding source for this study.
Epidemiology and Fracture Morphology (Twenty-two Patients)
The estimated incidence of lesser tuberosity fracture of the shoulder in adults was 0.46 per 100,000 population per year over the study period. The median age of the twenty-two patients was forty-three years (range, twenty-three to eighty-six years). There was a fairly even age distribution (Fig. 2), but only three patients were sixty years of age or older. There were fifteen men and seven women, with respective fracture incidences of 0.66 and 0.28 per 100,000 population per year over the study period.
Six fractures were sustained in a fall from a bicycle or motorcycle, and four were sustained in a fall from a horse. Five patients were injured in a fall down stairs and two, in a fall at home from or below a standing height. Three fractures were caused by contact sports injuries, one was sustained during an arm-wrestling bout, and one occurred during an assault.
Four patients had an associated posterior dislocation of the shoulder. No patient had an associated axillary nerve or brachial plexus injury. All but two fractures were displaced >1 cm; the displacement was between 1 and 2 cm in eleven fractures and was >2 cm in nine fractures.
Outcome After Operative Treatment (Seventeen Patients)
Clinical and Radiographic Outcome
All patients were treated with open reduction and internal fixation. The average duration of the operation was seventy-one minutes (range, twenty-five to 145 minutes), with an estimated average blood loss of 217 mL (range, 150 to 350 mL). No patient had a wound infection or nerve injury develop following surgery. All patients had residual fracture fragment displacement of <5 mm on plain radiographs after surgical reconstruction, and there was no fracture fragment redisplacement during follow-up. All fractures had united by six months. One twenty-three-year-old man, who originally had a posterior two-part fracture-dislocation, had shoulder stiffness develop. It was refractory to stretching exercises and required secondary treatment with manipulation under anesthesia and arthroscopic release at six months. No further complications were noted during follow-up evaluations. No shoulder had signs of arthritis on the two-year follow-up radiographs.
Functional Outcome
All patients attended their first two review appointments, but some patients missed one or more subsequent appointments (Table I). The two patients who did not attend the two-year follow-up had both been reviewed at one year after surgery. This was deemed to be an acceptable interval for assessment of the final outcome after the fracture in these two patients, since there was little improvement in functional outcome between the one and two-year assessments in the other fifteen patients.
The median Constant and DASH scores improved significantly throughout the first year of follow-up (p < 0.05 for each time interval; Figs. 3 and 4), after which there was no further measurable improvement. The median Constant score was 95 points (interquartile range, 93 to 96 points) at one year and 95 points (interquartile range, 94 to 98 points) at two years. The median DASH score was 12 points (interquartile range, 6 to 18 points) at one year and 12 points (interquartile range, 6 to 17 points) at two years. Both scores improved rapidly within the first six months postoperatively and then reached a plateau after one year. The patient who had posttraumatic shoulder stiffness develop had poorer functional scores compared with the other patients and is seen as an outlier in both Figures 3 and 4. However, at two years, the patient had functional scores similar to those of the rest of the study cohort, following the arthroscopic release. The average forward flexion at the two-year review was 173° (range, 155° to 180°), the average abduction was 161° (range, 135° to 180°), the average internal rotation at 90° of abduction was 97° (range, 80° to 110°), and the average external rotation at 90° of abduction was 76° (range, 35° to 95°). The change in the range of motion over the two years of follow-up is presented in Table I.
At two years, none of the patients had weak subscapularis function on the Gerber lift-off test. None had signs of internal impingement or coracoid impingement on the Neer impingement test, Hawkins-Kennedy test, Gerber test for internal impingement, or Copeland impingement test. No patient had biceps tendon dysfunction on the Speed test and the O'Brien test. At two years, no difference was detected in any of the eight components of the SF-36 compared with those of the age and sex-matched controls.
Prior to the injury, nine patients were working in a sedentary job, three were working in a job involving manual labor, and five patients were not working. By six months (median, two months; range, two to six months), all of the twelve previously employed patients had returned to their jobs. At the final review, all of these patients were still working except for one sixty-three-year-old patient whose retirement had been preplanned at the time of the injury. Patients who were not working at the time of the injury did not report any limitations to their normal activities of living or recreational activities at the time of the final review.
Fractures of the proximal end of the humerus are common injuries that are usually sustained by elderly women in a low-energy fall at home. Our study demonstrates that isolated fractures of the lesser tuberosity are atypical, and the patients who sustain them share none of these demographic features. These fractures are uncommon, with an estimated incidence of 0.46 per 100,000 population per year, compared with the remainder of proximal humeral fractures, which in five previous epidemiological studies have been shown to have an annual incidence of between sixty-three and 110 per 100,000 population per year43-47. There was considerable variation in the age and sex of the patients who sustained these injuries, but most of them were middle-aged men. These fractures were infrequently caused by low-energy falls, and most were caused by higher-energy events, such as a fall down stairs or during sports, including cycling and horse riding.
It has been hypothesized that the injury represents avulsion of the lesser tuberosity from forced contraction of the subscapularis muscle when the arm is forced into an externally rotated position. For most of our patients, it was difficult to elicit a definite history of the exact mechanism of injury on direct questioning, and most of them were unable to describe the exact details of the deforming force because of the rapid sequence of energy transfer during the injury. However, an avulsion injury appears implausible in the four two-part posterior fracture-dislocations. In these injuries, it is more likely that the fracture occurred either from propagation of the acute osteochondral fracture of the anterior aspect of the humeral head (a reverse Hill-Sachs defect) as it engaged on the posterior part of the glenoid, or as a shear fracture of the tuberosity against the anterior aspect of the glenoid rim.
We evaluated a consecutive series of patients from a well-defined catchment area during a fixed time period. However, it is likely that this is an underestimate of the true fracture incidence because some patients may not have sought medical advice after their injury. Some undisplaced fractures may also have been missed, despite radiographs having been made when the patients initially sought treatment. The large number of patients who presented late after lesser tuberosity fractures in previous reports supports this contention, although in our study only two patients presented later than six weeks after the injury. Furthermore, our study was confined to patients over thirteen years old, as our unit does not treat pediatric injuries. The numerous reports of lesser tuberosity avulsion injury in children and adolescents10,48,49 suggests that, during the period of our study, there would have been a number of these injuries in children, which we did not evaluate.
Neer recommended that displacement of a proximal humeral fracture fragment of >1 cm in any plane, or angulation of >45°, should be regarded as clinically important1. However, it has recently been suggested that 5 mm of displacement is a more acceptable threshold for operative reconstruction after a greater tuberosity fracture, given the risk of later rotator cuff dysfunction50,51. In our series, all lesser tuberosity fractures were either completely undisplaced or displaced by >1 cm. It is therefore still unclear as to the amount of fracture displacement that can be tolerated before there are deleterious effects from nonoperative treatment in this injury pattern. However, because of the unpredictable results with delayed reconstruction2,6,9 and the potential for further progressive displacement of the lesser tuberosity fragment due to the unopposed pull of the subscapularis tendon36, we suggest that all medically fit patients who have a radiographically visible lesser tuberosity fracture displacement of any degree should be treated surgically.
This study is the first, as far as we know, to evaluate by protocol the outcome after this method of treatment. Excellent functional results were obtained, with most patients regaining nearly normal shoulder function, with no clinical evidence of subscapularis weakness or secondary impingement syndromes. Only one patient had a clinically important complication following operative treatment, the development of shoulder stiffness, which eventually responded to secondary operative release. The patients who had been actively employed prior to the injury returned to their previous work duties. The complications that have been reported following operative treatment in previous case reports, including chronic pain and impaired range of shoulder motion, were rarely encountered in this series2,9.
The size and extent of the lesser tuberosity fragment is often ill-defined on conventional radiography, particularly when the lesser tuberosity fragment is large. We found that involvement of the bicipital groove and the articular surface of the humeral head is relatively common and can be assessed preoperatively with use of spiral computed tomography scanning with three-dimensional reconstruction. We currently use this investigation routinely to help in the preoperative planning of the reconstruction. Depending on the fracture characteristics and the size of the fragment, we use either cancellous screws or transosseous sutures to obtain definitive internal fixation.
There is a lack of consensus about the role of operative treatment for fractures of the lesser tuberosity. Some authors have suggested that operative treatment should only be considered for displaced or malunited fragments with a compromised internal rotation mechanism14. Others have suggested that open reduction and internal fixation should be the treatment of choice, regardless of fragment size or displacement2,23, to prevent progressive displacement, nonunion7,10,48,49, malunion5,10,49, impingement5, or dislocation of the biceps tendon2,10. With regard to long-term outcomes, nonoperative treatment has been shown to have poorer results compared with surgical intervention in a series of ten patients2, although some case reports have described good outcomes following nonoperative treatment combined with physiotherapy14,23,52.
Arthroscopic repair of subscapularis tears is now well established53-55, and recently this technique has been adapted to reconstruct an avulsion fracture of the lesser tuberosity3,5. However, medial displacement of the tuberosity makes portal placement and manipulation of the fracture fragment hazardous, and arthroscopic assessment of the adequacy of the fracture reduction and stability may be difficult. Arthroscopic repair is potentially minimally invasive and can provide better cosmesis, but the long-term functional outcome following arthroscopic repair remains unknown.
This study evaluated the results of operative intervention in a single institution with one surgeon performing all of the procedures. As such, our results may not be generalizable to other centers where a specialist shoulder service is unavailable. Another weakness of our study is that it provides only case series (Level-IV) evidence of the efficacy of operative treatment. We are unable to demonstrate that open surgery is superior to nonoperative or minimally invasive arthroscopic techniques in the treatment of these injuries. However, given the nearly normal shoulder function that we achieved after open surgery, it would require a large clinical trial to adequately power a study to evaluate whether the use of these alternative techniques is associated with an improved functional outcome.
Adequate preoperative assessment of these injuries is important, and it is aided by the use of computerized tomography with three-dimensional reconstructions. We believe that this method of imaging greatly enhances the assessment of both articular involvement and comminution of the fracture and assists in preoperative planning. We believe that our results support the routine use of primary operative reduction and internal fixation for all displaced fractures of the lesser tuberosity in medically fit patients. The functional results following operative treatment are excellent when the surgery is performed soon after the injury, and there is a low risk of complications. 
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