Radiological and biomechanical assessment of displaced greater tuberosity fractures

Abstract

Purpose Greater tuberosity fractures are challenging lesions concerning decision-making. In order to improve our treatment algorithm, we developed a new method, which allows predicting a possible subacromial conflict on standard anteroposterior radiographs, considering not only the displacement of the fragment but also the width of the subacromial space. Methods The measurement technique consisted of drawing three concentric circles on true anteroposterior radiographs. The inner circle (radius Rh) perfectly matched the humeral head surface. The medial circle (radius Rt) was tangent to the greater tuberosity, and the outer circle (radius Ra) touched the undersurface of the acromion. The ratio Rt/Rh, which describes how much the greater tuberosity projects above the articular surface, and the relationship (Rt-Rh)/(Ra-Rh), which quantifies the space occupied by the greater tuberosity under the acromion, were calculated and called Greater Tuberosity Index and Impingement Index, respectively. Five dry humeri were used to assess the influence of rotation and abduction on the Greater Tuberosity Index. The radiographs of 80 shoulders without any osseous pathology were analyzed to obtain reference values for both indices. Finally, greater tuberosity fractures with different displacements were created in five cadaver specimens, and subacromial impingement was correlated with these parameters. Results On anteroposterior radiographs, the greater tuberosity was most prominent in neutral rotation, regardless of abduction. In shoulders without osseous pathology, the Greater Tuberosity Index and the Impingement Index averaged 1.15 (range 1.06–1.28) and 0.46 (range 0.21–0.67). In the biomechanical experiments, the Impingement Index was a better discriminator for subacromial impingement than the Greater Tuberosity Index. A fracture with a displacement corresponding to an Impingement Index of 0.71 or greater was associated with subacromial impingement. Conclusions Reduction of a displaced greater tuberosity fragment should be considered if the Impingement Index is 0.7 or greater. The measurement method is simple and reliable and has the potential to be used for the assessment of subacromial impingement in other conditions.

Midterm results of pyrocarbon interposition shoulder arthroplasty: good outcomes after posttraumatic osteonecrosis without malunion of the tuberosities

“… 51 And, using a standardized protocol, the central observer compared the earliest available postoperative anteroposterior x-ray images (external, neutral, and internal rotations) with the 5-year one to assess the evolution of 2 radiographic criteria over time: glenoid erosion and thinning of the tuberosities. For both criteria, measurements were calculated relative to the implant diameter, to avoid scale errors, using measurements abacus inspired by a radiological study by Nyffeler et al 34 ( Fig. 1 ).…”

Avaliação funcional do ombro após osteossíntese da fratura da tuberosidade maior: Há influência da luxação glenoumeral?

“…The greater tuberosity requires surgical treatment if the fracture deviation is ≥ 5 mm. 6 Surgery is more indicated for young patients or those performing activities with arm elevation above the head. 7 The surgical treatment aims at an anatomical reduction between the greater tuberosity and the humeral head in a portion approximately 9 mm distal to its most proximal aspect.…”

“… 7 An improper reduction may cause secondary impingement syndrome and/or cuff failure (high tuberosity), or tendon rupture due to excessive stress (low tuberosity). 6 …”

“…O tratamento cirúrgico da tuberosidade maior é indicado se o desvio da fratura for ≥ 5 mm. 6 Recomenda-se mais o tratamento operatório a pacientes jovens ou que realizam atividades com elevação do braço acima da cabeça. 7 O tratamento cirúrgico tem como objetivo uma redução anatômica entre a tuberosidade maior e cabeça umeral em uma porção, em média, 9 mm distalmente ao aspecto mais proximal da cabeça do úmero.…”

“… 7 A redução inadequada pode causar síndrome do impacto secundária e/ou insuficiência do manguito (tuberosidade alta), ou ruptura do tendão devido à tensão excessiva (tuberosidade baixa). 6 …”