An awareness towards the possibility of an isolated fracture fragment would help in differentiating it from other more common pathologies. To confirm the diagnosis, an axillary view of the shoulder must be taken. With a patient presented with an indirect trauma, an avulsion fracture of the lesser tuberosity can easily be missed with only a routine antero-posterior and scapular view radiographs of the shoulder, especially if the avulsed fragment is minimally displaced. Anterior shoulder palpation should be done to suspect subluxation of the long head of biceps tendon and assessment of the gleno-humeral joint stability must be done to rule out associated shoulder dislocations. As well as, weakness in performing the 'lift off' test is suggestive of reduced internal rotation and increased passive external rotational, as compared to the contralateral shoulder. Patients presenting with an anterior shoulder tenderness, must be examined thoroughly to look out for tenderness over the lesser tuberosity region. Īn isolated avulsion fracture of the lesser tuberosity requires a high index of suspicion. In keeping with our epileptic patient, involuntary contraction of the subscapularis muscle might have been the cause of the lesser tuberosity fracture. The main mechanism of injury is believed to be muscular violence where the subscapularis muscle is forced to extend when it forcefully contracts to resist the abduction and external rotation of the shoulder, and this results in a strong traction force which avulses the lesser tuberosity. This rare indirect injury is most commonly caused by the pulling forces of the upper gleno-humeral ligament and the subscapularis muscle in hyperextension with increased abduction and external rotation of the shoulder. Due to its small size and its location on the medial side of the head of the humerus, the lesser tuberosity is protected from direct injury.
#Closed fracture of proximal end of right humerus series
It is uncommon to have an isolated avulsion fracture of the lesser tuberosity and therefore, experience in the management of this rare injury is less and clinical series remain as few or limited only to case reports. On his 3 rd month post op follow up, he had regained his normal shoulder function. Fracture fragment is reduced to its anatomical location with evidence of union. The axillary view clearly revealed an isolated avulsion fracture of lesser tuberosity of the left humerus (Figure 2).įigure 5: Postoperative anteroposterior radiograph at 10 weeks. Radiograph of the right shoulder taken in the anterior-posterior approach showed a fractured lesser tuberosity found to be displaced caudal to the glenoid (Figure 1). The passive range of motion of the left shoulder was 130° in forward flexion and 130° in abduction, while the passive extension and adduction was 20° and 40°, respectively. Pain was restricted during active extension and adduction achieved at 15°. Active external rotation was normal while active internal rotation was reduced to only 20%. Assessment of his left shoulder showed active forward flexion and abduction was 70°. Tenderness was localized to the anterior part of the left shoulder. Physical examination revealed an area of ecchymosis and swelling over the anterior left shoulder. Post seizure he experienced left anterior shoulder pain with limited range of motion in his left shoulder. He could not recall the position of his arm at the time of injury. We present a rare case of an isolated lesser tuberosity avulsion fracture post epilepsy that was treated operatively resulting in a good clinical outcome.Ī 21-year-old gentleman presented to the Emergency Department with a complaint of left shoulder pain after suffering an epileptic attack a day prior. Īcting as an antagonist, the subscapularis muscle forcefully contracts to resist, leading to an avulsion of the lesser tuberosity. The usual mechanism of injury resulting in an avulsion fracture is an abduction external rotation trauma of the shoulder. Isolated lesser tuberosity, Shoulder, Good clinical outcomeĪvulsion Fracture Lesser Tuberosity of The Humerus is a rare injury that usually occurs in association with fractures involving two or three parts of the proximal humerus or in association with a posterior fracture dislocation of the shoulder joint. Functional outcome was successful, and the patient regained his normal pain-free shoulder function 3 months surgery. Open reduction and internal fixation was performed. We report a isolated fractured lesser tuberosity occurring in a gentleman post seizure. Isolated humeral lesser tuberosity fracture is rare and is usually associated with fractures of the proximal humerus.
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