Greater Tuberosity

Patients with painful abduction and external rotation after shoulder trauma with no abnormality on plain ra- diographs should be always considered as potentially to have sustained an undisplaced greater tuberosity frac- ture. A consistent clinical finding that may differentiate from a rotator cuff injury is tenderness laterally over the greater tuberosity. Poor quality of radiographs, lack of the external rotation view or lack of clinical experience could be causes of missed diagnosis. MR examination subsequently performed due to persisting symptoms, re- vealed the fracture in all patients. Therefore, MRI should be always performed in patients with persistent pain, bony tenderness and decreased range of motion despite negative plain radiographs. This can avoid missed diagnosis and a potential source of patient dissatisfaction satisfaction and litigation.

All seven patients were male, and the mean age was 30.1 (range: 23 - 42). The mean interval between the accidents and the closed reductions was 8.4 hours, and the mean interval between the accidents and the open reductions was 7 days. Radiographic imaging (anteroposterior and true lateral scapular views) was performed for all cases before the closed reductions, which showed anterior shoulder dislocation with displaced fracture of greater tuberosity in all cases (Figure 1). Five patients had right shoulder dislocations and two had left shoulder disloca- tions. All were right-handed (Table 1).

To perform the morphometric analysis, specific regions of interest (ROIs) were defined within the greater tuber- osity of the humeral head (Figure 1). These ROIs were designed with the suture anchor positioning in arthro- scopic rotator cuff repair. The borders of the footprint were defined in each case. Next, the greater tuberosity was divided into two equally sized areas (area A and area P). Area A was set on the anterior side of the greater tu- berosity, and area P was set on the posterior side. Three rows were defined within each area: one medial row dir- ectly adjacent to the articular surface (Am, Pm), one lat- eral row along the lateral edge of the footprint (Al, Pl), and one far lateral row 1 cm from the lateral edge of the footprint (Af, Pf ). Each ROI had a cylindrical shape with a diameter of 5 mm and a depth of 15 mm, correspond- ing to the average volume of currently used suture an- chors. Each ROI was placed at a 45° angle to the greater tuberosity [21]. The ROIs were set 5 mm under the sur- face of the cortical bone to omit cortical bone artifact (Figure 2).

Abstract: Objective: The aim of this study was to provide the basis for implanting selection by comparing the biome- chanical performances of three fixation techniques used in the treatment of greater tuberosity fracture: screws, a tension band, or the locking plate which were specifically designed through the establishment of a three-dimension- al finite element model. Methods: Three-dimensional reconstructions of the scapula and proximal humerus were assembled and a finite element model was established. Loading force and traction testing was carried out using the maximal contraction force of the rotator cuff muscle. The maximum displacement, maximum Von Mises stress, and the displacement and stress distribution diagram of the three fixation models were compared. Results: The stress applied to the greater tuberosity of the locking plate and screw was lower than the yield strength of titanium alloy. The greater tuberosity locking plate demonstrated homogeneous stress distribution, and the stress was dispersed and transmitted rapidly, closer to the physiological state. The biomechanical stability was also greater than that of the screw fixation or tension band fixation. Conclusion: The locking plate demonstrated significant biomechanical advantages of stress dispersion and transmission compared to screw or tension band fixation in the treatment of greater tuberosity fracture.

In this biomechanical in-vitro study of arthroscopic su- ture anchor fixation techniques for greater tuberosity fractures, there was no significant difference between single-row and double-row repair regarding load to fail- ure and applied traction force for 1 mm fracture dis- placement. Thus the studies primary hypothesis must be rejected. To the best of our knowledge, this is the first study presenting biomechanical data on single- vs. double-row knotless suture anchor repair of greater tu- berosity fractures.

Background: Occult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period. The purpose of this study was to retrospectively assess the incidence rate of occult and missed surgical neck fractures in those initially diagnosed with isolated GT fracture. Methods: Records of patients diagnosed as having an isolated GT fracture were retrieved from a database in a medical center. Two senior orthopedic surgeons blindly reviewed all images of these patients three times to classify GT fracture types (split, avulsion and depression types), and recorded any surgical neck fractures found. Then a meeting was help to confirm the fracture types and presence of surgical neck fracture.

Although isolated fractures of the humeral GT are less common than three- or four-part fractures of the proximal humerus, they can still result in significant disability. More- over, the intimate association of the rotator cuff with the tu- berosities has a substantial impact on these injuries. When fractured, the greater tuberosity often displaces posteriorly and superiorly due to the deforming forces of the rotator cuff muscles. If its displacement is more than 5 mm, it can affect overhead elevation of the arm and cause subacromial impingement, and may block external rotation with the arm at the side [29, 30]. Arthroscopic and open fixation

For the scanning procedure the proximal humerus was fixed horizontally with the lesser tuberosity in a 12- o’clock position. A horizontal line running through the lowest point of the articular surface defined the inferior border of the humeral head. The HR-pQCT imaging sys- tem (XtremeCT, Scanco Medical, Brüttisellen, Switzerland) is equipped with a 70 μm focal spot. The X-ray tube was operated at 60 kVp and 900 μA. The integration time was set to 300 ms. Two-dimensional CT images were reconstructed in 1536 by 1536 pixel matrices from 750 projections using a standard convolution- backprojection procedure (see Figure 1). Images were stored in 3D arrays with an isotropic voxel size of 82 μm. The complete proximal end of the humerus was acquired with a total of 550–600 microtomo- graphic slices, corresponding to a length of 45–50 mm. All HR-pQCT scans were performed and analyzed by the same investigator (CK).

The position of the transducer is related to the long or short axis of the anatomic structure under examination. When imaging the supraspinatus tendon in the transverse direction (ie, the short axis), the transducer is placed in a sagittal plane with regard to the patient’s shoulder and is moved anterior to posterior following the course of the tendon . When the transducer has reached the most lateral part of the supraspinatus tendon insertion at the greater tuberosity, no rotator cuff can be visualized between the deltoid muscle and the humeral head . This could be misinterpreted as a full-thickness rotator cuff tear. To prevent making such an error, every possible lesion should be verified in two planes.

Greater tuberosity fracture is generally the result of recurrent shoulder dislocation or direct trauma without dislocation and can lead to shoulder joint impairment of motion especially abduction and also dam- age to rotator cuff (25-27). This problem needs more attention and may need surgery for reduction and fixation of tuberosity.

PHILOS plate was developed to provide angular stability and achieve a favorable screw– bone interface, especially in osteoporotic bone. The plate incorporates multiple locking screws in convergent and divergent directions to improve pullout strength and fixation strength. [Thanasas et al 2009].This creates a fixed angled device that acts as a single unit that captures a volume of bone as shown by wanner et al. In our study we observed, falls resulting in fracture of proximal humerus increasing with age. With Age incidence was almost equal in 30-60 years age group, whereas females were affected largely in elderly age group >60 years age group. This observation is attributable to the rising incidence of osteoporosis in the elderly & specially women. From the observations, we also concluded that incidence of humeral fractures increases as age progresses. Similar results were shown in other studies by Zeng L et al, Seluk Keser et al, Kayalar M et al. In our series it was seen that Neer’s 3-part fractures had comparatively better functional outcome as compared to the 4-part fractures. Greater tuberosity displacement and communition of fracture fragments was responsible for this delay as it is difficult to hold the reduction while the plate was being applied. The union time in our study was average of 11.2 weeks. One case who had screw perforation in joint, which took 24 weeks for union. Atilla et al and Moonot et al in their series of 32 patients and 31 showed radiological union at around 12 weeks and 10 weeks. Which was similar to our study As per our study, functional outcome improved withthe time, and were better in younger population, and patients undergoing proper physiotherapy. Olerued et al, Konard Get al and Plecko et al in their study showed mean DASH score of 26, 15.2 +/- 16.8 and18 at final follow up. The average UCLA score in our group was 27.8 at final follow up in our study. Handschin et al in his study of 31 patients showed that the UCLA scores were excellent in 10%, good in 67%, and fair in 23% of the patients treated with PHILOS plate fixation at the end of 19 months of follow up. similar result were shown by Hessmann et al and Helwig et al.

Literatures described the association between greater tuberosity fracture, dis- location, complete axillary and brachial plexus injury in conjunction with shoulder dislocation [18] [19]. The best means to confirm a concomitant peri- phery nerve injury with shoulder dislocation includes detailed subjective and objective clinical examinations, along with EMG studies [8]. EMG is the neuro- logical examination of choice for locating the level of compression. In this nerve-conduction study, it shows reduction of the amplitude of the potential and a reduced conduction velocity. In this study, EMG shows little active denerva- tion.

We further assessed the ‘plausibility’ of all combinations appearing in our data. Clearly possible combinations, for example, greater tuberosity fracture-dislocations in Neer (category 6) and in AO/OTA (subgroup A1.3) were termed ‘plausible’. Clearly impossible combinations, like articular surface fractures in Neer (categories 15 and 16) and extra-articular fracture in AO/OTA (type A or B), were termed ‘not plausible’. Other combinations which could not clearly be ruled out were termed ‘problematic’ and discussed further in the manuscript. A priori, we assumed a common understanding within the two classifi- cation systems of regarding whether a fracture was also dislocated.

Studies support the hypothesis that the conformation of the tibial tuberosity has an influence on the advance- ment in TTA surgery, and the cage size and position rela- tive to the tibial tuberosity also matters [20]. TTA-2 is a simplified variation of TTA that consists in a Maquet-like osteotomy, fixated with a new cage that eliminates stress risers created by the plate, fork, and screws, rendering plate and fork fixation unnecessary [21]. Stress risers were proven to occur in the osteotomized piece of bone as the holes are drilled perpendicular in the mediolateral plane for screw and fork placement [22].

duced greater insensible perspiration and RQ is greater for a carbohydrate-centered diet compared to a fat-centered diet [23]. We did not assess the diet of the participants on the day, but it is assumed that Korean males have a more carbohydrate-centered diet compared to Western male subjects. Secondly, there could be the effect of posture on insensible perspiration. Benedict and Wardlaw [7] found that the insensible water loss increased at an average of 20 % in the sitting position when compared with the lying position. Most previous studies were conducted in the lying position, while our subjects were in the sitting position. Thirdly, we reported insensible body mass loss whereas some of the previous reports calculated “in- sensible perspiration.” As insensible perspiration forms about 91 % of insensible body mass loss, such a differ- ence should be considered. Through the mass analysis

A 12-year-old boy presented with a left avulsion fracture of the ischial tuberosity. Informed consent was obtained from this patient and his family. The patient ’ s family history and previous medical history were unremark- able. The patient was a track-and-field athlete who felt severe pain in his left buttock while running. He visited a local hospital, where plain radiographs and computed tomography (CT) of the pelvis showed an avulsion frac- ture of the left ischium (Fig. 1). The fragment was displaced 20 mm. No neurological deficit was present. Complete non-weight-bearing therapy was performed as a conservative treatment, but the patient ’ s symptoms

The data and statistical models  in this study provide evidence that the non­displaced fracture  may be due to  stress on the tibial tuberosity during recovery.  Dogs undergo­ ing single[r]

CONMED Corporate Headquarters, Utica, NY, USA) (Fig. 1a, d). An Allis clamp (forceps) was subcutaneously inserted through the transverse incision in maximum ankle plantar flexion to maintain the tension of the distal stump, and then the percutaneous suture was crisscrossed through the distal stump (CONMED) (Fig. 1b, d). The end of the distal stump suture was subcutaneously passed through the transverse incision (Fig. 1c) and then looped through the proximal stump Krackow locking loop as the pulley (Fig. 2a, d). Two 0.5-cm long vertical incisions were bilaterally made on the posterior calcaneal tuberosity, and then the bird-beak arthroscopic suture passer was sub- cutaneously passed from the vertical incision to the trans- verse incision (Fig. 2b, d). The subcutaneous tunnel must be empty to avoid skin dimpling in the subsequent suture passage. The ipsilateral Krackow suture end and contralat- eral crisscross suture end were passed down to the distal mini-vertical incision (Fig. 2c). The sutures were seated at the posterior calcaneal tuberosity with two 4.5-mm suture anchors (PopLok® Knotless Suture Anchors; CONMED) (Fig. 3a, d). The tendon rupture gap became smooth and impalpable when the sutures were pulled to symmetrically proper tension in 30° of knee flexion and ankle plantar flexion. The anchors were then locked. A 3-0 absorbable running stitch (Monocryl; Ethicon, Johnson & Johnson Medical N.V., Belgium) was used at the epitenon (Fig. 3b). The wound was irrigated and closed layer by layer with 3- 0 and 4-0 monocryl subcutaneous sutures and finally closed with reinforced antimicrobial skin closures (Steri- Strips; 3 M Health Care, St. Paul, MN, USA). The Achilles tendon tension was checked with the leg erect immedi- ately post-surgery (Fig. 3c).

Avulsion fractures of pelvic skeleton are rare traumas occurring mostly in young athletes, caused by sudden trauma or unstable contraction of musculotendinous intersection during sports [1]. There are reports presenting avulsion fractures of pelvic ring in anterior inferior iliac spine (AIIS), anterior superior iliac spine (ASIS), ischial tuberosity, symphysis pubis apophysis and iliac crest [2-6]. Furthermore, although not often, avulsion injuries involving pelvic ring were reported in adults during daily actions unrelated to sports [7].

have influenced the observed healing delay in relation to GC animals that presented the fracture late, suggesting that the introduced stem cells may not have differenti- ated into osteoblasts, as expected, but again diverted to the new inflammatory process installed after the fracture of the tibial tuberosity. In addition, there is the fact that the timing of the therapeutic intervention in relation to the inflammatory state is an essential challenge to be ad- dressed according to El-Jawhari et al. (2016). In any case, both groups achieved complete ossification within the postoperative period of 8 to 10 weeks, as proposed by Hoffmann et al. (2006).