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Scientific Articles   |    
Surgical Treatment for Avulsion Injuries of the Humeral Lesser Tuberosity Apophysis in Adolescents
Peter S. Vezeridis, MD1; Donald S. Bae, MD1; Mininder S. Kocher, MD, MPH1; Dennis E. Kramer, MD1; Yi-Meng Yen, MD, PhD1; Peter M. Waters, MD1
1 Department of Orthopaedic Surgery, Children's Hospital Boston, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail address for D.S. Bae: donald.bae@childrens.harvard.edu
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Orthopaedic Surgery, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Oct 19;93(20):1882-1888. doi: 10.2106/JBJS.K.00450
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Abstract

Background: 

There is little published information regarding avulsion fractures of the humeral lesser tuberosity in adolescents, and no consensus exists on optimal treatment. The purpose of this study was to investigate the demographics, injury mechanisms, and results of operative treatment of lesser tuberosity avulsion fractures in skeletally immature patients.

Methods: 

Eight patients were treated with open reduction and internal fixation (ORIF) for lesser tuberosity avulsion fractures from 2000 through 2010. Data were collected regarding patient demographics, mechanisms of injury, operative findings, and early clinical results. Preoperative radiographic studies were evaluated, and patient-derived functional outcome scores were obtained. The mean age of the patients was 13.3 years. All patients were male and sustained sports-related injuries, typically from forceful shoulder abduction and external rotation with eccentric subscapularis load. The dominant extremity was injured in six patients. Six patients had initial radiographs that were interpreted as normal. Time from injury to surgery ranged from two weeks to five months. Surgical treatment consisted of ORIF with use of suture anchors (in six patients) or transosseous sutures (in two patients).

Results: 

All patients achieved pain relief, and there were no neurovascular complications. All patients had full return of internal rotation strength, negative lift-off tests, and negative belly-press tests postoperatively. Average time to return to sports was 4.4 months postoperatively. Return of full external rotation occurred in five patients at an average of 4.9 months postoperatively. There were no refractures. Patient-derived functional outcomes scores at an average of 24.6 months after surgery demonstrated excellent shoulder function and high patient satisfaction.

Conclusions: 

Humeral lesser tuberosity avulsion fractures do occur in adolescents, typically from high-energy sports injuries. Careful physical examination and magnetic resonance imaging (MRI) evaluation aid in achieving a timely diagnosis. Surgical reduction and suture fixation is safe and effective in restoring subscapularis function and return to sports, even in cases of delayed treatment. Full recovery of shoulder external rotation may not be seen until six months postoperatively.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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