The incidence of occult and missed surgical neck fractures in patients with isolated greater tuberosity fracture of the proximal humerus

Leo Shaw,Cheng-Li Lin,Ping-Hui Wang,Chih-Kai Hong,Wei-Ren Su,Fa-Chuan Kuan

doi:10.1186/s12891-019-2810-y

Abstract

BackgroundOccult 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.MethodsRecords 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.ResultsOccult surgical neck fractures were found in 5 out of 68 (7.4%) patients, whereas missed surgical neck fractures were found in 3 out of 68 (4.4%) patients. In total, 32 patients had split type GT fracture, 32 had avulsion type and 4 had depression type. For those with occult surgical neck fractures, 7 had the split type GT fracture, while the remaining one had the avulsion type. Although the proportion of occult surgical neck fracture was higher in the split-type GT fracture (21.9%) than in the avulsion-type GT fracture (3.1%), the difference was not statistically significant (p = 0.056).ConclusionOccult humeral surgical neck fractures occurred in 7.4% of isolated greater tuberosity fractures after re-evaluation, while missed humeral surgical neck fractures occurred in 4.4%.

Highlights

Occult and missed surgical neck fractures can be found in patients diagnosed with isolated greater tuberosity (GT) fracture during the follow up period
Given that the clinical presentations of the so-called occult surgical neck fractures are often indistinguishable when comparing to a patient with an isolated GT fracture, such diagnoses are often delayed until obvious displacement or healing evidence of surgical neck fracture is found in the follow-up radiography
In the patient with the varus angulation of surgical neck fracture, subtle fracture was noted after performing the screw fixation for the GT fracture; thereafter, a headshaft angle greater than 30° was observed to have developed in the late follow-up radiographs (Fig. 4)

Summary

Introduction

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. Displaced three-part fractures, involving the greater tuberosity (GT) and surgical neck, are considered severe injuries in the spectrum of proximal humeral fractures, which are commonly treated surgically except for elderly patients, low-demand patients, and those with significant medical comorbidities [2, 3]. Given that the clinical presentations of the so-called occult surgical neck fractures are often indistinguishable when comparing to a patient with an isolated GT fracture, such diagnoses are often delayed until obvious displacement or healing evidence of surgical neck fracture is found in the follow-up radiography. Delayed diagnosis of a coexisting surgical neck fracture might lead to poor outcome of the patient because of insufficient activity restriction and

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