Isolated fractures of the greater tuberosity: When are they treated conservatively?

Isolated fractures of the greater tuberosity: When are they treated conservatively? Original contribution 1 1 1 2 Obere Extremität 2018 · 13:106–111 Benedikt Schliemann · Lukas F. Heilmann · Michael J. Raschke ·HelmutLill · 1 2 https://doi.org/10.1007/s11678-018-0459-z J. Christoph Katthagen · Alexander Ellwein Received: 25 February 2018 Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Accepted: 17 April 2018 Germany Published online: 15 May 2018 Traumatology and Reconstructive Surgery, Diakovere Friederikenstift GmbH, Hannover, Germany © The Author(s) 2018 Isolated fractures of the greater tuberosity: When are they treated conservatively? Abaselinestudy Fractures of the greater tuberosity (GT) results in fractures with >3 mm displace- dislocations) comprised a fourth group. often occur with more complex proximal ment [22]. Similarly, other authors re- The fractures were further subdivided humerus fractures and are less frequently ported good to excellent results in their into simple fractures with only a sin- observed as an isolated pathology. Only patients who had conservative treatment gle fragment and comminuted fractures 14–20% of proximal humerus fractures for minimally displaced fractures [12, 17, with two or more fragments. are isolated lesions of the GT [4, 15, 23]. 24]. The indication for conservative treat- Upto30%ofthesefracturesareassociated The present baseline study aimed to ment was analyzed according to the pa- with anterior glenohumeral dislocations analyze under what circumstances iso- tients’ records. A follow-up period of at [25]. lated fractures of the GT are managed least 6 months was mandatory in order According to Neer, a displacement of conservatively. In addition to the in- to evaluate secondary surgical interven- the fragment of >10 mm and 45° (later dication for conservative treatment, the tions. Interventions were further sub- modified to >5 mm and 30°) is believed rate of secondary interventions for failed divided into fracture-related procedures to be an indication for operative treat- conservative treatment is evaluated. and procedures required for associated ment [20]. However, whether all other lesions, such as capsulolabral tears in pa- fractures can be managed successfully by tients who sustained a shoulder disloca- Patients and methods nonoperative treatment is unclear. Cur- tion or posttraumatic stiffness. rently, there is a lack of evidence in the lit- A retrospective data evaluation of iso- erature to support either conservative or lated GT fractures was performed from Results operative treatment strategies in GT frac- the clinical database of two german level- tures. Whether the fracture type and the I trauma centers from January 2010 to A total of 114 patients were identified. In etiology of the fracture impact the deci- June 2017. A total of 114 patients with sixpatientswithsevere displacement, op- sion-making and the final outcome also a GT fracture were initially treated con- erative treatment was recommended, but remains unclear. servatively. The mean age of the patients severe comorbidities (i.e. cardiovascular There are only a few reports on conser- at thetimeof the injury was 55years conditions) prevented surgical interven- vative treatment of isolated GT fractures. (range, 18–94 years). The mechanism tions. In addition, two patients refused to Platzer et al. compared the functional re- of the injury was a direct fall on the undergo surgery despite severe concomi- sultsof52 patientswho underwentopen affected shoulder in 61 cases, a traffic tant soft tissue lesions, and one patient reduction and internal fixation (ORIF) of accident in nine cases, and an anterior did not return to the hospital after an aGTfracturewithninepatientswhowere shoulder dislocation in 44 cases. All pa- magnetic resonance imaging (MRI) was treated conservatively for similar frac- tients had conventional radiographs of indicated. These nine patients were ex- tures. All patients had a displaced frac- the shoulder in the anteroposterior, axil- cluded from the study. Of the remaining ture (>5 mm) [23]. After a mean follow- lary, and Y-view. After an isolated frac- 105 fractures, 72 (68.6%) were not dis- up of 5.5 years, functional results were ture of the GT was identified, the degree placed (. Fig. 1), a mild displacement of significantly better aer ft operative treat- of displacement was assessed and clas- 1–3 mm was found in 27 cases (25.7%), ment than they were aeft r conservative sified as: (1) no displacement, (2) mild severe displacement (>3 mm) was found treatment. The same authors reported on displacement(1–3 mm), or(3)severedis- in two cases (1.9%), and the remain- 135 conservatively treated patients with placement (>3 mm). Impression frac- ing four fractures (3.8%) were classified an isolated GT fracture and found worse tures (usually related to glenohumeral as impression fractures (depression type 106 Obere Extremität 2 · 2018 Fig. 1 9 Conservatively treated fracture of the greater tuberosity: initial radiograph (a), follow-up after 3 weeks to exclude secondary displacement (b), and anatomic consoli- dation 3 months after the injury (c) Fig. 2 9 a Posterosuperior malunion of a solid greater tuberosity fracture. Preop- erative anteroposterior ra- diograph (left)andintraop- erative finding (right). b Os- teotomy of the fragment (left) with corresponding fluoroscopy (inset)andex- ternal view (right). c Under arthroscopic and fluoro- scopic guidance, the frag- ment is reduced and fixed with two 3.5-mm screws. d Functional outcome four months postoperatively fracture). The decision to treat the two all fractures were treated conservatively Patients were reexamined clinically caseswithmore severe displacementcon- with the affected arm immobilized in an and radiographically to identify sec- servatively was made based on an initial abduction brace to release tension from ondary displacements. If the patient had displacement of 4 mm. 51% of the frac- the rotator cuff on the fracture site. Pas- further complaints, MRI was performed tures weresimpleand 49% had multiple sive motion was allowed with range of to analyze the integrity of the rotator cuff fragments. Comminuted fractures were motion (ROM) limited to 90° of flexion and the capsuloligamentous complex. more likely to occur with shoulder dis- andabduction, freeexternalrotation, and Of the remaining 105 patients, 17 locations (57%). In the acute situation, no internal rotation for the first 3 weeks. underwent secondary surgical inter- Obere Extremität 2 · 2018 107 Abstract · Zusammenfassung Obere Extremität 2018 · 13:106–111 https://doi.org/10.1007/s11678-018-0459-z © The Author(s) 2018 B. Schliemann ·L.F.Heilmann · M. J. Raschke · H. Lill ·J.C. Katthagen ·A.Ellwein Isolated fractures of the greater tuberosity: When are they treated conservatively? A baseline study Abstract revision surgery after primary conservative Background. This study analyzed the Results. We identified 114 fractures. Nine treatment. indications for conservative management cases were excluded because patients refused Conclusion. Secondary interventions are of isolated greater tuberosity (GT) fractures. surgery or their comorbidities ruled it out. required more frequently after shoulder The rate of secondary interventions for failed Only two of the remaining 105 patients had dislocation. Surgery is most likely required conservative treatment was also assessed. an initial displacement >3 mm. All other GT for associated soft tissue lesions rather than Methods. A retrospective data evaluation of fractures (n = 103, 98%) were not displaced for secondary displacements. Thus, detailed isolated GT fractures was performed from or only slightly displaced (0–3 mm). The physical examination and magnetic resonance the clinical database of two level-I trauma fracture was associated with an anterior imaging should be used to screen for centers from January 2010 to June 2017. shoulder dislocation in 39 cases (37%); concomitant soft tissue injuries accompanying Conservatively treated GT fractures were 17 patients (16.2%) underwent surgery after GT fractures to prevent revision surgeries. identified and subdivided according to primary conservative treatment. Four of etiology, morphology, and amount of initial these 17 patients presented with a secondary Keywords displacement. Secondary surgical interven- displacement of the GT fragment. In all Greater tuberosity fracture · Shoulder tions were recorded and subcategorized other cases (76.5%), an associated soft dislocation · Proximal humeral fractures · into fracture-associated interventions and tissue lesion necessitated revision surgery. Concomitant lesions · Surgery interventions for associated soft tissue lesions. Young age, anterior shoulder dislocation, and concomitant injuries were risk factors for Isolierte Tuberculum-majus-Frakturen: Wann werden sie konservativ behandelt? Eine Statuserhebung Zusammenfassung Weichteilverletzungen stellten Risikofaktoren Hintergrund. Ziel der vorliegenden Arbeit Ergebnisse. Es wurden 114 TM-Frakturen dar, welche die Wahrscheinlichkeit für eine war es, die Indikationen für eine konservative identifiziert. Neun Fälle wurden aus der sekundäre chirurgische Intervention nach Behandlung bei isolierten Frakturen des Studie ausgeschlossen, weil die Patienten die primär konservativer Therapie erhöhten. Tuberculum majus (TM) zu ermitteln. empfohlene operative Therapie ablehnten Schlussfolgerung. Sekundäre chirurgische Darüber hinaus wurde die Rate sekundärer oder diese aufgrund von Komorbiditäten nicht Interventionen sind häufiger nach ante- chirurgischer Interventionen bei Versagen der möglich war. Bei nur 2 der verbliebenen 105 riorer Schulterluxation und mit größerer konservativen Therapie erfasst. Patienten war die Fraktur >3 mm disloziert, Wahrscheinlichkeit bei begleitenden Methoden. Es erfolgte eine retrospektive alle anderen TM-Frakturen (n = 103, 98 %) Weichteilverletzungen als bei sekundären Auswertung der Datenbanken zweier Level- waren initial nicht oder nur leicht disloziert Dislokationen notwendig. Daher sollte durch I-Traumazentren, in denen isolierte TM- (0–3 mm). In 39 Fällen (37 %) war die eine detaillierte körperliche Untersuchung Frakturen von Januar 2010 bis Juni 2017 Fraktur mit einer anterioren Schulterluxation und ggf. durch eine MRT der Fokus auf die erfasst wurden. Die konservativ behandelten assoziiert. Bei 17 Patienten (16,2 %) erfolgte Suche nach begleitenden Weichteilverlet- Frakturenwurdennachihrer Ätiologie nach initialer konservativer Therapie eine zungen bei TM-Frakturen gelegt werden, um sowie der Morphologie und Dislokation des sekundäre chirurgische Intervention. Bei Revisionsoperationen vorzubeugen. Fragments ausgewertet und unterschieden. 4 dieser 17 Patienten war die Revision Sekundäre chirurgische Interventionen wegen einer sekundären Dislokation des Schlüsselwörter wurden erfasst und ebenfalls weiter unter- TM-Fragments notwendig. In allen anderen Tuberculum-majus-Fraktur · Schulter- schieden in frakturassoziierte Maßnahmen Fällen (76,5 %) machte eine assoziierte luxation · Proximale Humerusfrakturen · und in Interventionen, die aufgrund von mit Weichteilverletzung die sekundäre Operation Begleitverletzungen · Operation Weichteilverletzungenerforderlich wurden. erforderlich. Junges Patientenalter, eine anteriore Schulterluxation und begleitende ventions (16.2%). In only four cases, cedures are listed in . Table 1.Given However, this difference was not statis- including the two patients with ini- that three patients refused to undergo tically significant (p= 0.415). tial displacement of the GT fragment surgery despite an indication because of The fracture morphology (single frag- >3 mm, a surgical revision was required secondary displacement and subsequent ment vs. comminuted fractures) had no owing to a secondary displacement of limited ROM, the revision rate would significant impact on the risk for sec- the fracture with subsequent impinge- have increased to 19%. ondary interventions. ment and limited ROM (. Fig. 2). In Patients for whom a shoulder dislo- By contrast, the amount of the initial all other cases (n= 13), an associated cation was the cause of the GT fracture displacement of the fragment is an indi- soft tissue lesion led to a secondary were more likely to undergo secondary cator of secondary displacement and sur- surgical intervention. The different pro- surgical intervention (20.5% vs. 13.6%). gical revisions; all patients with primary 108 Obere Extremität 2 · 2018 Table 1 Overview of secondary surgical interventions Patient Gender Displacement Trauma Reason for secondary Surgical intervention Time age diameter mechanism surgery point of revision surgery 77 Female 4mm (cranial) Traumatic Secondary displacement ORIF PHILOS plate 1 shoulder dis- location 80 Female 4mm (cranial) Fall Secondary displacement ORIF PHILOS plate 2.5 28 Male No displacement Traffic accident Secondary displacement Twinfix anchor 4.5 46 Female No displacement Traumatic Secondary displace- A. subacromial decompression + LHBT 21 shoulder dis- ment + LHBT tendinitis tenodesis location 64 Male No displacement Traumatic LHBT tendinitis + SSP rupture LHBT tenodesis + SSR 13.5 shoulder dis- location 44 Female 3 mm (lateral) Fall Malposition of healed frac- LHBT tenodesis, tuberculoplasty, SST 84 ture + LHBT tendinitis + SSP repair rupture 21 Male No displacement Traumatic Bankart lesion A. labral repair and capsular shift 54 shoulder dis- location 25 Male 1mm (cranial) Traumatic Bankart lesion+ PTSS A. arthrolysis, labral repair and capsular 20 shoulder dis- shift location 43 Male No displacement Traumatic PTSS A. arthrolysis 16 shoulder dis- location 55 Male No displacement Traumatic PTSS A. arthrolysis + LHBT tenode- 24 shoulder dis- sis + acromioplasty location 56 Female No displacement Fall PTSS + LHBT tendinitis A. arthrolysis + LHBT tenodesis 25 57 Female No displacement Traffic accident PTSS+ Impingement A. arthrolysis + acromioplasty 19 45 Male No displacement Fall SST, SLAP, LHBT rupture LHBT tenodesis + SSR 25 35 Male No displacement Fall SST SSR+ LHBT tenodesis 28 43 Female No displacement Fall SST SSR 24 62 Female No displacement Fall Impingement Subacromial decompression 8 29 Male 3mm (cranial) Traumatic Axillary nerve injury Neurolysis + decompression brachial 30 shoulder dis- plexus location Weeks after trauma PTSS posttraumatic shoulder stiffness, A. arthroscopic, ORIF open reduction and internal fixation, LHBT long head biceps tendon, SST supraspinatus tear, SSR supraspinatus repair, SLAP superior labral tear from anterior to posterior displacement of the GT fragment who tervention was 56 years (18–94 years). surgical interventions were not related were treated conservatively and needed However, this difference was not statis- to the secondary displacement of the GT revision surgery because of a secondary tically significant (p= 0.148). fracture but to concomitant lesions of the displacement of the GT fragment had rotator cuff and the capsuloligamentous a significant primary displacement of tissue. Discussion ≥3 mm. According tothe criteria originally de- Moreover, younger patients tend to The present database analysis revealed fined by Neer, a displacement of >10 mm require secondary interventions more three major findings: First, the majority and 45° is an indication for surgery, and frequently than older patients. The ofconservativelytreatedisolatedGTfrac- all other fractures can be successfully mean age of the patients who under- tures (68.6%) are nondisplaced, generally managed with a conservative approach went surgical intervention was 46 years justifying conservative treatment. Sec- [20]. Later, these criteria were modified (25–62 years), whereas the mean age ond, the rate of secondary interventions to 5 mm and 30° of displacement. How- of the cohort without secondary in- was 16.2%. Finally, mostofthe secondary ever, it is known that as little as 2–5 mm Obere Extremität 2 · 2018 109 Original contribution of displacement can cause impingement In addition, the amount of initial dis- rior shoulder dislocation. In the present and requires increased forces for abduc- placement is relevant to the decision on analysis, complex fracture patterns were tion [7–9]. In particular, fragment dis- thetreatmentmodality. However, thereis found even in patients without previous placement in the posterosuperior direc- an immediate need to reevaluate patients shoulder dislocation, although patients tion is associated with impaired function treated conservatively, since 50–60% of were more likely to have a multi-frag- and worse results [2, 27]. Therefore, op- fractures show further displacement over mentary fracture when they sustained erative treatment is recommended more time [22]. Younger patients are at an es- a shoulder dislocation. The risk for sec- aggressively, and numerous articles exist pecially heightened risk. Hebert-Davies ondary surgical interventions increased about different techniques and results [1, et al. found a 5.6-fold higher risk for sec- withdislocations butnotwithmulti-frag- 3, 5, 6, 13, 17, 23, 26]. ondary displacement in patients younger mentary fracture patterns. By contrast, there are only a few re- than 70 years compared with patients ports on conservative treatment of iso- over 70 years of age [10]. Similarly, in Limitations lated GT fractures. Platzer et al. reported our study, patients with secondary dis- on the functional results of 135 patients placementand surgicalinterventionwere Some inherent limitations apply to the treated conservatively for isolated GT younger than the mean age of the cohort present analysis. Only patient records fractureswith lessthan 6mm displace- (46 vs. 55 years). were analyzed, and the final functional ment [22]. They found good to excellent Therefore, both aspects, the degree and radiographic outcomes remain un- results in 97% of the cases. This is in ac- of displacement and how to adequately clear in most cases. Therefore, we cannot cordance with results from other studies assess it, must be further investigated. provide proof of whether or not con- of conservative treatment [12, 17, 20, 23, Another major finding of the present servative treatment leads to good results 24]. Ifthe displacementislessthan5 mm, analysis is that concomitant soft tissue le- in patients without secondary inter- satisfying results can be expected. In ad- sions lead to a secondary intervention af- ventions. Furthermore, the decision to dition, the present study shows that pa- ter initial conservative treatment in over apply conservative treatment was not tients with a nondisplaced or only slightly three quarters of the cases. In the present based on a distinct algorithm. There is displaced fracture (0–3 mm) that did not analysis, surgical intervention owing to a clear trend, however, toward conser- arise from a shoulder dislocation have secondary displacement was only per- vative treatment in patients with only a low risk for secondary surgical inter- formed in four cases (3.8%). Other minimally displaced fractures. In most ventions. Furthermore, fractures with common interventions include capsu- cases, patients with severely displaced an initial displacement of 3 mm or less loligamentous and rotator cuff repairs fractures were treated conservatively are unlikely to have further displacement (. Table 1). These findings highlight the when there were contraindications for over time (only 2% in the present study). need for further imaging, particularly surgery or when patients refused to Patients who required secondary surgery MRI scans, to detect any concomitant undergo surgical treatment. aeft r initial displacement had a primary lesions. Especially in patients with an- Finally, imaging modalities were not fracture displacement of >3 mm. terior shoulder dislocation and multi- consistent in all the cases since not every Unfortunately, defining the degree of fragmentary GT fracture, concomitant patient received a CT and/or MRI scan displacement has also been a matter of lesions are frequently found and require before the decision to apply conservative debate. When displacement is measured further operative treatment. Maman treatment was made. with only plain radiographs, errors of et al. reported on 24 arthroscopically up to 13 mm have been described [21]. treated patients with a GT fracture. Con- Practical conclusion A computed tomography (CT) scan may comitant soft tissue lesions were found help to minimize these errors. On the in 22 patients (94%) [16]. These findings 4 With the exception of two cases, other hand, Janssen et al. observed that are supported by Katthagen et al., who all patients included in this study the imaging modality did not influence found concomitant lesions (i. e., pulley/ had no displacement or only slight the reliability of the fracture assessment SLAP and Bankart lesions) in 69% of displacement of the GT fragment or the recommendation for surgical treat- patients who were treated arthroscopi- (0–3 mm) and a low risk for secondary ment [11]. Mutch et al. suggested using cally for a GT fracture [14]. Again, these surgical interventions. a greater tuberosity ratio (GT ratio) that lesions were found more frequently aer ft 4 Secondary interventions are required can be applied to plain radiographs [19]. shoulder dislocations. more frequently after shoulder dislo- They found a very strong correlation with Muhm et al. found concomitant le- cation. In addition, revision surgery computed tomography (CT) scans for su- sions in GT fractures with and without is most likely required because of perior GT displacement. Furthermore, adislocation [18]. However, in patients concomitant soft tissue lesions rather the GT ratio helped to accurately iden- with a dislocation, concomitant lesions than prompted by secondary dis- tify fractures as suitable for conservative were more likely to be treated opera- placements. or operative treatment or as benefitting tively. Interestingly, in the Muhm study, 4 Detailed physical examination and from further imaging. GT fractures with three or more frag- MRI scans should be utilized in order ments were always associated with ante- to screen for concomitant soft tissue 110 Obere Extremität 2 · 2018 fracture: the necessity of operative treatment. 24. Rath E, Alkrinawi N, Levy O et al (2013) Minimally injuries accompanying GT fractures JOrthopTrauma21:104–112 displaced fractures of the greater tuberosity: so as to prevent revision surgeries. 6. Flatow EL, Cuomo F, Maday MG et al (1991) outcome of non-operative treatment. J Shoulder 4 The study highlights the need for Open reduction and internal fixation of two-part ElbowSurg22:e8–e11 displaced fractures of the greater tuberosity of the 25. Robinson CM, Shur N, Sharpe T et al (2012) Injuries further prospective studies in order proximalpartofthehumerus. JBoneJointSurgAm associated with traumatic anterior glenohumeral to define clear indications for conser- 73:1213–1218 dislocations. JBoneJointSurgAm94:18–26 vative treatment based on fracture 7. Gallo RA, Sciulli R, Daffner RH et al (2007) Defining 26. Schoffl V,Popp D,Strecker W (2011) Asimpleand the relationship between rotator cuff injury and effective implant for displaced fractures of the patterns, imaging modalities, con- proximal humerus fractures. Clin Orthop Relat Res greater tuberosity: the “Bamberg” plate. Arch comitant lesions, and the patients’ 458:70–77 OrthopTraumaSurg131:509–512 individual requests. 8. George MS (2007) Fractures of the greater 27. Verdano MA, Aliani D, Pellegrini A et al (2014) tuberosity of the humerus. J Am Acad OrthopSurg Isolated fractures of the greater tuberosity 15:607–613 in proximal humerus: does the direction of 9. Green A, Izzi J Jr. (2003) Isolated fractures of displacement influence functional outcome? An Corresponding address the greater tuberosity of the proximal humerus. analysis of displacement in greater tuberosity JShoulderElbowSurg12:641–649 fractures. ActaBiomed84:219–228 PD Dr.med.B. Schliemann 10. Hebert-Davies J, Mutch J, Rouleau D et al (2015) Department of Trauma, Hand Delayed migration of greater tuberosity fractures and Reconstructive Surgery, associated with anterior shoulder dislocation. University Hospital Münster JOrthopTrauma29:e396–400 Albert-Schweitzer-Campus, 11. Janssen SJ, Hermanussen HH, Guitton TG et al building W1, 48149 Münster, (2016) Greater tuberosity fractures: does fracture assessment and treatment recommendation vary Germany based on imaging modality? Clin OrthopRelatRes benedikt.schliemann@ 474:1257–1265 ukmuenster.de 12. Jellad A, Bouaziz MA, Boudokhane S et al (2012) Isolated greater tuberosity fracture: short- term functional outcome following a specific rehabilitation program. Ann Phys Rehabil Med Compliance with ethical 55:16–24 13. JiJH,ShafiM,SongISetal(2010)Arthroscopicfixa- guidelines tion technique for comminuted, displaced greater tuberosityfracture. Arthroscopy26:600–609 14. Katthagen JC, Jensen G, Voigt C et al (2014) Conflict of interest. B. Schliemann, L.F. Heilmann, Arthroscopy for proximal humeral fracture. M.J.Raschke,H.Lill,J.C.Katthagen,andA.Ellwein Arthroskopie27:265–274 declare that they have no competing interests. 15. LindT, Kroner K, Jensen J(1989)The epidemiology of fractures of the proximal humerus. Arch Orthop This article does not contain any studies with human TraumaSurg108:285–287 participants or animals performed by any of the au- 16. Maman E, Dolkart O, Chechik O et al (2014) thors. Arthroscopic findings of coexisting lesions with greater tuberosity fractures. Orthopedics Open Access This article is distributed under the terms 37:e272–e277 of the Creative Commons Attribution 4.0 International 17. MattyasovszkySG,BurkhartKJ,AhlersCetal(2011) License (http://creativecommons.org/licenses/by/ Isolated fractures of the greater tuberosity of 4.0/), which permits unrestricted use, distribution, the proximal humerus: a long-term retrospective and reproduction in any medium, provided you give studyof30patients. ActaOrthop82:714–720 appropriate credit to the original author(s) and the 18. Muhm M, Arend S, Winkler H et al (2017) source, providealinktotheCreativeCommonslicense, Associated injuries with greater tuberosity and indicate if changes were made. fractures: mechanism of injury, diagnostics, treatment. Unfallchirurg120:854–864 19. Mutch JA, Rouleau DM, Laflamme GY et al (2014) References Accurate measurement of greater tuberosity displacement without computed tomography: 1. Bhatia DN, De Beer JF, Van Rooyen KS (2007) The validation of a method on plain radiography bony partial articular surface tendon avulsion to guide surgical treatment. 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Isolated fractures of the greater tuberosity: When are they treated conservatively?

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Original contribution 1 1 1 2 Obere Extremität 2018 · 13:106–111 Benedikt Schliemann · Lukas F. Heilmann · Michael J. Raschke ·HelmutLill · 1 2 https://doi.org/10.1007/s11678-018-0459-z J. Christoph Katthagen · Alexander Ellwein Received: 25 February 2018 Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Accepted: 17 April 2018 Germany Published online: 15 May 2018 Traumatology and Reconstructive Surgery, Diakovere Friederikenstift GmbH, Hannover, Germany © The Author(s) 2018 Isolated fractures of the greater tuberosity: When are they treated conservatively? Abaselinestudy Fractures of the greater tuberosity (GT) results in fractures with >3 mm displace- dislocations) comprised a fourth group. often occur with more complex proximal ment [22]. Similarly, other authors re- The fractures were further subdivided humerus fractures and are less frequently ported good to excellent results in their into simple fractures with only a sin- observed as an isolated pathology. Only patients who had conservative treatment gle fragment and comminuted fractures 14–20% of proximal humerus fractures for minimally displaced fractures [12, 17, with two or more fragments. are isolated lesions of the GT [4, 15, 23]. 24]. The indication for conservative treat- Upto30%ofthesefracturesareassociated The present baseline study aimed to ment was analyzed according to the pa- with anterior glenohumeral dislocations analyze under what circumstances iso- tients’ records. A follow-up period of at [25]. lated fractures of the GT are managed least 6 months was mandatory in order According to Neer, a displacement of conservatively. In addition to the in- to evaluate secondary surgical interven- the fragment of >10 mm and 45° (later dication for conservative treatment, the tions. Interventions were further sub- modified to >5 mm and 30°) is believed rate of secondary interventions for failed divided into fracture-related procedures to be an indication for operative treat- conservative treatment is evaluated. and procedures required for associated ment [20]. However, whether all other lesions, such as capsulolabral tears in pa- fractures can be managed successfully by tients who sustained a shoulder disloca- Patients and methods nonoperative treatment is unclear. Cur- tion or posttraumatic stiffness. rently, there is a lack of evidence in the lit- A retrospective data evaluation of iso- erature to support either conservative or lated GT fractures was performed from Results operative treatment strategies in GT frac- the clinical database of two german level- tures. Whether the fracture type and the I trauma centers from January 2010 to A total of 114 patients were identified. In etiology of the fracture impact the deci- June 2017. A total of 114 patients with sixpatientswithsevere displacement, op- sion-making and the final outcome also a GT fracture were initially treated con- erative treatment was recommended, but remains unclear. servatively. The mean age of the patients severe comorbidities (i.e. cardiovascular There are only a few reports on conser- at thetimeof the injury was 55years conditions) prevented surgical interven- vative treatment of isolated GT fractures. (range, 18–94 years). The mechanism tions. In addition, two patients refused to Platzer et al. compared the functional re- of the injury was a direct fall on the undergo surgery despite severe concomi- sultsof52 patientswho underwentopen affected shoulder in 61 cases, a traffic tant soft tissue lesions, and one patient reduction and internal fixation (ORIF) of accident in nine cases, and an anterior did not return to the hospital after an aGTfracturewithninepatientswhowere shoulder dislocation in 44 cases. All pa- magnetic resonance imaging (MRI) was treated conservatively for similar frac- tients had conventional radiographs of indicated. These nine patients were ex- tures. All patients had a displaced frac- the shoulder in the anteroposterior, axil- cluded from the study. Of the remaining ture (>5 mm) [23]. After a mean follow- lary, and Y-view. After an isolated frac- 105 fractures, 72 (68.6%) were not dis- up of 5.5 years, functional results were ture of the GT was identified, the degree placed (. Fig. 1), a mild displacement of significantly better aer ft operative treat- of displacement was assessed and clas- 1–3 mm was found in 27 cases (25.7%), ment than they were aeft r conservative sified as: (1) no displacement, (2) mild severe displacement (>3 mm) was found treatment. The same authors reported on displacement(1–3 mm), or(3)severedis- in two cases (1.9%), and the remain- 135 conservatively treated patients with placement (>3 mm). Impression frac- ing four fractures (3.8%) were classified an isolated GT fracture and found worse tures (usually related to glenohumeral as impression fractures (depression type 106 Obere Extremität 2 · 2018 Fig. 1 9 Conservatively treated fracture of the greater tuberosity: initial radiograph (a), follow-up after 3 weeks to exclude secondary displacement (b), and anatomic consoli- dation 3 months after the injury (c) Fig. 2 9 a Posterosuperior malunion of a solid greater tuberosity fracture. Preop- erative anteroposterior ra- diograph (left)andintraop- erative finding (right). b Os- teotomy of the fragment (left) with corresponding fluoroscopy (inset)andex- ternal view (right). c Under arthroscopic and fluoro- scopic guidance, the frag- ment is reduced and fixed with two 3.5-mm screws. d Functional outcome four months postoperatively fracture). The decision to treat the two all fractures were treated conservatively Patients were reexamined clinically caseswithmore severe displacementcon- with the affected arm immobilized in an and radiographically to identify sec- servatively was made based on an initial abduction brace to release tension from ondary displacements. If the patient had displacement of 4 mm. 51% of the frac- the rotator cuff on the fracture site. Pas- further complaints, MRI was performed tures weresimpleand 49% had multiple sive motion was allowed with range of to analyze the integrity of the rotator cuff fragments. Comminuted fractures were motion (ROM) limited to 90° of flexion and the capsuloligamentous complex. more likely to occur with shoulder dis- andabduction, freeexternalrotation, and Of the remaining 105 patients, 17 locations (57%). In the acute situation, no internal rotation for the first 3 weeks. underwent secondary surgical inter- Obere Extremität 2 · 2018 107 Abstract · Zusammenfassung Obere Extremität 2018 · 13:106–111 https://doi.org/10.1007/s11678-018-0459-z © The Author(s) 2018 B. Schliemann ·L.F.Heilmann · M. J. Raschke · H. Lill ·J.C. Katthagen ·A.Ellwein Isolated fractures of the greater tuberosity: When are they treated conservatively? A baseline study Abstract revision surgery after primary conservative Background. This study analyzed the Results. We identified 114 fractures. Nine treatment. indications for conservative management cases were excluded because patients refused Conclusion. Secondary interventions are of isolated greater tuberosity (GT) fractures. surgery or their comorbidities ruled it out. required more frequently after shoulder The rate of secondary interventions for failed Only two of the remaining 105 patients had dislocation. Surgery is most likely required conservative treatment was also assessed. an initial displacement >3 mm. All other GT for associated soft tissue lesions rather than Methods. A retrospective data evaluation of fractures (n = 103, 98%) were not displaced for secondary displacements. Thus, detailed isolated GT fractures was performed from or only slightly displaced (0–3 mm). The physical examination and magnetic resonance the clinical database of two level-I trauma fracture was associated with an anterior imaging should be used to screen for centers from January 2010 to June 2017. shoulder dislocation in 39 cases (37%); concomitant soft tissue injuries accompanying Conservatively treated GT fractures were 17 patients (16.2%) underwent surgery after GT fractures to prevent revision surgeries. identified and subdivided according to primary conservative treatment. Four of etiology, morphology, and amount of initial these 17 patients presented with a secondary Keywords displacement. Secondary surgical interven- displacement of the GT fragment. In all Greater tuberosity fracture · Shoulder tions were recorded and subcategorized other cases (76.5%), an associated soft dislocation · Proximal humeral fractures · into fracture-associated interventions and tissue lesion necessitated revision surgery. Concomitant lesions · Surgery interventions for associated soft tissue lesions. Young age, anterior shoulder dislocation, and concomitant injuries were risk factors for Isolierte Tuberculum-majus-Frakturen: Wann werden sie konservativ behandelt? Eine Statuserhebung Zusammenfassung Weichteilverletzungen stellten Risikofaktoren Hintergrund. Ziel der vorliegenden Arbeit Ergebnisse. Es wurden 114 TM-Frakturen dar, welche die Wahrscheinlichkeit für eine war es, die Indikationen für eine konservative identifiziert. Neun Fälle wurden aus der sekundäre chirurgische Intervention nach Behandlung bei isolierten Frakturen des Studie ausgeschlossen, weil die Patienten die primär konservativer Therapie erhöhten. Tuberculum majus (TM) zu ermitteln. empfohlene operative Therapie ablehnten Schlussfolgerung. Sekundäre chirurgische Darüber hinaus wurde die Rate sekundärer oder diese aufgrund von Komorbiditäten nicht Interventionen sind häufiger nach ante- chirurgischer Interventionen bei Versagen der möglich war. Bei nur 2 der verbliebenen 105 riorer Schulterluxation und mit größerer konservativen Therapie erfasst. Patienten war die Fraktur >3 mm disloziert, Wahrscheinlichkeit bei begleitenden Methoden. Es erfolgte eine retrospektive alle anderen TM-Frakturen (n = 103, 98 %) Weichteilverletzungen als bei sekundären Auswertung der Datenbanken zweier Level- waren initial nicht oder nur leicht disloziert Dislokationen notwendig. Daher sollte durch I-Traumazentren, in denen isolierte TM- (0–3 mm). In 39 Fällen (37 %) war die eine detaillierte körperliche Untersuchung Frakturen von Januar 2010 bis Juni 2017 Fraktur mit einer anterioren Schulterluxation und ggf. durch eine MRT der Fokus auf die erfasst wurden. Die konservativ behandelten assoziiert. Bei 17 Patienten (16,2 %) erfolgte Suche nach begleitenden Weichteilverlet- Frakturenwurdennachihrer Ätiologie nach initialer konservativer Therapie eine zungen bei TM-Frakturen gelegt werden, um sowie der Morphologie und Dislokation des sekundäre chirurgische Intervention. Bei Revisionsoperationen vorzubeugen. Fragments ausgewertet und unterschieden. 4 dieser 17 Patienten war die Revision Sekundäre chirurgische Interventionen wegen einer sekundären Dislokation des Schlüsselwörter wurden erfasst und ebenfalls weiter unter- TM-Fragments notwendig. In allen anderen Tuberculum-majus-Fraktur · Schulter- schieden in frakturassoziierte Maßnahmen Fällen (76,5 %) machte eine assoziierte luxation · Proximale Humerusfrakturen · und in Interventionen, die aufgrund von mit Weichteilverletzung die sekundäre Operation Begleitverletzungen · Operation Weichteilverletzungenerforderlich wurden. erforderlich. Junges Patientenalter, eine anteriore Schulterluxation und begleitende ventions (16.2%). In only four cases, cedures are listed in . Table 1.Given However, this difference was not statis- including the two patients with ini- that three patients refused to undergo tically significant (p= 0.415). tial displacement of the GT fragment surgery despite an indication because of The fracture morphology (single frag- >3 mm, a surgical revision was required secondary displacement and subsequent ment vs. comminuted fractures) had no owing to a secondary displacement of limited ROM, the revision rate would significant impact on the risk for sec- the fracture with subsequent impinge- have increased to 19%. ondary interventions. ment and limited ROM (. Fig. 2). In Patients for whom a shoulder dislo- By contrast, the amount of the initial all other cases (n= 13), an associated cation was the cause of the GT fracture displacement of the fragment is an indi- soft tissue lesion led to a secondary were more likely to undergo secondary cator of secondary displacement and sur- surgical intervention. The different pro- surgical intervention (20.5% vs. 13.6%). gical revisions; all patients with primary 108 Obere Extremität 2 · 2018 Table 1 Overview of secondary surgical interventions Patient Gender Displacement Trauma Reason for secondary Surgical intervention Time age diameter mechanism surgery point of revision surgery 77 Female 4mm (cranial) Traumatic Secondary displacement ORIF PHILOS plate 1 shoulder dis- location 80 Female 4mm (cranial) Fall Secondary displacement ORIF PHILOS plate 2.5 28 Male No displacement Traffic accident Secondary displacement Twinfix anchor 4.5 46 Female No displacement Traumatic Secondary displace- A. subacromial decompression + LHBT 21 shoulder dis- ment + LHBT tendinitis tenodesis location 64 Male No displacement Traumatic LHBT tendinitis + SSP rupture LHBT tenodesis + SSR 13.5 shoulder dis- location 44 Female 3 mm (lateral) Fall Malposition of healed frac- LHBT tenodesis, tuberculoplasty, SST 84 ture + LHBT tendinitis + SSP repair rupture 21 Male No displacement Traumatic Bankart lesion A. labral repair and capsular shift 54 shoulder dis- location 25 Male 1mm (cranial) Traumatic Bankart lesion+ PTSS A. arthrolysis, labral repair and capsular 20 shoulder dis- shift location 43 Male No displacement Traumatic PTSS A. arthrolysis 16 shoulder dis- location 55 Male No displacement Traumatic PTSS A. arthrolysis + LHBT tenode- 24 shoulder dis- sis + acromioplasty location 56 Female No displacement Fall PTSS + LHBT tendinitis A. arthrolysis + LHBT tenodesis 25 57 Female No displacement Traffic accident PTSS+ Impingement A. arthrolysis + acromioplasty 19 45 Male No displacement Fall SST, SLAP, LHBT rupture LHBT tenodesis + SSR 25 35 Male No displacement Fall SST SSR+ LHBT tenodesis 28 43 Female No displacement Fall SST SSR 24 62 Female No displacement Fall Impingement Subacromial decompression 8 29 Male 3mm (cranial) Traumatic Axillary nerve injury Neurolysis + decompression brachial 30 shoulder dis- plexus location Weeks after trauma PTSS posttraumatic shoulder stiffness, A. arthroscopic, ORIF open reduction and internal fixation, LHBT long head biceps tendon, SST supraspinatus tear, SSR supraspinatus repair, SLAP superior labral tear from anterior to posterior displacement of the GT fragment who tervention was 56 years (18–94 years). surgical interventions were not related were treated conservatively and needed However, this difference was not statis- to the secondary displacement of the GT revision surgery because of a secondary tically significant (p= 0.148). fracture but to concomitant lesions of the displacement of the GT fragment had rotator cuff and the capsuloligamentous a significant primary displacement of tissue. Discussion ≥3 mm. According tothe criteria originally de- Moreover, younger patients tend to The present database analysis revealed fined by Neer, a displacement of >10 mm require secondary interventions more three major findings: First, the majority and 45° is an indication for surgery, and frequently than older patients. The ofconservativelytreatedisolatedGTfrac- all other fractures can be successfully mean age of the patients who under- tures (68.6%) are nondisplaced, generally managed with a conservative approach went surgical intervention was 46 years justifying conservative treatment. Sec- [20]. Later, these criteria were modified (25–62 years), whereas the mean age ond, the rate of secondary interventions to 5 mm and 30° of displacement. How- of the cohort without secondary in- was 16.2%. Finally, mostofthe secondary ever, it is known that as little as 2–5 mm Obere Extremität 2 · 2018 109 Original contribution of displacement can cause impingement In addition, the amount of initial dis- rior shoulder dislocation. In the present and requires increased forces for abduc- placement is relevant to the decision on analysis, complex fracture patterns were tion [7–9]. In particular, fragment dis- thetreatmentmodality. However, thereis found even in patients without previous placement in the posterosuperior direc- an immediate need to reevaluate patients shoulder dislocation, although patients tion is associated with impaired function treated conservatively, since 50–60% of were more likely to have a multi-frag- and worse results [2, 27]. Therefore, op- fractures show further displacement over mentary fracture when they sustained erative treatment is recommended more time [22]. Younger patients are at an es- a shoulder dislocation. The risk for sec- aggressively, and numerous articles exist pecially heightened risk. Hebert-Davies ondary surgical interventions increased about different techniques and results [1, et al. found a 5.6-fold higher risk for sec- withdislocations butnotwithmulti-frag- 3, 5, 6, 13, 17, 23, 26]. ondary displacement in patients younger mentary fracture patterns. By contrast, there are only a few re- than 70 years compared with patients ports on conservative treatment of iso- over 70 years of age [10]. Similarly, in Limitations lated GT fractures. Platzer et al. reported our study, patients with secondary dis- on the functional results of 135 patients placementand surgicalinterventionwere Some inherent limitations apply to the treated conservatively for isolated GT younger than the mean age of the cohort present analysis. Only patient records fractureswith lessthan 6mm displace- (46 vs. 55 years). were analyzed, and the final functional ment [22]. They found good to excellent Therefore, both aspects, the degree and radiographic outcomes remain un- results in 97% of the cases. This is in ac- of displacement and how to adequately clear in most cases. Therefore, we cannot cordance with results from other studies assess it, must be further investigated. provide proof of whether or not con- of conservative treatment [12, 17, 20, 23, Another major finding of the present servative treatment leads to good results 24]. Ifthe displacementislessthan5 mm, analysis is that concomitant soft tissue le- in patients without secondary inter- satisfying results can be expected. In ad- sions lead to a secondary intervention af- ventions. Furthermore, the decision to dition, the present study shows that pa- ter initial conservative treatment in over apply conservative treatment was not tients with a nondisplaced or only slightly three quarters of the cases. In the present based on a distinct algorithm. There is displaced fracture (0–3 mm) that did not analysis, surgical intervention owing to a clear trend, however, toward conser- arise from a shoulder dislocation have secondary displacement was only per- vative treatment in patients with only a low risk for secondary surgical inter- formed in four cases (3.8%). Other minimally displaced fractures. In most ventions. Furthermore, fractures with common interventions include capsu- cases, patients with severely displaced an initial displacement of 3 mm or less loligamentous and rotator cuff repairs fractures were treated conservatively are unlikely to have further displacement (. Table 1). These findings highlight the when there were contraindications for over time (only 2% in the present study). need for further imaging, particularly surgery or when patients refused to Patients who required secondary surgery MRI scans, to detect any concomitant undergo surgical treatment. aeft r initial displacement had a primary lesions. Especially in patients with an- Finally, imaging modalities were not fracture displacement of >3 mm. terior shoulder dislocation and multi- consistent in all the cases since not every Unfortunately, defining the degree of fragmentary GT fracture, concomitant patient received a CT and/or MRI scan displacement has also been a matter of lesions are frequently found and require before the decision to apply conservative debate. When displacement is measured further operative treatment. Maman treatment was made. with only plain radiographs, errors of et al. reported on 24 arthroscopically up to 13 mm have been described [21]. treated patients with a GT fracture. Con- Practical conclusion A computed tomography (CT) scan may comitant soft tissue lesions were found help to minimize these errors. On the in 22 patients (94%) [16]. These findings 4 With the exception of two cases, other hand, Janssen et al. observed that are supported by Katthagen et al., who all patients included in this study the imaging modality did not influence found concomitant lesions (i. e., pulley/ had no displacement or only slight the reliability of the fracture assessment SLAP and Bankart lesions) in 69% of displacement of the GT fragment or the recommendation for surgical treat- patients who were treated arthroscopi- (0–3 mm) and a low risk for secondary ment [11]. Mutch et al. suggested using cally for a GT fracture [14]. Again, these surgical interventions. a greater tuberosity ratio (GT ratio) that lesions were found more frequently aer ft 4 Secondary interventions are required can be applied to plain radiographs [19]. shoulder dislocations. more frequently after shoulder dislo- They found a very strong correlation with Muhm et al. found concomitant le- cation. In addition, revision surgery computed tomography (CT) scans for su- sions in GT fractures with and without is most likely required because of perior GT displacement. Furthermore, adislocation [18]. However, in patients concomitant soft tissue lesions rather the GT ratio helped to accurately iden- with a dislocation, concomitant lesions than prompted by secondary dis- tify fractures as suitable for conservative were more likely to be treated opera- placements. or operative treatment or as benefitting tively. Interestingly, in the Muhm study, 4 Detailed physical examination and from further imaging. GT fractures with three or more frag- MRI scans should be utilized in order ments were always associated with ante- to screen for concomitant soft tissue 110 Obere Extremität 2 · 2018 fracture: the necessity of operative treatment. 24. Rath E, Alkrinawi N, Levy O et al (2013) Minimally injuries accompanying GT fractures JOrthopTrauma21:104–112 displaced fractures of the greater tuberosity: so as to prevent revision surgeries. 6. Flatow EL, Cuomo F, Maday MG et al (1991) outcome of non-operative treatment. J Shoulder 4 The study highlights the need for Open reduction and internal fixation of two-part ElbowSurg22:e8–e11 displaced fractures of the greater tuberosity of the 25. Robinson CM, Shur N, Sharpe T et al (2012) Injuries further prospective studies in order proximalpartofthehumerus. JBoneJointSurgAm associated with traumatic anterior glenohumeral to define clear indications for conser- 73:1213–1218 dislocations. JBoneJointSurgAm94:18–26 vative treatment based on fracture 7. Gallo RA, Sciulli R, Daffner RH et al (2007) Defining 26. Schoffl V,Popp D,Strecker W (2011) Asimpleand the relationship between rotator cuff injury and effective implant for displaced fractures of the patterns, imaging modalities, con- proximal humerus fractures. Clin Orthop Relat Res greater tuberosity: the “Bamberg” plate. Arch comitant lesions, and the patients’ 458:70–77 OrthopTraumaSurg131:509–512 individual requests. 8. George MS (2007) Fractures of the greater 27. Verdano MA, Aliani D, Pellegrini A et al (2014) tuberosity of the humerus. J Am Acad OrthopSurg Isolated fractures of the greater tuberosity 15:607–613 in proximal humerus: does the direction of 9. Green A, Izzi J Jr. (2003) Isolated fractures of displacement influence functional outcome? An Corresponding address the greater tuberosity of the proximal humerus. analysis of displacement in greater tuberosity JShoulderElbowSurg12:641–649 fractures. ActaBiomed84:219–228 PD Dr.med.B. Schliemann 10. Hebert-Davies J, Mutch J, Rouleau D et al (2015) Department of Trauma, Hand Delayed migration of greater tuberosity fractures and Reconstructive Surgery, associated with anterior shoulder dislocation. University Hospital Münster JOrthopTrauma29:e396–400 Albert-Schweitzer-Campus, 11. Janssen SJ, Hermanussen HH, Guitton TG et al building W1, 48149 Münster, (2016) Greater tuberosity fractures: does fracture assessment and treatment recommendation vary Germany based on imaging modality? Clin OrthopRelatRes benedikt.schliemann@ 474:1257–1265 ukmuenster.de 12. Jellad A, Bouaziz MA, Boudokhane S et al (2012) Isolated greater tuberosity fracture: short- term functional outcome following a specific rehabilitation program. Ann Phys Rehabil Med Compliance with ethical 55:16–24 13. JiJH,ShafiM,SongISetal(2010)Arthroscopicfixa- guidelines tion technique for comminuted, displaced greater tuberosityfracture. Arthroscopy26:600–609 14. Katthagen JC, Jensen G, Voigt C et al (2014) Conflict of interest. B. Schliemann, L.F. Heilmann, Arthroscopy for proximal humeral fracture. M.J.Raschke,H.Lill,J.C.Katthagen,andA.Ellwein Arthroskopie27:265–274 declare that they have no competing interests. 15. LindT, Kroner K, Jensen J(1989)The epidemiology of fractures of the proximal humerus. Arch Orthop This article does not contain any studies with human TraumaSurg108:285–287 participants or animals performed by any of the au- 16. Maman E, Dolkart O, Chechik O et al (2014) thors. Arthroscopic findings of coexisting lesions with greater tuberosity fractures. Orthopedics Open Access This article is distributed under the terms 37:e272–e277 of the Creative Commons Attribution 4.0 International 17. MattyasovszkySG,BurkhartKJ,AhlersCetal(2011) License (http://creativecommons.org/licenses/by/ Isolated fractures of the greater tuberosity of 4.0/), which permits unrestricted use, distribution, the proximal humerus: a long-term retrospective and reproduction in any medium, provided you give studyof30patients. ActaOrthop82:714–720 appropriate credit to the original author(s) and the 18. Muhm M, Arend S, Winkler H et al (2017) source, providealinktotheCreativeCommonslicense, Associated injuries with greater tuberosity and indicate if changes were made. fractures: mechanism of injury, diagnostics, treatment. Unfallchirurg120:854–864 19. Mutch JA, Rouleau DM, Laflamme GY et al (2014) References Accurate measurement of greater tuberosity displacement without computed tomography: 1. Bhatia DN, De Beer JF, Van Rooyen KS (2007) The validation of a method on plain radiography bony partial articular surface tendon avulsion to guide surgical treatment. 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Court-Brown CM, Garg A, Mcqueen MM (2001) greatertuberosity. Injury36:1185–1189 The translated two-part fracture of the proximal 23. Platzer P, Thalhammer G, Oberleitner G et al (2008) humerus. Epidemiology and outcome in the older Displaced fractures of the greater tuberosity: patient. JBoneJointSurgBr83:799–804 a comparison of operative and nonoperative 5. DimakopoulosP,PanagopoulosA,KasimatisGetal treatment. JTrauma65:843–848 (2007) Anterior traumatic shoulder dislocation associated with displaced greater tuberosity Obere Extremität 2 · 2018 111

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Obere ExtremitätSpringer Journals

Published: May 15, 2018

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