Isolated Avulsion Fracture of the Lesser Tuberosity of The

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Isolated Avulsion Fracture of the Lesser Tuberosity of the Humerus in an Adult: Case Report and Literature Review Aman Dhawan, MD, Kevin Kirk, DO, Thomas Dowd, MD, and William Doukas, MD

solated avulsion fractures of also describe our operative technique, comminuted 3-cm lesser tuberosity the lesser tuberosity of the including use of heavy, nonabsorb- fracture fragment retracted approxi- proximal humerus are rare. able suture. mately 2 cm from the donor site We report the case of a right- (Figures 1B–1D). No biceps tendon Ihand–dominant woman in her early ase eport subluxation or injury and no intra- C R 30s who sustained such an injury, A right-hand–dominant woman in articular pathology were noted. with an intact subscapularis tendon her early 30s presented with right The lesser tuberosity fracture was attached to the lesser tuberosity frag- shoulder pain 1 day after a fall down surgically repaired less than 2 weeks ment. Treatment included surgery to a flight of stairs. During the acci- after injury. Through a deltopectoral restore tension to the subscapularis dent, as her feet slipped out from approach, the rotator interval and muscle and maintain the force couple underneath her and her torso fell the 3×2-cm fracture fragment were about the shoulder joint. One year after injury, the patient reported no pain, excellent range of motion, and “[To be diagnosed] this injury...requires... return to activities. This case demonstrates the diag- careful review of orthogonal radiographs nostic challenge of this injury, which requires a high index of suspicion and and advanced imaging.” careful review of orthogonal radiographs and advanced imaging. We backward, she used her right hand identified. The subscapularis tendon to try to break her fall, with the was intact and attached to the fracture MAJ Dhawan, MC, USA, is Assistant shoulder in an extended and exter- fragment, which had retracted medi- Professor of Surgery, Uniformed Services nally rotated position. She then had ally. No injury to the biceps tendon University of the Health Sciences, marked pain with shoulder motion was appreciated. The donor site was Bethesda, Maryland. and sought medical attention. visualized with external rotation of MAJ Kirk, MC, USA, is Chief, Orthopaedic On examination, there was no vis- the extremity. Foot and Ankle Surgery, Brooke Army Medical Center, San Antonio, Texas. ible asymmetry to her shoulder con- The donor site was prepared for CPT Dowd, MC, USA, is Orthopaedic tours. Ecchymosis and swelling were fixation using curettes and irriga- Surgery Resident, Brooke Army Medical present about the right axilla. The tion. The fracture fragment was care- Center, San Antonio, Texas. patient had pain with motion, par- fully dissected from surrounding COL Doukas, MC, USA, is Chairman, ticularly internal and external rota- fibrous tissue using a freer. As the Integrated Department of Orthopaedics and Rehabilitation, National Naval Medical tion. Strength testing demonstrated surgery was performed in the acute Center/Walter Reed Army Medical Center, decreased strength (4/5) in internal setting, the subscapularis maintained Bethesda, Maryland/Washington, DC. rotation compared with the contralat- the excursion necessary for anatomi- eral side. The patient was unable to cal reduction. Fiberwire suture was Address correspondence to: Aman perform liftoff and belly-press maneu- placed through the fracture fragment Dhawan, MD, Department of Orthopaedic 1,2 and Rehabilitative Services, Carl R. vers with the right upper extremity. to allow for manipulation (Figure 2). Darnall Army Medical Center, Fort Hood, Anteroposterior, scapular Y, and Heavy, nonabsorbable suture (No. TX 76544-4752 (tel, 254-288-8050; fax, axillary (Figure 1A) radiographs 5 Ticron) on a large cutting needle 254-286-7285; e-mail, amandhawan@ showed a small avulsion fracture of was used to secure the reduction. hotmail.com). the lesser tuberosity of the right prox- The suture was passed from medial Am J Orthop. 2008;37(12):627-630. imal humerus. Magnetic resonance to lateral through the fracture frag- Copyright Quadrant HealthCom Inc. 2008. imaging (MRI) showed an intact sub- ment, through the donor site, and out All rights reserved. scapularis tendon attached to a non- through the lateral cortex of the prox-

December 2008 627 Isolated Avulsion Fracture of the Lesser Tuberosity of the Humerus

One year after surgery, range of motion was near symmetric with forward elevation of 180°, abduction of 180°, external rotation with the elbow at the side to 60°, and internal rotation to T6. There was no appreciable strength deficit on manual muscle testing, and the patient reported no deficits in activities of daily living. In objective evaluation using the Neer criteria, she received a score of 85 A C of a possible 100 points (satisfactory score, >80 points; excellent score, >89 points). The pain score reflected the patient’s only deficit; she reported slight occasional pain with no com- promise in activity level.3

Discussion Isolated avulsion fractures of the lesser tuberosity of the proximal humerus are rare, and few cases have been reported in the English-language literature.4-17 B D The injury is often reported in com- bination with posterior humeral head Figure 1. Fracture fragment as seen on (A) axillary radiograph and (B) T1-weighted axillary magnetic resonance imaging (MRI). (C) T2-weighted axillary MRI shows donor site dislocations and in association with a at lesser tuberosity. (D) T2-weighted coronal MRI shows intact subscapularis tendon comminuted fracture of the proximal attached to retracted lesser tuberosity fracture fragment. humerus.18,19 Most authors agree that the avulsion fracture occurs as the sub- imal humerus. The suture was then nal rotation, and full forward flexion and scapularis muscle contracts eccentri- passed again from lateral to medial abduction were permitted. At 6 months, cally to resist a sudden abduction and back through the proximal humerus, the patient had painless range of motion; external rotation force of the proximal through the fracture, and again out however, active forward flexion was humerus.4,8 Another proposed mecha- through the fracture fragment from limited to 120° because of stiffness. nism involves an axial load along the lateral to medial. The result was a Internal and external rotation was sym- long axis of the humerus with the mattress suture. The knot was hand- metric to the contralateral shoulder. glenohumeral joint extended and exter- tied and secured down to maintain the reduction of the lesser tuberosity to its anatomical position while the arm was held in neutral rotation (Figure 3). The rotator interval capsule was repaired using a side-to-side stitch. No redundancy was noted in the capsule at this point, and examination under anesthesia demonstrated glenohumeral translation within normal limits; therefore, capsular imbri- cation was not performed. After surgery, the patient was placed into a shoulder immobilizer for soft- tissue rest for 3 weeks, and pendulum- type shoulder exercises were begun. External rotation to neutral and active- assist forward elevation and abduction to 90° were allowed; however, active internal rotation was restricted. At 3 Figure 2. Intraoperative photograph of fracture fragment after dissection and placement weeks, active internal rotation, full exter- of grasping suture.

628 The American Journal of Orthopedics® A. Dhawan et al nally rotated.4 This injury mechanism, provides satisfactory results, con- Conclusions consistent with our patient’s, results in sistently better outcomes (including Lesser tuberosity fractures are a diag- anterosuperior migration of the humer- improvements in pain and function) nostic dilemma and should be suspect- al head and increased tension of the occur with operative fixation of a dis- ed in patients who present with anterior subscapularis muscle and the superior placed fracture.4,6-8 Operative repair shoulder pain, particularly after trauma. glenohumeral ligament.4,9 restores tension and insertion of the A complete set of orthogonal radio- subscapularis muscle tendon and graphs is mandatory, and advanced Diagnostic Considerations preserves the anteroposterior rotator imaging can be helpful in both diagno- Diagnosis of an isolated lesser cuff force couple to the shoulder. Of sis and treatment planning. tuberosity fracture can be challeng- the literature cases diagnosed acute- For displaced lesser tuberos- ing, and a high index of suspicion ly, approximately 60% were treated ity fractures, we recommend using

“For displaced lesser tuberosity fractures, we recommend using operative fixation to restore the normal mechanics about the shoulder...” is required. Evidence of missed operatively.4 Chronic symptomatic operative fixation to restore the nor- diagnoses is demonstrated by the lesser tuberosity fracture nonunions mal mechanics about the shoulder number of reported cases in which communicate pain anteriorly about and prevent chronic symptoms. Our the injury is found to be chron- the shoulder, and this pain is exacer- patient had satisfactory results after ic.4 The injury may be difficult bated by overhead activity.20 Ogawa open reduction and suture fixation of to see on plain radiographs.6,10,11 and Takahashi4 described hyperex- the fracture fragment. On an anteroposterior radiograph, a ternal rotation and pain induction lesser tuberosity fracture is visible by the anterior apprehension test Authors’ Disclosure only when the fracture fragment is as findings specific to this inju- Statement and large or significantly displaced.10 ry pattern. Conservative treatment Acknowledgments Internally rotating the proximal initially should be tried for The authors report no actual or poten- humerus provides the best view chronic avulsion of the lesser tuber- tial conflict of interest in relation to of this injury.10 Smaller fracture osity.4 Persistence of symptoms this article. fragments, with less displacement, warrants surgical repair; symptom The authors are employees of the are better imaged with an axil- improvement after surgery has been US government. The opinions and lary radiograph.9,10 MRI, computed well documented.4,6-8 assertions contained herein are their tomography, and sonography are helpful in further evaluating subscapularis tendon status, fracture fragment size, donor site location, fragment comminution and com- plexity, and concomitant pathology (eg, biceps tendon injury).4,6,10 In our patient’s case, MRI helped with our treatment algorithm and surgical planning—it showed a large, noncomminuted fracture fragment, without significant retraction, attached to an edematous but intact subscapularis tendon. No additional pathology was noted.

Treatment Lesser tuberosity fractures have been treated both operatively and nonoperatively.4-17 Although nonop- Figure 3. Lesser tuberosity fracture is reduced and secured with heavy, nonabsorbable erative treatment with physiotherapy suture using a mattress stitch.

December 2008 629 Isolated Avulsion Fracture of the Lesser Tuberosity of the Humerus

private views and are not to be con- 6. Van Laarhoven HA, te Slaa RL, van Laarhoven the humerus. A case report and review EW. Isolated avulsion fracture of the less- of the literature. J Bone Joint Surg Am. strued as official or as reflecting the er tuberosity of the humerus. J Trauma. 1975;57(7):1011. views of the US Army or the US 1995;39(5):997-999. 15. Andresen AT. Avulsion fracture of lesser 7. McGuinness JP. Isolated avulsion fracture of tuberosity of humerus. Lancet. 1948;1:750- Department of Defense. the lesser tuberosity of the humerus. Lancet. 751. 1939;1:508. 16. Neviaser JS, Neviaser JS. Isolated fracture of eferences 8. Haas SL. Fracture of the lesser tuberosity of the lesser tuberosity of the humerus. Orthop R the humerus. Am J Surg. 1944;63:253-256. Trans. 1977;1:166. 1. Paschal SO, Hutton KS, Weatherall PT. 9. Shibuya S, Ogawa K. Isolated avulsion fracture 17. Klasson SC, Vander Schilden JL, Park JP. Isolated avulsion fracture of the lesser tuberosity of the humerus in adolescents. A of the lesser tuberosity of the humerus. A case Late effect of isolated avulsion fractures of report of two cases. J Bone Joint Surg Am. report. Clin Orthop. 1986;(211):215-218. the lesser tubercle of the humerus in children. 1995;77(9):1427-1430. 10. Ross GJ, Love MB. Isolated avulsion fracture of Report of two cases. J Bone Joint Surg Am. 2. Gerber C, Krushell RJ. Isolated rupture of the the lesser tuberosity of the humerus: report of 1993;75(11):1691-1694. tendon of the subscapularis muscle. Clinical two cases. Radiology. 1989;172(3):833-834. 18. Santee HE. Fractures about the upper end features in 16 cases. J Bone Joint Surg Br. 11. Earwaker J. Isolated avulsion fracture of the of the humerus. Ann Surg. 1924;80:103- 1991;73(3):389-394. lesser tuberosity of the humerus. Skeletal 114. 3. Neer CS 2nd. Displaced proximal humer- Radiol. 1990;19(2):121-125. 19. Finkelstein JA, Waddell JP, O’Driscoll SW, al fractures. I. Classification and evaluation. 12. McAuliffe TB, Dowd GS. Avulsion of the sub- Vincent G. Acute posterior fracture disloca- J Bone Joint Surg Am. 1970;52(6):1077-1089. scapularis tendon. A case report. J Bone Joint tions of the shoulder treated with the Neer 4. Ogawa K, Takahashi M. Long-term outcome Surg Am. 1987;69(9):1454-1455. modification of the McLaughlin procedure. of isolated lesser tuberosity fractures of the 13. Hauser ED. Avulsion of the tendon of the J Orthop Trauma. 1995;9(3):190-193. humerus. J Trauma. 1997;42(5):955-959. subscapularis muscle. J Bone Joint Surg Am. 20. Sugalski MT, Hyman JE, Ahmad CS. Avulsion 5. Hartigan JW. Separation of the lesser tuberos- 1954;36(1):139-141. fracture of the lesser tuberosity in an adoles- ity of the head of the humerus. N Y Med J. 14. LaBriola JH, Mohaghegh HA. Isolated avul- cent baseball pitcher: a case report. Am J 1895;61:276. sion fracture of the lesser tuberosity of Sports Med. 2004;32(3):793-796.

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What is the Real Value of Gender-Specific Medicine? Plus: Practice management advice An interview with Kathleen Weber, MD, MS

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