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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-e263
www.elsevier.com/locate/ymse
CASE REPORTS
Case report of a proximal humeral fracture with an avulsion fracture of the lesser tuberosity in an adolescent girl Maarten C. Koper, MD*, Tijs S.C. Jakma, MD Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands Fractures of the proximal humerus in the adolescent population are rare and account for about 4% of all fractures. This number is increasing, especially because adolescents place higher demands on their shoulder joints as a result of high levels of activity.5 Nonsurgical treatment for proximal humeral fractures in adolescents is widely accepted. Multiple studies show good to excellent clinical results. About 80% of the longitudinal growth of the humerus comes from the proximal humeral physis, which favors the nonsurgical treatment.5 However, more reviews of excellent results after surgical intervention make this treatment controversial.1-3,5 Surgical treatment is advisable when adolescents reach their skeletal maturity and limited remodeling occurs. Also, with greatly displaced or angulated fractures, surgical intervention is the first choice.3 Proximal humeral fractures combined with an avulsion fracture of the humeral lesser tuberosity are rare, and no literature about this topic was found. Literature about isolated avulsion fractures of the humeral lesser tuberosity in adolescents is limited. There is often a delay in diagnosis, which makes the right time of treatment difficult to determine. A review from Vezeridis et al4 describes the different treatment options and compares nonsurgical vs. surgical treatment. This is a case report. It needs no Institutional Review Board or Ethical Committee approval. The patient and her mother gave informed consent and permission for this publication. *Reprint requests: Maarten C. Koper, MD, Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, NL-3318 AT Dordrecht, The Netherlands. E-mail address: [email protected] (M.C. Koper).
Surgical intervention has in its favor an early start of functional exercises. However, complications such as infection, injury of vital nerves and vessels, and perforation of the nail are documented. These complications are rare but possible.5 Negative side effects of nonsurgical treatment can be deformities, upper limb length discrepancy, humerus varus or valgus (which can cause decreased mobility), and cosmetic problems.5
Case report In May 2013, a healthy 12-year-old girl presented to another clinic after she fell from a horse. She complained of severe pain in the right arm. She had a swollen and painful right shoulder. Neurologic and vascular functions were not impaired. Radiographic examination revealed a proximal humeral fracture on the right side with a small bone fragment anteromedial (Fig. 1). A closed reduction was performed, and the patient was discharged. A few days later, the patient visited our outpatient clinic for follow-up. A new radiographic examination showed no change, and magnetic resonance imaging (MRI) of the right shoulder was performed to determine the origin of the loose fragment (Fig. 2). The MRI showed a proximal humeral fracture with a bone fragment medial from the shaft and ventromedial from the glenoid with the musculus subscapularis attached to it, identifying the fragment as the lesser tuberosity. All muscle structures were unimpaired. Nonsurgical treatment with sling immobilization and frequent follow-up was the therapy of choice. After 2
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.05.054
Humeral fracture with isolated lesser tuberosity fracture
Figure 1
e261
Left to right, Anteroposterior radiographs 2 weeks, 5 weeks, and 12 weeks after the initial trauma.
Figure 2 T2 spectral attenuated inversion recovery coronal MRI of the right shoulder. Left, A proximal humeral fracture with the same small bone fragment as described on the plain radiograph. The fragment is located medial from the shaft and ventromedial from the glenoid and has the musculus subscapularis attached to it. Right, The bone fragment with the musculus subscapularis attached to it.
weeks, a physical examination and radiographs were performed. The pain in the right shoulder was significantly decreased. Functional examination showed flexion of 40 , abduction of 30 , external rotation of 10 , and internal rotation of 30 .
We started with physiotherapy and functional exercises. After 5 weeks, she presented with no pain and improved function of the right shoulder. After a total of 12 weeks, she regained complete function of the right shoulder, free of pain (Table I and Fig. 3). Radiographic examination
e262 Table I
M.C. Koper, T.S.C. Jakma Physical examination results of the right shoulder during the recovery period
Flexion Abduction Internal rotation
2 weeks
5 weeks
12 weeks
40 30 30
180 60 90
180 180 T4
After 12 weeks, our patient regained full range of motion.
Figure 3 Functional examination. Left, An endorotation of 180 after 5 weeks. Right, Our patient showed full endorotation after 12 weeks.
showed consolidation of the fracture, and bone callus was observed.
Discussion This report describes a case of an adolescent girl with severe pain in the right arm after she fell from a horse. Radiographic examination and MRI showed a proximal humeral fracture with an avulsion fracture of the lesser tuberosity. We treated the fractures nonsurgically and achieved a full range of motion after 3 months. Nonsurgical treatment of proximal humeral fractures is widely used and accepted. The remodeling potential of the proximal humerus in adolescents favors this treatment. However, limited remodeling occurs when children reach their skeletal maturity. For this group, and especially in severe displaced or angulated proximal humeral fractures, surgical intervention is an acceptable modality of treatment.3 A study of Pahlavan et al2 claimed that
patients younger than 10 years should be treated nonsurgically, whereas operative treatment should be considered for patients older than 13 years. For optimal treatment between the ages of 10 and 13 years, they gave no consensus. There are only a few reports of fractures of the lesser tuberosity in adolescents. These fractures occur mostly in isolation and are especially seen in high-energy sport injuries. Vezeridis et al4 reviewed the literature and favor surgical reduction and suture fixation as treatment. Our patient, a 12-year-old girl, was treated nonsurgically and regained complete function of the right shoulder after 3 months. Radiographic examination showed consolidation and callus formation.
Conclusion Based on the found literature and our case we advice nonsurgical treatment in adolescents with non displaced
Humeral fracture with isolated lesser tuberosity fracture humeral fractures and avulsion of the lesser tuberosity. Our case was treated with close follow-up by physical examination and radiographs and achieved a good functional outcome. Surgical treatment is only favored with greatly displaced fractures or if nonsurgical treatment fails.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
e263
References 1. Di Gennaro GL, Spina M, Lampasi M, Libri R, Donzelli O. Fractures of the proximal humerus in children. Chir Organi Mov 2008;92:89-95. http://dx.doi.org/10.1007/s12306-008-0050-7 2008 2. Pahlavan S, Baldwin KD, Pandya NK, Namdari S, Hosalkar H. Proximal humerus fractures in the pediatric population: a systematic review. J Child Orthop 2011;5:187-94. http://dx.doi.org/10.1007/s11832-0110328-4 3. Pandya NK, Behrends D, Hosalkar HS. Open reduction of proximal humerus fractures in the adolescent population. J Child Orthop 2012;6: 111-8. http://dx.doi.org/10.1007/s11832-012-0398-y. 2012 4. Vezeridis PS, Bae DS, Kocher MS, Kramer DE, Yen YM, Waters PM. Surgical treatment for avulsion injuries of the humeral lesser tuberosity apophysis in adolescents. J Bone Joint Surg Am 2011;93:1882-8. http:// dx.doi.org/10.2106/JBJS.K.00450 5. Wang X, Shao J, Yang X. Closed/open reduction and titanium elastic nails for severely displaced proximal humeral fractures in children. Int Orthop 2014;38:107-10. http://dx.doi.org/10.1007/s00264-013-2122-z
www.elsevier.com/locate/ymse
CASE REPORTS
Case report of a proximal humeral fracture with an avulsion fracture of the lesser tuberosity in an adolescent girl Maarten C. Koper, MD*, Tijs S.C. Jakma, MD Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands Fractures of the proximal humerus in the adolescent population are rare and account for about 4% of all fractures. This number is increasing, especially because adolescents place higher demands on their shoulder joints as a result of high levels of activity.5 Nonsurgical treatment for proximal humeral fractures in adolescents is widely accepted. Multiple studies show good to excellent clinical results. About 80% of the longitudinal growth of the humerus comes from the proximal humeral physis, which favors the nonsurgical treatment.5 However, more reviews of excellent results after surgical intervention make this treatment controversial.1-3,5 Surgical treatment is advisable when adolescents reach their skeletal maturity and limited remodeling occurs. Also, with greatly displaced or angulated fractures, surgical intervention is the first choice.3 Proximal humeral fractures combined with an avulsion fracture of the humeral lesser tuberosity are rare, and no literature about this topic was found. Literature about isolated avulsion fractures of the humeral lesser tuberosity in adolescents is limited. There is often a delay in diagnosis, which makes the right time of treatment difficult to determine. A review from Vezeridis et al4 describes the different treatment options and compares nonsurgical vs. surgical treatment. This is a case report. It needs no Institutional Review Board or Ethical Committee approval. The patient and her mother gave informed consent and permission for this publication. *Reprint requests: Maarten C. Koper, MD, Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, NL-3318 AT Dordrecht, The Netherlands. E-mail address: [email protected] (M.C. Koper).
Surgical intervention has in its favor an early start of functional exercises. However, complications such as infection, injury of vital nerves and vessels, and perforation of the nail are documented. These complications are rare but possible.5 Negative side effects of nonsurgical treatment can be deformities, upper limb length discrepancy, humerus varus or valgus (which can cause decreased mobility), and cosmetic problems.5
Case report In May 2013, a healthy 12-year-old girl presented to another clinic after she fell from a horse. She complained of severe pain in the right arm. She had a swollen and painful right shoulder. Neurologic and vascular functions were not impaired. Radiographic examination revealed a proximal humeral fracture on the right side with a small bone fragment anteromedial (Fig. 1). A closed reduction was performed, and the patient was discharged. A few days later, the patient visited our outpatient clinic for follow-up. A new radiographic examination showed no change, and magnetic resonance imaging (MRI) of the right shoulder was performed to determine the origin of the loose fragment (Fig. 2). The MRI showed a proximal humeral fracture with a bone fragment medial from the shaft and ventromedial from the glenoid with the musculus subscapularis attached to it, identifying the fragment as the lesser tuberosity. All muscle structures were unimpaired. Nonsurgical treatment with sling immobilization and frequent follow-up was the therapy of choice. After 2
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2015.05.054
Humeral fracture with isolated lesser tuberosity fracture
Figure 1
e261
Left to right, Anteroposterior radiographs 2 weeks, 5 weeks, and 12 weeks after the initial trauma.
Figure 2 T2 spectral attenuated inversion recovery coronal MRI of the right shoulder. Left, A proximal humeral fracture with the same small bone fragment as described on the plain radiograph. The fragment is located medial from the shaft and ventromedial from the glenoid and has the musculus subscapularis attached to it. Right, The bone fragment with the musculus subscapularis attached to it.
weeks, a physical examination and radiographs were performed. The pain in the right shoulder was significantly decreased. Functional examination showed flexion of 40 , abduction of 30 , external rotation of 10 , and internal rotation of 30 .
We started with physiotherapy and functional exercises. After 5 weeks, she presented with no pain and improved function of the right shoulder. After a total of 12 weeks, she regained complete function of the right shoulder, free of pain (Table I and Fig. 3). Radiographic examination
e262 Table I
M.C. Koper, T.S.C. Jakma Physical examination results of the right shoulder during the recovery period
Flexion Abduction Internal rotation
2 weeks
5 weeks
12 weeks
40 30 30
180 60 90
180 180 T4
After 12 weeks, our patient regained full range of motion.
Figure 3 Functional examination. Left, An endorotation of 180 after 5 weeks. Right, Our patient showed full endorotation after 12 weeks.
showed consolidation of the fracture, and bone callus was observed.
Discussion This report describes a case of an adolescent girl with severe pain in the right arm after she fell from a horse. Radiographic examination and MRI showed a proximal humeral fracture with an avulsion fracture of the lesser tuberosity. We treated the fractures nonsurgically and achieved a full range of motion after 3 months. Nonsurgical treatment of proximal humeral fractures is widely used and accepted. The remodeling potential of the proximal humerus in adolescents favors this treatment. However, limited remodeling occurs when children reach their skeletal maturity. For this group, and especially in severe displaced or angulated proximal humeral fractures, surgical intervention is an acceptable modality of treatment.3 A study of Pahlavan et al2 claimed that
patients younger than 10 years should be treated nonsurgically, whereas operative treatment should be considered for patients older than 13 years. For optimal treatment between the ages of 10 and 13 years, they gave no consensus. There are only a few reports of fractures of the lesser tuberosity in adolescents. These fractures occur mostly in isolation and are especially seen in high-energy sport injuries. Vezeridis et al4 reviewed the literature and favor surgical reduction and suture fixation as treatment. Our patient, a 12-year-old girl, was treated nonsurgically and regained complete function of the right shoulder after 3 months. Radiographic examination showed consolidation and callus formation.
Conclusion Based on the found literature and our case we advice nonsurgical treatment in adolescents with non displaced
Humeral fracture with isolated lesser tuberosity fracture humeral fractures and avulsion of the lesser tuberosity. Our case was treated with close follow-up by physical examination and radiographs and achieved a good functional outcome. Surgical treatment is only favored with greatly displaced fractures or if nonsurgical treatment fails.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
e263
References 1. Di Gennaro GL, Spina M, Lampasi M, Libri R, Donzelli O. Fractures of the proximal humerus in children. Chir Organi Mov 2008;92:89-95. http://dx.doi.org/10.1007/s12306-008-0050-7 2008 2. Pahlavan S, Baldwin KD, Pandya NK, Namdari S, Hosalkar H. Proximal humerus fractures in the pediatric population: a systematic review. J Child Orthop 2011;5:187-94. http://dx.doi.org/10.1007/s11832-0110328-4 3. Pandya NK, Behrends D, Hosalkar HS. Open reduction of proximal humerus fractures in the adolescent population. J Child Orthop 2012;6: 111-8. http://dx.doi.org/10.1007/s11832-012-0398-y. 2012 4. Vezeridis PS, Bae DS, Kocher MS, Kramer DE, Yen YM, Waters PM. Surgical treatment for avulsion injuries of the humeral lesser tuberosity apophysis in adolescents. J Bone Joint Surg Am 2011;93:1882-8. http:// dx.doi.org/10.2106/JBJS.K.00450 5. Wang X, Shao J, Yang X. Closed/open reduction and titanium elastic nails for severely displaced proximal humeral fractures in children. Int Orthop 2014;38:107-10. http://dx.doi.org/10.1007/s00264-013-2122-z