肱骨大结节骨折席智杰

ArthroscopicfixationwithcannulatedscrewsforisolatedgreatertuberosityfracturesDepartmentofOrthopaedics，ShanghaiGuanghuaHospitalofIntegratedTraditionalChineseandWesternMedicine，ShanghaiZhi-jieXi,M.D.Anatomy•Thegreatertuberosityastheinsertionofrotatorcuff,oncefracture,duetoretractionofrotatorcuff,woulddisplaceposteriororsuprertiormorphologicalclassificationAnavulsionfractureAsplitfracturemorphologicalclassificationAdepressedfracturmorphologicalclassificationCTfindingsAnartist’srendition(a),anteroposteriorradiograph(b),coronalCTview(c)andaxialCTview(d)ofthedepression-typefracture.NotetheimpactionoftheGTfragmentintothehumeralheadmorphologicalclassificationMalunionofthegreatertuberositycancausemechanicalimpingementonthesubacromialarchAfterdiagnosticevaluationwiththearthroscopeinthestandardposteriorportal(A),wedebridethearticular-siderotatorcuffandmalunitedgreatertuberosityintheglenohumeraljoint(B).Accurateplacementisensuredbyusinganoutside-intechniquewithaspinalneedlepercutaneously(C,D).Toopentherotatorcuff–attachedmalunitedgreatertuberosityWeopentherotatorcuff–attachedmalunitedgreatertuberosityusingashaverasafull-thicknessrotatorcufftearundersubacromialarthroscopicvision(A,B).Thesuperiordisplacedandmalunitedbonyprotuberanceofthegreatertuberosityisdebridedandremovedusingashaverandburr(C,D).SutureanchorsareplacedatthearticularmarginSutureanchorsareplacedatthearticularmargintocreateamedialrow(A,B).Asuturestrandfromeachanchorinthemedialrowisretrieved.ThePushLockanchorisadvancedintothepilotholecompletely(C).ThesestepsarerepeatedforasecondPushLock(D).ThetuberoplastyofthemalunitedgreatertuberosityisseenonplainradiographPlainradiographicTheseWndingsrevealedafractureofthelessertuberosityandafractureofthegreatertuberositywithoutdislocationCTfindingsCTWndings.CTWndings.Thelessertuberositywasmarkedlydisplacedmedially,andapproximately1/3ofthebonefragmentextendedbeyondtheanteriormarginoftheglenoidfossaThree-dimensionalCTWndings3-DCTishelpfultoclassifyandchoiceagoodfixationmethod.Three-dimensionalCTWndingsThegreatertuberositywasalsofractured,andwasdisplacedsuperiorlyMRIfingdingsMRIisagoodchoiceforoccultfractureorcombingwithsoft-tissueinjurySurgeryorconservativetreatment?Displacement2mmshoulderbetreatwithsurgeryCase1UnitedbonewasconWrmedat3monthspostoperatively.PostoperativeradiographicfindingsCase2aTrueanteroposteriorradiographand3DCTaIntra-articularaspectofthehumeralheadandsubscapularistendonwithhaematomasurroundingthefracturegap.bInsertionofthecranialsutureanchornexttothelessertuberosity.cTranstendinoussubscapularisperforationformattressstitchconfiguration.dThedislocatedmedialaspectofthegreatertuberosityfragmentisreducedusinganexaminationhook.eTheposteriortranstendinoussutureanchorisinsertedforgreatertuberosityfixation.fTranstendinoussuturepassagenexttothesupraspinatustendonfootprint,about18mmapartCase2aFluoroscopycontrolofproperreductionandtemporaryfixationofthegreatertuberosity,priortocannulateddrillingforscrewinsertion.bFinalintra-articularaspect.cX-rayfollow-up(truea.p.)at6weekspostoperatively:thefracturelinearoundthedistalgreatertuberosityisnotyetfullyconsolidated.dThreedimensionalreconstructionofafollow-upCT-scanat6monthspostoperatively,showinganatomicintegrationofthefragmentsCase2Case3aAnteroposteriorradiographshowingagreatertuberosityfracturewithcomminutionanddislocation.bPost-reductionmagneticresonanceimage,T1obliquecoronalview,showingagreatertuberosityfractureaArthroscopicfindingsshowedthesuperiormigrationofthegreatertuberosityfracturefragment(arrowhead).bThesutureswereanchoredintothelateralcortexusingVersalokanchorsforthesuture-bridgetechnique.c,dArthroscopicandradiographicfindingsofthefinalfixationofthegreatertuberosityfracturebytheuseoftwoinvertedmattresssuturesandtwolateralanchorsCase4Anteroposteriorradiographoftheshouldershowingincompleteunionofthegreatertuberosityfragmentwithradiolucentgappingandmarginalsclerosis,andproximallydisplaceddeformityMRIoftheshouldershowingaproximallydisplacedfractureofgreatertuberositywithcontinuityofthesupraspinatustendonatthehumeralinsertionsiteonobliquecoronalT2Case53D-CTscanoftheshouldershowingaproximalandposteriorlydisplacedmalunitedgreatertuberosityfragmentArthroscopicfindingsofamalunitedgreatertuberosityfragmentinthesubacromialspaceviewedfromtheposteriorportalArthroscopicfindingsshowingthesuture-bridgetechniqueoftheosteotomizedfragmentArthroscopicfindingsofamalunitedgreatertuberosityfragmentinthesubacromialspaceviewedfromtheposteriorportal3D-CTscanoftheshouldershowingaproximalandposteriorlydisplacedmalunitedgreatertuberosityfragment•Plainradiograph,APviewshowingavulsionfractureofthesuperolateralend,proximalhumerusAcromialimpressionfractureofthegreatertuberositywithmassiverotatorcufftear:thisneednotbeanightmare!——Case6Acromialimpressionfractureofthegreatertuberositywithmassiverotatorcufftear:thisneednotbeanightmare!Acromialimpressionfractureofthegreatertuberositywithmassiverotatorcufftear:thisneednotbeanightmare!——Case6case7T2-weighted,coronalmagneticresonanceimageshowinggre