Fracture of the coracoid process with acute subscapularis tear without shoulder dislocation

Coracoid process fracture is an uncommon injury and can be easily missed. An associated acute subscapularis tear is still rare. Herein, we describe a 61 year old male who fell from a 2 meter height (stair case) and presented with isolated coracoid process fracture with acute subscapularis tear without dislocation of (R) shoulder joint. The plain x-rays, CT scan and MR arthrography comprised the diagnosis. He was operated upon with reattachment of subscapularis to lesser tuberosity and conjoint tendons to pectoralis major. At 6 mo followup he had good range of motion and his MRI revealed complete healing.     

Subscapularis function after total shoulder replacement: results with lesser tuberosity osteotomy

Until recently, little consideration was placed on the integrity of the subscapularis tendon after total shoulder arthroplasty. We have noted that several of our patients exhibited loss of internal rotation strength and subscapularis function after total shoulder arthroplasty utilizing an anatomic soft tissue repair of the subscapularis, both with and without bone tunnels. On the basis of those results, we began removing the subscapularis with a small piece of bone by a lesser tuberosity osteotomy in an attempt to achieve improved subscapularis function through bony healing at the repair site. A retrospective review of 28 patients (30 shoulders) was done of patients who had total shoulder arthroplasty performed between 2001 and 2003. The lesser tuberosity and attached subscapularis were repaired through bone tunnels in all cases. The mean follow-up was 1.1 years. Terminal internal rotation was evaluated by the belly-press examination. Subscapularis function was assessed by the patient's ability to tuck in a shirt behind the back, and 25 of 30 patients (83.3%) reported no difficulty. Belly-press examination results were normal in 18 of 30 patients (60%). Removal of the subscapularis through a lesser tuberosity osteotomy results in reliable restoration of internal rotation strength after total shoulder arthroplasty, as measured by the ability to perform a stomach press and to tuck in a shirt. In comparing these results with our earlier cohort of patients with similar demographics and postoperative rehabilitation that had soft tissue repair, improved results were seen in the group that underwent lesser tuberosity osteotomy.     

Lesser tuberosity osteotomy minimizes subscapularis insufficiency in shoulder replacement

Take down of the subscapularis tendon is a necessary step in performing total shoulder arthroplasty through the deltopectoral approach. Anatomic repair and healing of the subscapularis is vital to achieving reliable functional outcomes postoperatively. Detachment of the subscapularis is typically achieved by either tenotomy, subscapularis peel, or lesser tuberosity osteotomy. Previous reports have suggested that subscapularis dysfunction after either tenotomy or peel is remarkably high. It is our opinion that lesser tuberosity osteotomy is the preferred method of subscapularis take down during shoulder arthroplasty. Herein we review the literature comparing the various techniques of subscapularis management and discuss our preferred method for lesser tuberosity osteotomy during total shoulder arthroplasty via the standard deltopectoral approach.     

Subscapularis tenotomy vs. lesser tuberosity osteotomy during total shoulder arthroplasty: When less is more

Mobilization of the subscapularis is necessary during total shoulder arthroplasty, but high rates of subscapularis dysfunction have been reported postoperatively. Two methods are commonly used: subscapularis tenotomy with tendon-to-tendon repair and lesser tuberosity osteotomy with bone-to-bone repair. There is conflicting data as to which of these methods provides superior results. This article reviews the literature to date and provides the preliminary results from a prospective randomized controlled trial comparing subscapularis tenotomy to lesser tuberosity osteotomy. Our results show that lesser tuberosity osteotomy and subscapularis tenotomy both provide a reliable, consistent healing method for subscapularis management with comparably excellent outcomes.     

Isolated avulsion fracture of the lesser tuberosity of the humerus. A case report

An extremely rare isolated avulsion fracture of the lesser tuberosity, not complicated with other proximal humeral fractures or posterior shoulder dislocations, occurred in a 12-year-old girl. The avulsion fracture of the upper part of the lesser tuberosity appears to have been caused by hyperextension and hyperexternal rotation of the shoulder. In this position, the coracohumeral ligament, superior glenohumeral ligament, and subscapularis tendon could have pulled out the upper part of the lesser tuberosity. She gained full recovery of left shoulder function after three months of conservative treatment, although follow-up roentgenograms show nonunion of the fracture. An isolated avulsion fracture of the lesser tuberosity is extremely rare. Only 12 cases, none in children, have been found in the literature since Hartigan's report in 1895.     

Subscapularis muscle function and structure after total shoulder replacement with lesser tuberosity osteotomy and repair

BACKGROUND: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes. METHODS: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis. RESULTS: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%). CONCLUSIONS: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.     

Lesser Tuberosity Avulsions in Adolescents

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.     

Avulsion fractures of the lesser tuberosity of the humerus in adolescents: review of the literature and case report

Isolated fracture of the lesser tuberosity is an unusual phenomenon in children and adolescents. These injuries are difficult to diagnose acutely and often present as chronic shoulder pain. In this study, we report on 1 case of a displaced lesser tuberosity apophysis avulsion fracture in an adolescent treated with open reduction and internal fixation, as well as a review of the literature. A 14-year-old adolescent male presented to the senior surgeon complaining of left shoulder pain and weakness 10 days after a wrestling injury. He was diagnosed with a displaced, isolated fracture of the lesser tuberosity apophysis for which he underwent open reduction and internal fixation. A combination of sutures passed through drill holes in the proximal humerus and bioabsorbable suture tacks were used to anatomically fix the lesser tuberosity fragment and subscapularis tendon. Postoperatively, he underwent a progressive physical therapy regimen. At 4 months follow-up, he had full range of motion, complete return of strength, and returned to competitive athletics. We report here on the successful surgical treatment of a fracture of the lesser tuberosity apophysis in an adolescent.     

The subscapular and subcoracoid bursae: descriptive and functional anatomy

The subscapularis and subcoracoid bursae, as well as the subscapularis muscle, were studied in 42 fresh cadaveric shoulders. Fibrous bands were found in the medial part of the muscle; they were intercalated with the distal tendon-like bands. The superior distal fibrous band was always found to be thicker than the others. Strong fibrous attachments of the subscapularis muscle were found along the lateral border of the scapula as well as along the medial third of the bony crests in the subscapular fossa. Between the crests, the muscle bundles were directly attached to the bone. In the lateral part of the scapula, the subscapularis muscle had only weak connective links with the bone. The subscapularis bursa was found in all cases as a pouch strongly attached to the scapular neck and the adjacent part of the joint capsule. The top of the bursa was linked to the coracoid process by a fibrous attachment called the suspensory ligament. The subcoracoid bursa had only weak connective links with the coracoid process. In 28% of cases, the subscapularis and subcoracoid bursae merged into a unique wide bursa. The subscapular bursa had two types of links with the muscle: (1). weak connective links with the superficial muscle bundles and (2). at least 2 fibrous arcs joining the lateral tendon-like bands, the bursa, and bony crests of the subscapularis fossa. These arcs allow the bursa to follow the course of the muscle exactly. During movements of the glenohumeral joint, the subscapularis muscle sustains huge changes of orientation, particularly the upper part of the muscle that coils around the coracoid process. The strong superior fibrous band enables the muscle to maintain contact with the coracoid process. It is the function of the subscapularis and subcoracoid bursae to manage the friction of the superficial fibers against the scapular neck, the humeral head, and the coracoid process.     

Subscapularis management in open shoulder surgery

Management of the subscapularis in open shoulder surgery is a controversial topic. Subscapularis tenotomy has been the traditional approach, but other techniques have recently been developed to preserve the integrity of the subscapularis tendon. These include subscapularis peel, subscapularis split, and lesser tuberosity osteotomy. The biologic healing and biomechanical properties associated with each surgical approach must be evaluated to determine the best option for each patient. A strong, anatomic repair is required to achieve optimal clinical outcomes.     

Lesser tuberosity osteotomy

After total shoulder replacement, there is a risk of poor function of the subscapularis, which may subsequently affect clinical outcomes. A number of direct repair techniques have been described in order to restore good subscapularis function after surgery. Repair using a lesser tuberosity osteotomy instead of a tenotomy has been shown to be effective.     

Subscapularis tendon rupture in an 8-year-old boy: a case report

Since falling off a motorcycle 2 years earlier, an 8-year-old, right-hand-dominant boy reported anterior shoulder pain and weakness. After being evaluated by his family physician and completing a course of physical therapy with no symptomatic improvement, he was seen at our institution. Physical examination was remarkable for diminished strength with internal rotation (4/5). In addition, bellypress and lift-off tests were positive, suggesting a lesion of the subscapularis. Magnetic resonance imaging of the shoulder showed a full-thickness subscapularis tendon tear and a supraspinatus tendon signal that could have represented a partial-thickness tear vs supraspinatus tendinosis. The patient underwent right shoulder diagnostic arthroscopy with debridement of a partial-thickness articular-sided tear of the supraspinatus tendon followed by open repair of the subscapularis tendon rupture. This case illustrates a traumatic subscapularis tendon injury that is rare in this age group. A few other traumatic subscapularis injuries have been reported in children, but they all demonstrated bony avulsion of the lesser tuberosity.     

Fly Fishing-related lesser tuberosity avulsion in an adolescent

Stress lesions of the shoulder in athletic and active adolescents are most commonly associated with overhead sports. One of the most uncommon stress lesions of the shoulder in adolescents is an avulsion of the lesser tuberosity of the proximal humerus. To our knowledge, only 2 other cases of lesser tuberosity avulsions from repetitive motion have been reported, both of which were secondary to baseball pitching.This article describes a case of an isolated partial avulsion of the lesser tuberosity of the humerus in an adolescent as a result of repetitive stress from fly fishing. The patient had no symptoms in his shoulder until after casting for approximately 10 hours a day for 3 days. He presented with anterior shoulder pain that worsened with abduction and external rotation. On examination, he had tenderness over the lesser tuberosity and pain with subscapularis muscle testing, such as the lift-off test. He had a negative apprehension sign but no signs of a superior labrum tear. Conventional radiography with an axillary view confirmed the diagnosis. He recovered with rest and gradual return to activities. Two years after injury, the patient had no limitations functionally, and his shoulder examination was normal.This case highlights the importance of being aware that (1) this lesion can occur in activities other than baseball, (2) characteristic physical findings exist with this lesion, (3) obtaining an axillary radiograph can confirm diagnosis, and (4) these avulsions can be treated successfully with nonoperative interventions.     

Lesser tuberosity cysts and their relationship with subscapularis tears and subcoracoid impingement

Background

We aimed to evaluate cysts in the lesser tuberosity of humeral head seen on magnetic resonance imaging (MRI) and their relationship with subcoracoid impingement and subscapularis tears evident on arthroscopic surgery videos. Our hypothesis was that the cysts would be more frequent with subscapularis tears and in the case of subcoracoid impingement.

An anatomic evaluation of the active compression test

The goal of this study was to describe the anatomic relationships present during the active compression test. Four pairs of cadaveric shoulders were positioned to simulate the active compression test. The shoulders were embedded in polyurethane and evaluated in the axial and coronal planes with a planer. In the axial plane, all internally rotated shoulders demonstrated contact between the lesser tuberosity and subscapularis tendon and the superior aspect of the glenoid and labrum. In the externally rotated position, there was no contact between the superior structures of the shoulder. In the coronal plane, the internally rotated specimens revealed contact between the supraspinatus tendon and the lateral aspect of the acromion. There was no contact between the supraspinatus tendon and the acromion when the shoulders were externally rotated in the coronal plane. The results demonstrate that the active compression test can be used to assist in the diagnosis of superior labrum anterior-posterior lesions as well as other shoulder pathology.     

Release of the subscapularis tendon and muscle: a limited gain in length

This study measured in vitro the degree of lateral advancement of the subscapularis tendon achieved by circumferential release. Thirty-eight cadaveric shoulders underwent circumferential subscapularis release with anterior capsulotomy. Release was performed in two phases. The first phase consisted of four stages: 1) cutting the capsule parallel to the superior border of the subscapularis tendon to the level of the glenoid; 2) division of the anterior capsule and blunt dissection along the glenoid neck; 3) safe separation of the capsule and muscle inferiorly; and 4) blunt, with a finger, dissection between the conjoined tendon and the subscapularis to the level of the joint line. The second phase was performed by cutting the coracohumeral ligament and the consistently found fibrous band that connects the superior aspect of the subscapularis tendon to the base of the coracoid. After each phase, 3 kg of traction were applied to the muscle and the lateral advancement of the subscapularis was measured using a millimeter caliper. The lateral advancement of the subscapularis was 5.5 +/- 3.4 mm after the first step and 9.8 +/- 4.5 mm after the second step. The difference was statistically significant (P < .001). These results indicate that, although necessary, anterior soft tissue balancing during shoulder replacement is limited.     

Rotator interval dimensions in different shoulder arthroscopy positions: a cadaveric study

The rotator interval was defined as a triangular structure, where the base of the triangle was the coracoid base, the upper border was the anterior margin of the supraspinatus, and the lower border was the superior margin of the subscapularis muscle-tendon unit. We evaluated the rotator interval dimensions in 15 shoulders from 10 lightly embalmed adult cadavers in 3 shoulder arthroscopy positions: 0 degrees of abduction and 30 degrees of flexion (beach chair [BC]), 45 degrees of abduction and 30 degrees of flexion (lateral decubitus 1), and 70 degrees of abduction and 30 degrees of flexion (lateral decubitus 2). In each shoulder position, measurements were made in neutral rotation (NR), 45 degrees of external rotation (ER), and 45 degrees of internal rotation (IR). The coracoid base lengthened with IR in all positions and shortened in ER in the lateral decubitus position but not in the BC position. Abduction significantly lengthened the coracoid base, which was shortest in the BC position with ER (24 +/- 4 mm) and longest in the lateral decubitus 2 position with IR (33 +/- 5 mm). The coracoid base, where sutures are placed during plication of the interval, was observed to lengthen and, therefore, loosen with IR and abduction. To prevent postoperative ER restriction, plication should be made in ER or neutral rotation when operating in the BC position and the degree of abduction should be decreased and the shoulder held in ER when operating in the lateral decubitus position.