Subscapularis Avulsion in a 12-Year-Old Wrestler

Abstract

Background:

Traumatic rotator cuff injuries are infrequently encountered among pediatric patients. Literature describing isolated subscapularis injuries, specifically with an associated avulsion fracture of the lesser tuberosity, is limited to case reports, with most patients undergoing operative management.

Indications:

In this video submission, we present the case of a 12-year-old male patient who presented to the clinic with right shoulder pain following a traumatic injury during competitive wrestling. The patient's examination was notable for pain and weakness with testing of subscapularis function. Magnetic resonance imaging revealed an isolated right subscapularis injury with avulsion of the lesser tuberosity. There was maintained attachment of the superior aspect of the subscapularis insertion and integrity of the biceps sling, but the remainder of the lesser tuberosity apophysis was displaced. For these reasons, shoulder diagnostic arthroscopy and arthroscopic versus open subscapularis repair were pursued.

Technique Description:

The patient was placed in the standard beach-chair position. Diagnostic arthroscopy was performed, but there was limited visualization of the apophyseal avulsion, given that the superior border of the subscapularis tendon remained attached. Conversion to open repair via a standard deltopectoral approach was performed. A complete avulsion of the subscapularis tendon apophyseal complex distal to the biceps tendon was discovered. Two all-suture-based anchors were used to fixate the subscapularis avulsion to its native footprint. Postoperatively, the patient was made nonweightbearing in a sling and followed a standard rotator cuff repair protocol with gradual reestablishment of shoulder motion beginning at 6 weeks and initiation of rotator cuff strengthening at 3 months postoperatively.

Results:

There were no complications encountered throughout the procedure. The patient progressed with physical therapy, achieving full shoulder range of motion by 12 weeks. Strengthening was initiated at 3 months, and by the 6-month follow-up, the patient had returned to all sports, experiencing no pain or deficits in shoulder range of motion and strength.

Discussion/Conclusion:

This pediatric patient's subscapularis tear and lesser tuberosity avulsion fracture were successfully repaired via an open approach, resulting in an excellent outcome and a return to the previous level of sports activity.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

For this video, we are presenting the findings and treatment of a subscapularis avulsion injury in a 12-year-old wrestler.

The authors have no relevant disclosures to this presentation.

Background

Rotator cuff injuries in the pediatric patient are infrequently encountered. ² These injuries are always traumatic, and the incidence is increasing with the rise in competitive youth sports and sports specialization.^2-5 This case presentation reviews the diagnosis and surgical management of an isolated subscapularis avulsion injury in a young athlete who sustained the injury after a traumatic external rotation injury while wrestling. The injury was successfully repaired via an open approach, which resulted in an overall excellent outcome and return to sport.

Indications

The patient is a 12-year-old male right-hand-dominant wrestler who was wrestling above his weight class when he sustained a traumatic external rotation injury to the right shoulder. The patient had an immediate onset of pain and weakness of the shoulder with an inability to continue athletic participation.

Upon medical evaluation, the patient, who is 5′1′′ tall and weighs 97 lbs, has focal tenderness to the anterior shoulder with limitation in full forward flexion and external rotation. He exhibits pain with internal and external rotation of the shoulder and has noted 4/5 weakness with isolated testing of the subscapularis muscle.

Initial radiographic images do not demonstrate any obvious signs of injury; thus, magnetic resonance imaging (MRI) of the injured shoulder was obtained. The MRI demonstrates an acute avulsion injury of the lesser tuberosity with the attached subscapularis tendon.

Good outcomes can be achieved with nonoperative management of partial tears, but surgical treatment is indicated for full-thickness injuries or displaced avulsion injuries. When managing these injuries operatively, both arthroscopic and open techniques are acceptable, depending on the pattern of injury and the ability to achieve an anatomic repair.

For this case, the plan was to proceed with operative management with arthroscopic and possible open subscapularis repair. The authors were prepared for conversion to open repair if there was limited visualization of the injury during shoulder arthroscopy.

Technique Description

The patient underwent general anesthesia and was placed in the beach-chair position.

Physical examination under anesthesia demonstrated that the patient had a full retained shoulder range of motion. There was no increased shoulder laxity or instability, as the patient had appropriate 1+ anterior and 1+ posterior humeral translation.

Diagnostic arthroscopy reveals intact glenohumeral articular cartilage and superior bicep-labrum complex. Significant hemorrhagic edema is noted throughout the anterior glenohumeral recess. The upper border of the subscapularis tendon appears to be intact, and there is no disruption of the biceps sling superior to the subscapularis insertion. The remainder of the rotator cuff attachments of the supraspinatus, infraspinatus, and teres minor are intact. There is no evidence of a humeral avulsion of the glenohumeral ligament, and the anteroinferior labrum is intact. Closer inspection of the inferior subscapularis attachment site raises concern for a displaced periosteal injury. Due to these findings, the decision is made to proceed with open repair. A deltopectoral approach is then performed in a standard fashion, utilizing a longitudinal incision extending from the palpable coracoid process and in line with the deltopectoral groove. The clavipectoral fascia is then incised, and the conjoint tendon is retracted medially to expose the underlying subscapularis tendon and lesser tuberosity fragment. A tag stitch is placed through the subscapularis tendon to assist with mobilization. This photo shows the displaced cartilaginous piece with the anatomic footprint below. The area of the injury is gently debrided with a curette to better expose the native footprint. Gentle traction demonstrates the dynamic displacement of the lesser tuberosity and subscapularis tendon and the ability to anatomically reduce the piece to the proximal humerus after adequate mobilization. A series of 2 all-suture-based anchors is then drilled and placed into the proximal humerus at the location of the lesser tuberosity footprint. Care is taken to minimize trauma to the physis. The sutures from each anchor are then passed through the subscapularis tendon and around the cartilaginous lesser tuberosity fragment using a free needle in a mattress configuration. The location of these passes just medial to the lesser tuberosity is important so as not to overtighten the subscapularis tendon. Next, the subscapularis and cartilaginous lesser tuberosity fragment are reduced into anatomic position using the traction suture, and the previously passed sutures from the anchor are tied around the cartilaginous lesser tuberosity fragment to achieve reduction and maintain compression of the fragment to the proximal humerus lesser tuberosity footprint. The lateral border of the repair site is then oversewn to further augment the repair. This also ensures the single-row repair does not gap open laterally. The deltopectoral interval is then reapproximated, and the subcutaneous and skin layers are closed in a standard fashion.

The most common potential complications related to this surgery are postoperative stiffness, reinjury, and infection. Postoperatively, the patients are engaged with physical therapy and closely monitored to ensure adequate initial return of passive shoulder range of motion is achieved. The risk of reinjury can further be reduced with appropriate patient and family education and adherence to a rehabilitation program with a skilled physical therapist. Patients are immobilized in a sling, and external rotation is initially limited to reduce the risk of reinjury. Infection prevention is achieved with strict adherence to aseptic surgical technique and administration of preoperative antibiotic prophylaxis.

Results

The postoperative rehabilitation consists of a period of nonweightbearing in a sling for 6 weeks with gentle passive range of motion and no external rotation permitted beyond neutral. No active shoulder range of motion is allowed during this time. Beginning 6 weeks postoperatively, the sling may be discontinued, and active-assisted range of motion exercises may be initiated. At 3 months postoperatively, the patient may then progress with strengthening exercises and, with the appropriate return of strength, may progress in a gradual return to sport.

At 3 months postoperatively, the patient is doing well, with a full return of shoulder range of motion without pain. Strength is also noted to be full and symmetric to the contralateral shoulder. In this video, the patient demonstrates excellent subscapularis function with the ability to successfully perform belly press and lift-off tests. At this time, the patient is then progressed with physical therapy to initiate a strengthening program. At 6 months postoperatively, the patient is allowed to return to sports after making a full recovery. At 9 months postoperatively, he continues to wrestle with no pain or deficits in shoulder range of motion or strength.

Discussion/Conclusion

A systematic review of the literature indicates that after rotator cuff repair surgery, most patients are able to return to unrestricted activity and sports at approximately 6 months postoperatively. ¹ At this time, patients have achieved full painless shoulder range of motion and strength that is comparable to the contralateral side.

This presentation highlights a rare subscapularis avulsion injury in a pediatric athlete successfully repaired with soft tissue fixation via an open approach. With proper surgical intervention and adherence to a structured rehabilitation program, an excellent outcome and return to sport are achievable.

Thank you.