Tuberosity Fractures Research Articles

An Unusual Presentation of Chaput Tubercle Fracture with Coexisting Bimalleolar Component Involving Lateral and Posterior Malleoli: A Case Report

Background: Chaput tubercle fracture is a counterpart to adolescent Tillaux fracture, which occurs at the anterolateral part or the attachment site of the antero-inferior tibiofibular ligament on the distal tibia. It is rare, and its presentation may not be well appreciated in X-rays, which depicts the importance of a computed tomography (CT) scan of the ankle to reveal the same. Case Report: A 25-year-old gentleman presented to Chettinad Hospital, India, casualty with acute onset of pain, swelling, and restricted movements at the ankle joint following a road traffic accident. Ankle CT revealed a Chaput fracture along with a bimalleolar fracture (posterior and lateral malleoli). The complex displaced fracture was managed with open reduction internal fixation (ORIF) with plate osteosynthesis for the posterior malleoli and lateral malleoli, and tension band wiring was done for the Chaput tubercle fracture. At the end of two-year follow-up, the patient was able to mobilise without any support. Conclusion: Through this case report, we would like to enumerate the rarity of Chaput tubercle fracture associated with bimalleolar fracture of the ankle, which will be evaluated better with a CT evaluation in the first place. At the same time, it gives valuable information for the preoperative surgical plan.

Acute irreducible anterior shoulder dislocation due to interposition of the subscapularis muscle and the lesser tuberosity: a case report.

Efforts to reduce an anterior shoulder dislocation can fail due to numerous mechanical obstructions caused by soft tissue interposition (long head of the biceps, rotator cuff muscles, labrum, musculocutaneous nerve) and/or bony elements (displaced fragment of a greater tuberosity or glenoid fracture, bone impaction such as a Hill-Sachs lesion fixed on the glenoid rim, a bony Bankart lesion). Herein, we report the case of a 35-year-old man who sustained an anterior shoulder fracture-dislocation of his left shoulder after a fall. Despite a postreduction radiological examination that appeared misleadingly reassuring, subtle signs of persistent subluxation raised concerns. A computed tomography (CT) scan revealed subscapularis muscle entrapment along with avulsion of its bony insertion from the lesser tuberosity of the humerus, and a comminuted avulsion fracture of the greater tuberosity of the humerus. The patient underwent surgery using a deltopectoral approach. This involved releasing the entrapped subscapularis muscle and fixing the two fractured fragments. The lesser tuberosity was reduced and secured with two cannulated screws, and the comminuted fragment of the greater tuberosity was reattached using transosseous sutures. At 12-month follow-up, the patient achieved a Constant-Murley score of 85 of 100, with limitation in internal rotation at L3 but no signs of instability or new dislocation episode. This case underscores the importance of confirming shoulder reduction on at least two orthogonal views and paying close attention to the patient's feedback about sensation in their shoulder. Additionally, it highlights the utility of CT or magnetic resonance imaging scans if doubt exists about the integrity of the reduction.

Excellent clinical and radiological outcomes after arthroscopic reduction and double row-suture bridge for large-sized greater tuberosity fractures of the humerus.

Currently, there is limited information on the clinical outcomes of arthroscopic reduction and double-row suture bridge fixation for large greater tuberosity fractures of the proximal humerus. This study aimed to evaluate the radiological and clinical outcomes of arthroscopic reduction and double-row suture bridge fixation for these fractures, hypothesizing that arthroscopic reduction and double-row suture bridge fixation is a safe, effective and minimally invasive treatment for large greater tuberosity fractures. This retrospective study analysed patients with large greater tuberosity fractures (fracture fragment ≥30 mm in diameter) who underwent arthroscopic reduction and double-row suture bridge fixation and had a follow-up period exceeding 2 years. The anatomic reduction was confirmed by assessing the step-off on radiographs immediately after surgery, and the radiologic union time was recorded. At the final follow-up, range of motion and functional outcome scores were evaluated. Additionally, any surgery-related complications were evaluated. Fifteen patients with a mean follow-up of 57.7 ± 23.1 months were included in the study. The mean fracture fragment size was 32.5 ± 2.4 mm, with a mean displacement of 5.1 ± 1.6 mm. Immediately postsurgery, 13 of 15 patients (86.7%) had a fracture step-off of <3 mm, with an average union time of 3 months. At the final follow-up, patients demonstrated excellent outcomes, with an average forward flexion of 167 ± 9.7° and external rotation of 70 ± 16.3. Functional outcome scores showed significant improvement compared with preoperative scores (p < 0.001). No major surgery-related complications were reported. Arthroscopic reduction and double-row suture bridge fixation for large-sized greater tuberosity fractures is safe and shows good fracture reduction and excellent clinical outcomes. Therefore, this surgical method can be considered an alternative to open reduction for large greater tuberosity fractures. Level IV.

Adult Tillaux-Chaput tubercle fracture of the ankle with rupture of the peroneus tertius muscle: a case report

BackgroundTillaux-Chaput tubercle fractures occur in adolescents, which are often associated with the separation of the distal tibial growth plate. These types of fractures are rare in adults and even rarer when accompanied by a rupture of the peroneus tertius muscle. Given the limited number of reported cases, there is limited clinical awareness, resulting in missed diagnoses and delayed treatment, ultimately affecting ankle function.Case presentationWe report a case of an adult patient who experienced a right ankle injury resulting in swelling and pain after a traffic accident. Initial examination failed to identify the rupture of the peroneus tertius muscle, but the patient was observed to have restricted dorsiflexion and eversion of the foot. Surgical exploration through an anterolateral incision confirmed the rupture and the muscle was then repaired. The patient received four weeks of cast immobilization and then engaged in progressive rehabilitation exercises.Discussion and conclusionThis report shares the diagnostic and therapeutic experiences of an adult with a Tillaux-Chaput tubercle fracture associated with peroneus tertius muscle rupture to improve clinical recognition of such injuries, thus preventing misdiagnosis and treatment delays.

Surgical management and results of glenohumeral combination fractures of the anterior glenoid rim and the proximal humerus.

The combination of anterior large glenoid rim fractures (GRF) and proximal humerus fractures (PHF) is rare, with limited data available on specific treatments for these glenohumeral combination fractures (GCF). This study aimed to evaluate the treatment approaches for GCF, analyze patient outcomes, and outline surgical management strategies for different fracture types. This retrospective study included patients with GCF, excluding those with fossa glenoidalis fractures, isolated greater tuberosity fractures, or small glenoid rim fractures (< 5mm). Preoperative radiographs, CT scans, and follow-up radiographs were reviewed. Clinical outcomes were assessed using the Constant-Murley Score (CMS), Western Ontario Shoulder Instability Index (WOSI), Rowe Score (RS), and Oxford Shoulder Score (OSS). Sixteen patients with 17 GCFs (mean age 62years) were followed for an average of 39months. PHFs were categorized into three-part (76%), four-part (12%), and two-part fractures (12%). The average medial displacement of GRF was 5mm, with an average dehiscence of 4mm in the sagittal plane. Fourteen patients (88%) underwent surgical treatment; 35% had only the PHF surgically addressed, while 53% had both lesions surgically treated. Two patients (12%) received non-operative treatment. Complications were observed in 29% of cases, primarily involving the humeral side. The average CMS was 68 points, WOSI was 75%, RS was 77 points, and OSS was 41 points. Treating GCF is complex and routinely necessitates surgical intervention, with or without GRF refixation. CT imaging is crucial for precise assessment of fracture morphology. The involvement of the minor tuberosity is critical in selecting the optimal surgical approach and managing the subscapularis muscle.

Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation.

The risk factors for recurrent instability (RI) following a primary traumatic anterior shoulder dislocation (PTASD) remain unclear. In this study, we aimed to determine the rate of RI in a large cohort of patients managed nonoperatively after PTASD and to develop a clinical prediction model. A total of 1,293 patients with PTASD managed nonoperatively were identified from a trauma database (mean age 23.3 years (15 to 35); 14.3% female). We assessed the prevalence of RI, and used multivariate regression modelling to evaluate which demographic- and injury-related factors were independently predictive for its occurrence. The overall rate of RI at a mean follow-up of 34.4 months (SD 47.0) was 62.8% (n = 812), with 81.0% (n = 658) experiencing their first recurrence within two years of PTASD. The median time for recurrence was 9.8 months (IQR 3.9 to 19.4). Independent predictors increasing risk of RI included male sex (p < 0.001), younger age at PTASD (p < 0.001), participation in contact sport (p < 0.001), and the presence of a bony Bankart (BB) lesion (p = 0.028). Greater tuberosity fracture (GTF) was protective (p < 0.001). However, the discriminative ability of the resulting predictive model for two-year risk of RI was poor (area under the curve (AUC) 0.672). A subset analysis excluding identifiable radiological predictors of BB and GTF worsened the predictive ability (AUC 0.646). This study clarifies the prevalence and risk factors for RI following PTASD in a large, unselected patient cohort. Although these data permitted the development of a predictive tool for RI, its discriminative ability was poor. Predicting RI remains challenging, and as-yet-undetermined risk factors may be important in determining the risk.

Incidence of Tibial Tubercle Fractures in Patients With and Without Osgood-Schlatter Disease.

Patients with Osgood-Schlatter disease (OSD) may be at increased risk of tibial tubercle fractures due to an underlying weakness of the tibial tubercle apophysis relative to the patellar tendon as a result of repetitive microtrauma. The purpose of this study is to analyze the incidence of tibial tubercle fractures in patients with and without Osgood-Schlatter disease. We hypothesized that the incidence of tibial tubercle fractures would be higher in patients with Osgood-Schlatter disease. A retrospective cohort analysis of the PearlDiver database was performed by querying all patients diagnosed with Osgood-Schlatter disease between January 2010 and October 2022. An OSD cohort of 146,672 patients was captured using International Classification of Diseases, Ninth Revision (ICD-9), Tenth Revision (ICD-10) billing codes, and age as inclusion/exclusion criteria. The Student t test and the χ 2 analyses were used to compare the demographics and obesity between the OSD and control cohorts. Multivariable logistic regressions, controlling for residual differences in age, sex, and obesity, were used to compare rates of tibial tubercle fractures. Patients with a recent history of OSD were found to have higher rates of tibial tubercle fractures than the control group at all measured time points ( P <0.001). The 1-year rate of tibial tubercle fractures was 0.62% in the OSD group. The incidence of tibial tubercle fractures in the OSD group was 627.3 cases per 100,000 person-years compared with 42.7 cases per 100,000 person-years in the control group ( P <0.001). Male sex and obesity were also associated with an increased risk of sustaining a tibial tubercle fracture within these patient populations ( P <0.001). We report a significantly higher incidence of tibial tubercle fractures among patients with OSD compared with controls. This increase was most significant at 1 month following OSD diagnosis, however, held true for all measured time points. In addition, male patients and those with obesity were also noted to have increased incidence of tibial tubercle fractures regardless of an OSD diagnosis.

Sagittal Fragment Rotation and Ogden Type-I Classification Are Hallmarks of Combined Tibial Tubercle Fracture and Patellar Tendon Injury.

Tibial tubercle fractures (TTFs) are uncommon injuries, comprising <3% of all proximal tibial fractures. These fractures occasionally occur in conjunction with a patellar tendon injury (PTI). We aimed to identify risk factors associated with combined TTF and PTI. A retrospective review was performed of patients presenting to a single, tertiary children's hospital with TTF between 2012 and 2023. Demographic data, operative details, radiographs, and injury patterns were analyzed. Radiographs were assessed for the epiphyseal union stage (EUS), Ogden classification, and fracture patterns. Multiple logistic regression models were used to assess the impact of body mass index, comminution, fracture fragment rotation, EUS, bilateral injury, and Ogden classification on injury type. We identified 262 fractures in 252 patients (mean age, 13.9 ± 1.31 years). Of the patients, 6% were female and 48% were Black. Of the 262 fractures, 228 (87%) were isolated TTFs and 34 (13%) were TTFs with PTI. Multivariable analysis demonstrated fragment rotation on lateral radiographs (p < 0.0001) and Ogden Type-I classification (p < 0.0001) to be the most predictive risk factors for a combined injury. Rotation was associated with a substantial increase in the odds of a combined injury, with an odds ratio of 22.1 (95% confidence interval [CI], 6.1 to 80.1). Ogden Type-I fracture was another significant risk factor, with an odds ratio of 10.2 (95% CI, 3.4 to 30.4). The Ogden classification and fragment rotation are the most useful features for distinguishing between isolated TTF and combined TTF with PTI. This is the first study to identify risk factors for TTF combined with PTI. Surgeons may use this information to aid in preoperative planning. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Type 4 Tibial Tuberosity Avulsion Fractures: Surgical Treatment Early Outcomes and a Presentation of the Distal Cortical Fixation.

Background: The most published surgical technique for fixating Type 4 (Salter-Harris II) tibial tubercle avulsion fractures is uni-cortical in nature, and stability is suboptimal. This study presents a technique modification that is consistent with AO principles, by which the screws are aimed distally to purchase the posterior cortex of the distal fragment. This technique is defined as a "Distal Cortical Fixation". This modification has not been studied to date and harbors potential advantages. We aimed to assess the safety and efficacy of surgical fixation techniques for the above-mentioned fractures and to describe the new modification. Methods: A retrospective review was conducted at a level 1 children's hospital for surgically treated Salter-Harris II tibial tubercle fractures. Inclusion criteria were patients who sustained Salter-Harris II tibial tubercle avulsion fractures and were documented to reach one of two radiographic endpoints: union (regardless of alignment) or non-union that necessitated additional interventions. Medical records and radiographic studies were analyzed for fracture union and alignment. A comparative analysis was conducted to evaluate outcomes based on different fixation techniques that included Distal Cortical Fixation, a Proximal Screw Technique, and a crossed or multiple screws/pins construct. Results: A total of 37 patients were included with a mean age of 14.8 ± 1.2 years, with 34/37 (91.9%) being male. The most common procedure was a 1 to 3 screw fixation with a Distal Cortical Fixation (n = 21 (56.75%)), followed by a Proximal Screw Technique (n = 8, 21.62%), and a crossed or multiple screws/pins construct (n = 8, 21.62%). There was no difference between the groups in medical history and demographic features. The mean follow-up duration was 35.17 ± 36.79 weeks. There were no non-unions, and only a minimal change in the sagittal and coronal alignment (0.4 ± 1.94 (p = 0.872) and 0.53 ± 3.51 (p = 0.296) degrees, respectively) was noted and was not associated with the surgical technique. Conclusions: The surgical treatment of Salter-Harris II tibial tubercle avulsion fractures, including Distal Cortical Fixation, was presented and was found to provide satisfactory union rates on a short term follow up.

Do we consent to change? An evaluation of oral and maxillofacial outpatient department dentoalveolar consent forms

Obtaining informed consent before performing any dentoalveolar procedure is a professional, ethical, and legal obligation. Prior to this work, in this oral and maxillofacial department, no standardised consent process existed for dentoalveolar procedures. A targeted literature review established localised gold standards for dentoalveolar procedures, and retrospective data from 56 dentoalveolar consent forms over a four-week period assessed baseline compliance with these standards. Data analysis identified that risks of dry socket and trismus were documented in only 7% of cases, and maxillary tuberosity fracture was never documented. Thirty-three per cent of lower third molar cases did not include consent for inferior alveolar nerve injury. Findings were discussed in a departmental audit meeting, and a root cause analysis identified memory failure, repetition fatigue, and varying clinician knowledge and experience, as key drivers. The evidence base and localised gold standards were discussed. A standardised, bilingual, triple-copy dentoalveolar consent form was developed, including predefined indications, additional procedures, and risks, in a tick-box format. This form was presented to the Department of Patient Safety and Quality and gained local approval. Cases completed with the new form will now be evaluated against the localised gold standards, with a mixed-methods feedback survey investigating staff and patient opinions. Local processes for obtaining and documenting valid consent for dentoalveolar treatment were found to be inconsistent and frequently inadequate. Fifteen localised gold standards were set, and a new standardised consent form developed, which will be evaluated for effectiveness and acceptability.

Hip Injuries in the Pediatric Athlete—Pelvic Apophyseal Avulsions

Pelvic apophyseal avulsion fractures have been occurring more commonly in young athletes in the context of increased intensive year-round training and early specialization in youth sports, and this diagnosis must be considered in the pediatric patient presenting with hip pain. An understanding of the relevant anatomy can guide the history and physical exam to arrive at the diagnosis, which is usually confirmed with plain radiographs. Although non-operative management remains the mainstay of treatment for these patients, surgery may be warranted for ischial tuberosity fractures displaced > 2 cm and for symptomatic nonunions The objective of this review is to provide a comprehensive overview of pelvic apophyseal avulsion injuries.

Fixation of the rotator cuff tendons for the greater tuberosity fracture of the humerus

Introduction Strategical approaches to managing patients with a greater tuberosity fracture of the humerus are controversial and there are discussions about surgical treatment options. Nondisplaced fractures require no surgical management. Shoulder replacement can be indicated for the surgical treatment of proximal humeral fractures with limited function of the upper limb and difficulties in refixation of the rotator cuff tendons due to the peculiar anatomical location of the tendon fixation. Solution to this problem can improve the quality of life of patients with greater tuberosity fracture of the humerus.The objective was to evaluate the treatment outcome of a patient with a greater tuberosity fracture of the humerus repaired with open refixation of the rotator cuff tendons and medialization of the border of the articular surface of the humerus.Material and methods A 46-year-old patient presented with limited movements and severe pain in the left shoulder after humerus dislocation and a greater tuberosity fracture.Results The condition was repaired with an open repair of the rotator cuff tendons and medialization of the border of the articular surface of the humerus. The patient reported neither pain nor limited movements in the left shoulder at the one-year follow-up.Discussion Treatment options for patients with a greater tuberosity injury remains controversial. The effectiveness and results of organ-saving surgery have not been explored and require scientific evaluation using a larger cohort of patients.Conclusion Excellent functional results were achieved in a patient with injury to the greater tuberosity using surgical refixation of the rotator cuff tendons and medialization of the cartilaginous surface.

Conservative Treatment of an Isolated Greater Tuberosity Fracture With Dislocation: Management of Post-Traumatic Subacromial Impingement Syndrome and a Mini-Review of the Literature

Conservative Treatment of an Isolated Greater Tuberosity Fracture With Dislocation: Management of Post-Traumatic Subacromial Impingement Syndrome and a Mini-Review of the Literature

Classification and Treatment Strategies of Tibial Tubercle Fractures in Adults.

Tibial tubercle is a crucial player in maintaining the structural integrity and functional stability of the knee joint. Currently, there is no standardized protocol for the classification and treatment of tibial tubercle fractures in adults. This study analyzed the incidence and treatment strategies of tibial tubercle fractures in adults according to the four-column and nine-segment classification system. Data of patients with proximal tibial fractures involving tibial tubercle fractures who were treated at our hospital from August 2007 to March 2023 were retrospectively reviewed. The fractures were classified using the AO/OTA classification and four-column and nine-segment classification systems, and the treatment protocol (surgically treated or conservatively treated) was recorded. The number and distribution proportion of patients were counted. A two-sided t-test was conducted to determine the significance of differences between the gender and sides. In total, 169 tibial tubercle fractures were found in 1484 proximal tibial fractures. According to the AO/OTA classification, seven of the 169 patients, (4.1%) were type A, 36 patients (21.3%) were type B, and 126 patients (74.6%) were type C. According to the four-column and nine-segment classification, type 1 cleavage without free fragments was the most common type of fracture (93/169, 55.0%), followed by type 2 dissociative segmental fragments (48/169, 28.4%) and type 3 comminuted fractures (28/169, 16.6%). Overall, 139 of the 169 proximal tibial fractures with tuberosity involvement were treated surgically. Among them, additional fixation of the tubercle fragment was performed in 52 fractures. The incidence of tibial tubercle fractures involved in proximal tibial fractures was approximately 11.4% (169/1484) in adults, and approximately one-third of the tubercle bone fragment required additional fixation (30.8%, 52/169). The injury types in the four-column and nine-segment classifications are helpful for accurately judging and making treatment-related decisions for tibial tubercle fractures.

Classification and management of tibial tubercle avulsion fractures in children.

Fractures of the tibial tubercle are an uncommon injury, constituting 0.4-2.7% of all epiphyseal injuries. They occur in the adolescent age group, often during sports such as basketball and football. They are often classified using the modified Ogden classification. Understanding the anatomy and pathophysiology is essential in the management of these fractures, to predict complications and counsel patients and families on care. Tibial tubercle fractures generally have favourable overall outcomes when the correct treatment modality is chosen, with a high rate of union and a 98% return to preinjury activities. This article provides a guide for doctors on the classification and management of these injuries, to ensure that appropriate treatment is given according to current literature and best practice.

The Prevalence of Acute Compartment Syndrome in Pediatric Tibial Tubercle Fractures.

Tibial tubercle fractures are a unique class of pediatric orthopaedic injuries that frequently necessitate surgical treatment and strict monitoring due to the associated risk of acute compartment syndrome (ACS). However, current literature is conspicuously limited in its ability to estimate the risk of ACS after these fractures. Therefore, the purpose of this study is to utilize a nationwide database to estimate the prevalence of ACS after pediatric tibial tubercle fractures. We utilized the Healthcare Cost and Utilization Project's Kids' Inpatient Database (2019) to identify all pediatric patients, 18 years of age and under, with isolated tibial tubercle fractures (International Classification of Diseases, 10th revision Clinical Modification S82.151-S82.156) and ACS (T79.A0, T79.A2, T79.A29). Patients were excluded if they had additional lower extremity injuries (ie, tibial shaft, plateau, etc). A subanalysis was conducted for those undergoing fasciotomy, with and without an ACS diagnosis. Among the 591 isolated tibial tubercle fractures, there were 8 ACS cases for a prevalence of 1.35%. There were 22 (3.72%) additional cases of fasciotomy without an ACS diagnosis. All ACS cases were diagnosed during the original hospitalization; all were male and had closed fractures. The cohort included 469 teenagers (13+ years) and 77 pre-teens, with 40 females and 506 males. Racial demographics: 132 white, 232 black, 112 Hispanic, 15 Asian, 4 Native American, 23 unknown, and 28 others. No significant associations were found between ACS and age, race, insurance status, mechanism of injury, or hospital region. The rate of ACS in pediatric tibial tubercle fractures appears to be much lower than previously reported, at 1.35%. However, the nearly three-fold higher prevalence of fasciotomy without an ACS diagnosis, suggests a generous use of prophylactic fasciotomies and/or an undercharacterization of actual ACS cases from miscoding. This is the first and largest study to employ a nationally representative database to investigate the prevalence of ACS after tibial tubercle fractures. Level III.

Classification and management of tibial tubercle avulsion fractures in children

Abstract Fractures of the tibial tubercle are an uncommon injury, constituting 0.4–2.7% of all epiphyseal injuries. They occur in the adolescent age group, often during sports such as basketball and football. They are often classified using the modified Ogden classification. Understanding the anatomy and pathophysiology is essential in the management of these fractures, to predict complications and counsel patients and families on care. Tibial tubercle fractures generally have favourable overall outcomes when the correct treatment modality is chosen, with a high rate of union and a 98% return to preinjury activities. This article provides a guide for doctors on the classification and management of these injuries, to ensure that appropriate treatment is given according to current literature and best practice.

Classification of Hamate Fractures: An Analysis of 247 Patients with Hamate Fractures.

Background: We devised a new classification of hamate fractures named the TOUCH classification. Each letter of this acronym depicts a fracture type - Type I (Transverse fracture), Type II (Open and/or complex fracture), Type III (Ulnar/medial tuberosity fracture), Type IV (Coronal fracture) and Type V (Hook fracture). Each fracture type was further divided into two or three subtypes (a, b, and/or c) based on degree of severity. The aim of this study is to classify the hamate fractures treated at our centre using this classification. Methods: A retrospective review of all patients with hamate fractures treated at our hospital between 2003 and 2022 was done. Patient data with regard to age, gender, mechanism of injury, injured limb and any associated injuries was collected. Hamate fractures were classified based on the TOUCH classification. Results: A total of 247 patients with hamate fractures were included. Patients in the age group of 20-40 years accounted for 73.6% of all fractures. Female patients accounted for only 6.9% of all fractures and 76.5% of women with hamate fractures were older than 40 years. The incidence of hamate fracture tended to increase with age in women. The most common mechanism of injury was a fall (69 patients). The injury involved the right upper limb in 195 patients. And 164 patients had associated injuries in the same upper limb. Type III (coronal fracture of the hamate body) accounted for 57.4%, followed by type V (hook of hamate fracture) in 26.7% of patients. Conclusions: The TOUCH classification could cover all kinds of hamate fractures. It is easy to remember and may guide surgeons in considering treatment options. Level of Evidence: Level IV (Diagnostic).

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

What is the Utilization and Impact of Advanced Imaging for Tibial Tubercle Fractures? An Analysis of 598 Patients From the Tibial Tubercle Study (TITUS) Group.

Given the rare nature of tibial tubercle fractures, previous studies are mostly limited to small, single-center series. This results in practice variation. Previous research has shown poor surgeon agreement on utilization of advanced imaging, but improved evidence-based indications may help balance clinical utility with resource utilization. The purpose of this study is to quantify diagnostic practices for tibial tubercle fractures in a large, multicenter cohort, with attention to the usage and impact of advanced imaging. This is a retrospective series of pediatric tibial tubercle fractures from 7 centers between 2007 and 2022. Exclusion criteria were age above 18 years, missing demographic and pretreatment data, closed proximal tibial physis and tubercle apophysis, or a proximal tibia fracture not involving the tubercle. Demographic and injury data were collected. Fracture classifications were derived from radiographic evaluation. The utilization of advanced imaging was recorded as well as the presence of findings not identified on radiographs. Standard descriptive statistics were reported, and χ2 tests were performed (means reported±SD). A total of 598 patients satisfied the inclusion criteria, of which 88.6% (530/598) were male with a mean age of 13.8±1.9 years. Internal oblique x-rays were obtained in 267 patients (44.6%), computed tomography (CT) in 158 (26.4%), and magnetic resonance imaging (MRI) in 64 (10.7%). There were significant differences in the frequency at which CT (7.2% to 79.4%, P<0.001) and MRI were obtained (1.5% to 54.8%, P<0.001). CT was obtained most frequently for Ogden type IV fractures (50/99, 50.5%), and resulted in novel findings that were not visualized on radiographs in a total of 37/158 patients (23.4%). The most common finding on CT was intra-articular fracture extension (25/37). MRI was obtained most frequently for Ogden type V fractures (13/35, 37.1%), and resulted in novel findings in a total of 31/64 patients (48.4%). The most common finding was patellar tendon injury (11/64), but only 3 of these patients required tendon repair. Substantial variation exists in the diagnostic evaluation of tibial tubercle fractures. CT was most helpful in clarifying intra-articular involvement, while MRI can identify patellar tendon injury, periosteal sleeve avulsion, or a nondisplaced fracture. This study quantifies variation in diagnostic practices for tibial tubercle fractures, highlighting the need for evidence-based indications for advanced imaging. Level III.