|Year : 2016 | Volume
| Issue : 2 | Page : 153-155
Complete supraspinatus tear with greater tuberosity fracture in a 14-year-old boy: Case report and review of literature
Sang-Hoon Lhee, Anant Kumar Singh
Department of Orthopedics, CM Chungmu Hospital, Seoul, South Korea
|Date of Web Publication||13-Apr-2016|
Dr. Sang-Hoon Lhee
CM Chungmu Hospital, 93 Yeongdeungpo-Dong 4-Ga, Yeongdeungpo-Gu, Seoul
Source of Support: None, Conflict of Interest: None
There are several possible etiologies for rotator cuff pathology, which vary based on age and sports participation. We are reporting a case of complete supraspinatus tear with associated greater tuberosity fracture in a 14-year-old boy, and to the best of our knowledge, this is the first case of complete supraspinatus tear with greater tuberosity fracture in a boy younger than 15 years.
تمزق كامل فوق الشوكة مع أكبر كسر الحدبة في صبي يبلغ من العمر 14 عاما: تقرير حالة ومراجعة الأدبيات
هناك العديد من المسببات المحتملة لأمراض الكفة، والتي تختلف باختلاف العمر ونوع الرياضية التى يشارك فيها الفرد. وفى هذه الورقة بلغ عن حالة تمزق كامل فوق الشوكة المرتبط بكسر فى الحدبة في صبي يبلغ من العمر 14 عاما، وعلى حد علمنا،
Keywords: Greater tuberosity fracture, rotator cuff tear, young athlete
|How to cite this article:|
Lhee SH, Singh AK. Complete supraspinatus tear with greater tuberosity fracture in a 14-year-old boy: Case report and review of literature. Saudi J Sports Med 2016;16:153-5
|How to cite this URL:|
Lhee SH, Singh AK. Complete supraspinatus tear with greater tuberosity fracture in a 14-year-old boy: Case report and review of literature. Saudi J Sports Med [serial online] 2016 [cited 2022 Oct 3];16:153-5. Available from: https://www.sjosm.org/text.asp?2016/16/2/153/180186
| Introduction|| |
Acute rotator cuff tears in young patients are a rare condition and are commonly associated with high-energy trauma. Rotator cuff tears are a well-recognized clinical entity in overhead athletes and in older patients. There are several possible etiologies for rotator cuff pathology, which vary based on age and sports participation. In the skeletally immature thrower, the physis is the weakest structural link in the kinetic chain and poorly tolerates the biomechanical stress of throwing. Because of the presence of an open growth plate and lack of substantial degeneration within the rotator cuff tendon in this patient population, shoulder injuries are more commonly expected to involve the physis (e.g. Little League shoulder), the bones (e.g. fractures), and supporting soft tissues (e.g. glenoid labrum). Rotator cuff tears, in particular, are extremely uncommon in the pediatric population.  We are reporting a case of complete supraspinatus tear with associated greater tuberosity fracture in a 14-year-old boy, and to the best of our knowledge, this is the first case of complete supraspinatus tear with greater tuberosity fracture in a boy younger than 15 years.
| Case Report|| |
A right-handed 14-year-old baseball hitter presented with a 3-week history of acute anterolateral shoulder pain in his dominant shoulder. He reported that he had injured it while sliding. Pain was exacerbated with overhead activity and range of motion. Physical examination 3 weeks after injury demonstrated no muscular atrophy but revealed point tenderness just lateral to the acromion and along the upper trapezius. Range of motion of the shoulder was full; however, end motions were painful, and scapular dyskinesia was seen with shoulder abduction. Cross-body adduction test and throwing aggravation test was positive. He demonstrated normal strength in internal and external rotation but had diminished strength in abduction as determined with the empty can test about the affected shoulder compared with the opposite extremity. Impingement signs including both Hawkins' and Neer's were negative, drop arm test was negative, and anterior apprehension/relocation test was negative for signs of instability. Anteroposterior and lateral shoulder radiographs were obtained, which showed healing greater tuberosity fracture [Figure 1]. Because of the severity of his symptoms, magnetic resonance arthrogram ordered which demonstrated a full-thickness tear of the supraspinatus tendon [Figure 2].
|Figure 2: Magnetic resonance imaging showing complete supraspinatus cuff tear with greater tuberosity fracture|
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Considering patient age and undisplaced greater tuberosity fracture, author decided to treat patient nonoperatively with a physical therapy program that included core strengthening, scapular stabilization, and range of motion exercises. After completion of 8 weeks of physical therapy, he had a range of motion equal to his preoperative motion and equal strength bilaterally with no pain, but he was instructed not to participate in baseball for the remainder of the season.
| Discussion|| |
Baseball is by far the greatest contributor to injury in the adolescent upper extremity, both in frequency and severity. The many anatomic and physiologic changes occurring in the adolescent body can create vulnerabilities that result in injury to the shoulder, with the most important and generally the weakest link in the adolescent shoulder being the physis. Rotator cuff injuries with avulsion of lesser tuberosity have been reported in literature,  but rotator cuff injury with greater tuberosity fracture to the best of our knowledge has not been reported in literature.
At any age, rotator cuff injury may occur as a result of (1) impingement; (2) tensile overload; or (3) primary tendon degeneration. Rotator cuff tears occur more commonly in middle-aged and elderly patients, and previous studies demonstrate that <1% of rotator cuff tears occur in patients younger than 20 years.  Although the muscle-tendon units may have elevated risk of overuse injuries in the growing child (because they have to stretch to keep up with bone lengthening), rotator cuff tears in adolescents remain very uncommon. When rotator cuff injury does occur in the young throwing athlete, it is typically caused by high-energy trauma. On reviewing the literature, we found few case reports of supraspinatus tear in young age but most of them had either partial tear or patient age was 14 years or more. Battaglia et al. was the first to report high-grade partial-thickness tear of the supraspinatus tendon that occurred in a 13-year-old baseball pitcher.  Gerstman et al. reported near full-thickness tear of the supraspinatus tendon in a 12-year-old baseball pitcher.  Similarly, Turman et al. documented a traumatic four-tendon rotator cuff tear in a 16-year-old high school quarterback. 
We found few small case series also in which authors had reported supraspinatus tear. Tarkin et al. reported series of four cases in which two had supraspinatus tear. One with partial-thickness supraspinatus tear in 12-year-old patient and other full-thickness supraspinatus tear in a 14-year-old patient.  Itoi and Tabata reported three patients aged between 15 and 19-years with traumatic supraspinatus tears. All were high-grade partial-thickness tears with the exception of a "pinhole-size" full-thickness component in one patient. Similarly, Weiss et al. reported six adolescent athletes with rotator cuff tears or tuberosity fractures, but only one of these patients had a supraspinatus tear, and he was also 17 years old.  Burns et al. had reported two cases of complete full-thickness supraspinatus tear in adolescent girls of 15 years and 14 years, respectively. Both of them are softball catcher, and one had associated posterosuperior labrum tear also.  Recently, Zbojniewicz et al. reported his experience of 201 patients in which he had identified 12.2% rotator cuff tears in children and adolescents. However, in that report also, only one patient had complete supraspinatus tear and his age was 18 years. 
In most of the previous cases, patient was treated by arthroscopic repair after the failure of nonoperative treatment, but in this case, patient till now is doing very well with physical therapy. One way to decrease the repetitive loads placed on the shoulder joint is to teach the young pitchers about proper throwing mechanics. Poor mechanics place increased forces across the shoulder joint and may predispose to injury. Use of proper throwing technique can allow for preservation of throwing velocity without placing pathologic energy demands on the shoulder. Proper throwing mechanics also entails the correct use of lower extremity and core musculature. Lower body strength has been demonstrated to be key for both pitching performance and injury prevention. The pitching motion derives energy from the lower extremity, transfers it through pelvis and trunk rotation, and subsequently releases it through the upper extremity. In a study of collegiate and high school pitchers, the lower extremities were found to generate forces up to 35% of the pitcher's body weight during push-off in the cocking phase.  These push-off forces were found to correlate with wrist velocity. The lower extremities also generate a "braking" force of up to 72% body weight just before ball release. This force serves to slow the motion of the lower limbs, and this energy is then transferred to the trunk and arms to decelerate them and to help prevent shoulder injury. Strengthening of the lower extremities has been hypothesized to enhance the stability of pitching and decrease the incidence of other disorders caused by unstable pitching. 
Because of the rarity of rotator cuff tears in adolescents, no definitive recommendations regarding treatment are proposed till now. Determining the most appropriate treatment for these uncommon injuries will require more study with larger numbers of patient. Some experts recommend debridement for the majority of tears <50% thickness and performance of arthroscopic repairs for those >50%.  We believe that greater tuberosity fracture with complete supraspinatus tear in young patient is very rare injury, and it can be managed nonoperatively, but future research with bigger sample size will be required to come at a definitive conclusion.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]