Sat., 10/6/12 Upper Extremity Injuries, PAPER #89, 11:13 am OTA-2012
Fractures of the Greater Tuberosity of the Humerus: A Study of Associated Rotator Cuff Injury and Atrophy
Luojun Wang1; Jennifer Mutch2; George-Yves Laflamme, MD2; Nicola Hagemeister3;
Dominique M. Rouleau, MD2;
1Université de Montréal, Montreal, Quebec, Canada;
2Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada;
3Centre Hospitalier de l’Université de Montréal, École de Technologie Supérieure,
Montreal, Quebec, Canada
Purpose: Fractures of the greater tuberosity represent a particular challenge as tendinomuscular injuries of the rotator cuff may occur in conjunction. MRI performed after proximal humerus fractures in general has shown an incidence of 40% full-thickness rotator cuff tears. In addition, the degree of fatty muscle atrophy has been shown to correlate with functional outcome in rotator cuff tears and shoulder arthroplasty but no study has been done following isolated greater tuberosity fracture. The objective of this study is to evaluate the incidence of full-thickness rotator cuff tear and bicipital pathologies in patients with previous greater tuberosity fracture.
Methods: All cases of isolated greater tuberosity fractures seen at our institution from July 2007 until December 2010 were reviewed. 50 patients with adequate initial radiographs were invited to return for an ultrasound of their affected shoulder; the contralateral shoulder was used for comparison. The examinations were performed by a single experienced musculoskeletal radiologist. Tendinosis, tears, and position of the biceps tendon were noted and any partial or complete rotator cuff tears were identified and measured. A dynamic evaluation assessed subacromial impingement. Atrophy of the supraspinatus and infraspinatus muscles was measured using the occupation ratio validated by Khoury et al. Fatty infiltration was evaluated by comparing rotator cuff muscle echogenicity to that of the deltoid and trapezius muscles. Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH), Short Form-12 (SF-12), Western Ontario Rotator Cuff Index (WORC), and pain score were used to assess clinical outcome.
Results: The 50 recruited patients had an average age of 58 (standard deviation [SD]: 15; range, 32-92) and 45% were male. 66% of the ultrasounds demonstrated at least one partial tear. Six patients showed full-thickness tear; all of them were male. Biceps evaluation showed 11 subluxations (22%) and 28 tendinitis (56%). 53% of all patients had evidence of subacromial impingement. The average surface ratios of the supraspinatus and infraspinatus muscles of the affected and unaffected side were not significantly different (0.79 and 0.76). However, fatty infiltration was present in 11 supraspinatus (22%) and 26 infraspinatus (52%) muscles of the affected side. Patients with full-thickness tears had worse upper limb function as shown by the Q-DASH. (average 35 vs 16, P = 0.05). They were also reporting more pain (average 3.5 of 10 vs 1.7of 10, P = 0.05). The biceps subluxation was associated with higher WORC score (average 89 vs 73, P = 0.05).
Conclusion: This study describes the tendinous pathology associated with isolated greater tuberosity fractures of the proximal humerus. Following these fractures, a significant portion of patients were shown to have rotator cuff pathology regardless of age. More than half of the patients demonstrated evidence of subacromial impingement. Patients with greater tuberosity fractures may therefore benefit from additional imaging to evaluate their rotator cuff.
Alphabetical Disclosure Listing (808K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.