Arthroscopic Fixation of Greater Tuberosity Fractures: A New Technique
Arthroscopic Fixation of Greater Tuberosity Fractures: A New Technique
Arthroscopic Fixation of Greater Tuberosity Fractures: A New Technique
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CASE REPORT
Introduction
Greater tuberosity fractures are seen in conjunction with 515% of anterior shoulder dislocations.2 Despite adequate reduction of the shoulder they may still displace secondarily as a result of the supraspinatus pull. Even small amount of posterosuperior displacement can cause impingement and subsequent shoulder dysfunction.1 The arthroscopic management of this fracture provides an alternative to conventional techniques with the advantage of an anatomic reduction under direct vision.
combined with an inter-scalene block, with the patient in the beech chair position. The arm was draped separately and held by an assistant so as to achieve accurate positioning as required. Standard portals were used and the shoulder joint was examined arthroscopically (Fig. 2). In this case there was no associated rotator cuff, labral or bony pathology either of the glenoid or the humeral head. Following evacuation of the haematoma, the fracture site was visualised and debrided (Fig. 3). A 1.2-mm guide wire was then passed percutaneously from the pos-
Figure 1 Radiograph of the shoulder following closed manipulation of the dislocation, showing the displaced greater tuberosity fracture.
1572-3461/$ see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.02.039
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S. Joshy, A. Iossidis
Figure 2 Portals used for the arthroscopic xation of the greater tuberosity.
Figure 5 Guide wires inserted percutaneously while the fracture site is visualised using arthroscopy.
Figure 6 xation.
Figure 4 Reduction of the fracture with the aid of guide wire under arthroscopic visualization.
Figure 7 xation.
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terolateral aspect of the shoulder through the fractured greater tuberosity and in to the fracture site. This was visualised using the posterior portal (Fig. 4). The fracture was manipulated using the guide wire and accurately reduced under direct arthroscopic vision. An anatomic reduction was conrmed by visualising the fracture from within and above the joint. Following reduction two further guide wires were inserted percutaneously (Fig. 5) and their positions conrmed both by arthroscopy and image intensier. Fixation was achieved with three cannulated screws (Figs. 6 and 7). Post operatively, the arm was supported in a sling and at 6 weeks follow-up the patient had regained a pain free elevation and lateral functional rotation.
alternative to the conventional open methods and causes only minimal disruption to the soft tissues. Arthroscopy also allows adequate visualisation of associated labral and rotator cuff tear pathologies, which could be treated if indicated at the time of surgery. In addition, the arthroscopic assisted method permits adequate preparation of the fracture fragment using motorised instruments and an anatomic reduction under direct arthroscopic vision. Finally the deltoid morbidity avoided and the post-operative recovery is shortened.
Conclusion
The arthroscopically assisted percutaneous xation of the greater tuberosity provides an anatomic reduction and xation of the fracture and results in early functional recovery. It can therefore be considered as a viable alternative to conventional open techniques.
Discussion
Greater tuberosity fractures are common and could result in signicant shoulder dysfunction, when not properly treated. Accepting a displacement of more than 0.5 mm has been associated with poor results.1,2 Open reduction and xation of the fracture of the greater tuberosity however, can cause signicant disruption of the deltoid and increased morbidity.1,2 Preservation of the shoulder soft tissue envelope has been the main concern of shoulder surgery in the last decade and as a result most of the elective procedures are now performed arthroscopically. We believe that extending the arthroscopic techniques to fracture management allows a viable
References
1. Bonsell S, Buford DA, Dallas TX. Arthroscopic reduction and internal xation of a greater tuberosity fracture of the shoulder: A case report. J Shoulder Elbow Surg 2003;12: 397400. 2. Carera EF, Matsumotto MH, Netto NA, Faloppa F. Fixation of a greater tuberosity fractures. J Arthrosc Rel Surg 2004;20(8): 10911.