Shoulder & Elbow

Humeral shaft fractures account for about 1% of all fractures.¹ With the exception of the few absolute indications for surgical intervention, such as the presence of an open fracture, the current teaching on treatment of these fractures is that the majority can be successfully managed nonoperatively.^1-3 These conservative measures consist of bandages, abduction splints, U-casts, hanging arm casts, and, most commonly, functional bracing, which is considered the gold standard for treatment of humeral shaft fractures by many authors.^1-3 One of the most often cited disadvantages of nonoperative management over surgical treatment is the higher incidence of residual deformity, the most common of which is varus angulation.⁴

The incidence of malunion (>20° of angulation in any plane or shortening of ≥2.5 cm) after nonoperative treatment varies in the literature from 0% to 13%,^2,4-9 with a recent literature review documenting a mean incidence of 4.4% within the frontal plane and 2% within the sagittal plane across all studies.² As reported initially by Sarmiento and colleagues^3,9 and echoed by other authors,^2,5,8 angular deformity of less than 20° is thought to be both cosmetically and functionally acceptable. Whether angular deformities or malunion of more than 20° actually leads to functional limitations is unknown. Although some observational reports suggest that the degree of radiographic malalignment does not necessarily correlate with functional outcome,⁸ no studies have specifically evaluated patient outcomes of humeral shaft fracture malunions.

We conducted a study to determine the overall incidence and long-term clinical and functional outcomes of patients with malunion after nonoperative management of humeral shaft fractures. Long-term outcomes were assessed with current symptoms, physical examination findings, need for subsequent operative intervention, DASH (Disabilities of the Arm, Shoulder, and Hand) scores, and a self-reported questionnaire. We hypothesized that patients who develop a malunion after nonoperative treatment of a closed humeral shaft fracture will have satisfactory functional outcomes based on subjective reports, physical examination findings, and DASH scores.

Methods

After obtaining institutional review board approval for the study, we selected patients from a retrospective medical record review of all those 18 years or older with a humeral shaft fracture managed nonoperatively at our institution between January 1, 2001, and June 30, 2012, with a minimum 1-year follow-up. We identified 156 patients with nonoperatively managed midshaft humerus fractures. Study exclusion criteria included fracture associated with a tumor (3 patients), ipsilateral upper extremity injury (9), open/ballistic injury (18), nonunion (9), underlying cognitive disability or psychiatric illness (4), and insufficient follow-up to clinical or radiographic healing (22). Ninety-one patients were eligible for study inclusion. Radiographs at time of final clinical visit were reviewed to assess for evidence of malunion at the fracture site, as defined by previously reported criteria³ (>20° angulation in anterior/posterior or varus/valgus plane of motion or shortening of ≥2.5 cm). Fifteen patients met all the inclusion criteria for further evaluation.

Medical records were retrospectively reviewed for information on age at injury, sex, comorbidities (eg, diabetes, osteoporosis, smoking), body mass index, type and duration of immobilization, complications, return to work, cosmetic perception, time to final clinical follow-up, and symptoms at final clinical follow-up. Incidence of potential risk factors associated with malunion—obesity, noncompliance, and comorbidities such as smoking and diabetes—was compared between the 15 patients with malunion and the other study patients, who healed without malunion.

For long-term postoperative follow-up, patients were contacted to be seen in clinic to complete an updated physical examination, self-reported questionnaire, and the DASH form. Physical examination included measurements of range of motion (ROM) and strength involving the shoulder, elbow, and forearm, with ROM reported as the difference between the injured and contralateral upper extremities. Neurovascular status and focal tenderness to palpation were also assessed on examination. When in-person examination was not possible, the questionnaire and DASH form were completed over the telephone. The self-reported questionnaire asked for information on smoking status, pain, functional limitations, cosmetic perception, satisfaction, and whether or not the patient would still opt for nonoperative management if presented with the same injury again. Pain and satisfaction were measured on numerical scales: Pain scores ranged from 0 (no pain) to 10 (worst possible pain), and satisfaction scores ranged from 1 (not satisfied) to 5 (very satisfied). Data are presented as mean values.

Results

Of the 91 study-eligible patients, 15 (16%) met the radiographic criteria for the diagnosis of malunion. Retrospective data were available for all 15 patients from time of injury to final clinical follow-up (mean, 19 weeks; range, 7-53 weeks). Mean age at injury was 39 years (range, 20-79 years). Additional demographics are listed in Table 1. Incidence of potential risk factors, such as body mass index (26.5 vs 25.4), smoking (33% vs 33%), and diabetes (0% vs 8%), was not significantly different between the malunion and healed-without-malunion groups, respectively. Furthermore, all malunion patients were compliant with their treatment protocol.

Radiographs were assessed at time of final follow-up to confirm healing and to document malunion. Varus malunion was found in 13 patients (mean, 24°; range, 20.5°-35.5°), and shortening was documented in the other 2 patients (mean, 4 cm; range, 3-5 cm). Patients were immobilized a mean of 10 weeks (range, 6-13 weeks). Initial fracture management consisted of coaptation splinting for 1 to 2 weeks (12 patients), hanging arm cast for 1 week (1 patient), and posterior splint for 1 week (1 patient). Patients were then transitioned to Sarmiento fracture bracing for the duration of their treatment (range, 5-12 months). One patient, followed initially at an outside institution, was managed in a sling throughout the duration of treatment (12 weeks) (Table 1). All 15 patients were neurovascularly intact at time of final clinical examination, with return of full upper extremity ROM in all but 3 patients. Only 1 of these 3 patients reported residual pain and functional limitations 4 months after injury (Table 2). Twelve patients were evaluated for return to work, with all successfully returning to work without restrictions at time of final follow-up. The 1 minor complication noted during the treatment period involved medial-sided elbow skin breakdown from brace wear, which resolved with local wound care. No patient required or requested surgical intervention for their residual malunion.

Of the 15 patients, 8 (53%) were reached for in-person examination (6 patients) or telephone interview (2 patients) for follow-up assessment by means of DASH form and self-reported questionnaire a mean of 47 months (range, 12-99 months) after initial injury. The 6 patients who had a physical examination were neurovascularly intact, lacked focal tenderness to palpation, and demonstrated full (5/5) strength within the deltoid, biceps, triceps, pronator, and supinator musculature. Each patient had equal ROM compared with the contralateral uninjured extremity on shoulder forward flexion and abduction, elbow flexion and extension, and forearm pronation and supination. Three patients (50%) had mild residual loss of ROM, with 2 demonstrating decreased shoulder external rotation of 10° and 15°, respectively, and 1 demonstrating decreased shoulder internal rotation of 10°.

Mean DASH score was 10.4 (range, 0-49.2). Evaluation of the self-reported questionnaire revealed a mean pain score of 1.1 (range, 0-7), with only 2 patients reporting any ongoing pain. In addition, 2 patients reported functional limitations, both related to overhead activities. However, 6 (75%) of the 8 patients reported noticeable cosmetic deformity, most commonly varus angulation (4 patients), as well as palpable bony prominence (2) and muscle atrophy (1). The majority of patients were satisfied with the outcome of their treatment (mean, 4; range, 2-5), with 6 patients reporting being satisfied or very satisfied, and all 6 indicating they would undergo nonoperative management again if presented with the same injury. Two patients reported being dissatisfied with their outcome, 1 because of cosmetic appearance and 1 because of cosmetic appearance and functional limitations. Both patients indicated they would choose operative management if presented with the same injury. There was no apparent relationship between outcome and degree of residual deformity, as both patients with varus angulation of more than 30° reported no residual pain or functional limitation and were very satisfied with the outcome of their treatment (Table 2).

Of the 7 patients who could not be reached for final follow-up, 2 on initial contact expressed overall satisfaction with their outcome and denied functional limitations. However, both asked to complete the study at a later date. Subsequently, these 2 patients could not be reached to complete the formal follow-up.

Discussion

Humeral shaft fractures are usually managed nonoperatively. One of the most commonly cited disadvantages of nonoperative management is its higher incidence of residual angular deformity, up to 13% in previous studies.⁴ Our study found a slightly higher incidence, 16%, on review of 91 nonoperatively managed humeral shaft fractures treated over an 11.5 year period. Although previous studies have reported acceptable functional and cosmetic outcomes with residual angular deformity of less than 20°,^2,3,5,8,9 only observational reports have suggested acceptable function in patients with a documented malunion.⁸

To our knowledge, ours is the first study to correlate malunion with functional parameters and subjective patient-reported outcomes. We found that malunion was not associated with significant pain or functional limitation after nonoperative management of humeral shaft fractures. Furthermore, 75% of patients were satisfied or very satisfied with the outcome of their treatment and indicated they would undergo nonoperative management if presented with the same injury again. However, 75% of patients reported a noticeable cosmetic deformity, and one-third of these patients cited it as a major reason for dissatisfaction with their overall outcome. Regarding function, all patients returned to full strength and ROM of the affected extremity, aside from small losses of internal or external shoulder rotation on the magnitude of 10° to 15° in 50% of those patients tested. In addition, 75% of patients returned to regular activity without functional limitations; the other 25% reported trouble with overhead activities. There were no significant complications during the treatment or follow-up period, once the fracture had healed.

The major limitation of this study was its small patient population. (Obtaining a larger series of patients with malunion after nonoperative treatment of humeral shaft fractures likely would require a multicenter study.) Some of our study findings, such as lack of correlation between degree of malunion and subsequent functional or subjective outcomes, would require a larger sample size for verification and more definitive conclusions. Another limitation is that the study was not designed to evaluate the cause of malunion. Therefore, we cannot draw any definitive conclusions regarding what may have contributed to the development of malunion in our study population. However, all our malunion patients were compliant with their treatment protocol, and they showed no significant difference in incidence of potential risk factors (eg, obesity, comorbidities) compared with the patients who healed without malunion.

Conclusion

Malunion after nonoperative management of humeral shaft fractures does not appear to result in significant pain, dissatisfaction, or functional limitation as measured on physical examination and with validated objective outcome measures in the majority of patients. Furthermore, no patients in this study required surgical intervention for any residual limitations or complications after malunion. The majority of patients reported a noticeable cosmetic deformity, which left a small subset of patients dissatisfied. Overall, our study findings can be used to help counsel patients before and during nonoperative management—particularly patients who appear to be healing with some malunion. Our findings suggest that operative intervention to prevent malunion is not necessary, as it likely would not result in any overall improvement in patient function or satisfaction, but patients should be counseled regarding the high likelihood of cosmetic deformity, which may or may not be bothersome.

Humeral shaft fractures account for about 1% of all fractures.¹ With the exception of the few absolute indications for surgical intervention, such as the presence of an open fracture, the current teaching on treatment of these fractures is that the majority can be successfully managed nonoperatively.^1-3 These conservative measures consist of bandages, abduction splints, U-casts, hanging arm casts, and, most commonly, functional bracing, which is considered the gold standard for treatment of humeral shaft fractures by many authors.^1-3 One of the most often cited disadvantages of nonoperative management over surgical treatment is the higher incidence of residual deformity, the most common of which is varus angulation.⁴

The incidence of malunion (>20° of angulation in any plane or shortening of ≥2.5 cm) after nonoperative treatment varies in the literature from 0% to 13%,^2,4-9 with a recent literature review documenting a mean incidence of 4.4% within the frontal plane and 2% within the sagittal plane across all studies.² As reported initially by Sarmiento and colleagues^3,9 and echoed by other authors,^2,5,8 angular deformity of less than 20° is thought to be both cosmetically and functionally acceptable. Whether angular deformities or malunion of more than 20° actually leads to functional limitations is unknown. Although some observational reports suggest that the degree of radiographic malalignment does not necessarily correlate with functional outcome,⁸ no studies have specifically evaluated patient outcomes of humeral shaft fracture malunions.

We conducted a study to determine the overall incidence and long-term clinical and functional outcomes of patients with malunion after nonoperative management of humeral shaft fractures. Long-term outcomes were assessed with current symptoms, physical examination findings, need for subsequent operative intervention, DASH (Disabilities of the Arm, Shoulder, and Hand) scores, and a self-reported questionnaire. We hypothesized that patients who develop a malunion after nonoperative treatment of a closed humeral shaft fracture will have satisfactory functional outcomes based on subjective reports, physical examination findings, and DASH scores.

Methods

After obtaining institutional review board approval for the study, we selected patients from a retrospective medical record review of all those 18 years or older with a humeral shaft fracture managed nonoperatively at our institution between January 1, 2001, and June 30, 2012, with a minimum 1-year follow-up. We identified 156 patients with nonoperatively managed midshaft humerus fractures. Study exclusion criteria included fracture associated with a tumor (3 patients), ipsilateral upper extremity injury (9), open/ballistic injury (18), nonunion (9), underlying cognitive disability or psychiatric illness (4), and insufficient follow-up to clinical or radiographic healing (22). Ninety-one patients were eligible for study inclusion. Radiographs at time of final clinical visit were reviewed to assess for evidence of malunion at the fracture site, as defined by previously reported criteria³ (>20° angulation in anterior/posterior or varus/valgus plane of motion or shortening of ≥2.5 cm). Fifteen patients met all the inclusion criteria for further evaluation.

Medical records were retrospectively reviewed for information on age at injury, sex, comorbidities (eg, diabetes, osteoporosis, smoking), body mass index, type and duration of immobilization, complications, return to work, cosmetic perception, time to final clinical follow-up, and symptoms at final clinical follow-up. Incidence of potential risk factors associated with malunion—obesity, noncompliance, and comorbidities such as smoking and diabetes—was compared between the 15 patients with malunion and the other study patients, who healed without malunion.

For long-term postoperative follow-up, patients were contacted to be seen in clinic to complete an updated physical examination, self-reported questionnaire, and the DASH form. Physical examination included measurements of range of motion (ROM) and strength involving the shoulder, elbow, and forearm, with ROM reported as the difference between the injured and contralateral upper extremities. Neurovascular status and focal tenderness to palpation were also assessed on examination. When in-person examination was not possible, the questionnaire and DASH form were completed over the telephone. The self-reported questionnaire asked for information on smoking status, pain, functional limitations, cosmetic perception, satisfaction, and whether or not the patient would still opt for nonoperative management if presented with the same injury again. Pain and satisfaction were measured on numerical scales: Pain scores ranged from 0 (no pain) to 10 (worst possible pain), and satisfaction scores ranged from 1 (not satisfied) to 5 (very satisfied). Data are presented as mean values.

Results

Of the 91 study-eligible patients, 15 (16%) met the radiographic criteria for the diagnosis of malunion. Retrospective data were available for all 15 patients from time of injury to final clinical follow-up (mean, 19 weeks; range, 7-53 weeks). Mean age at injury was 39 years (range, 20-79 years). Additional demographics are listed in Table 1. Incidence of potential risk factors, such as body mass index (26.5 vs 25.4), smoking (33% vs 33%), and diabetes (0% vs 8%), was not significantly different between the malunion and healed-without-malunion groups, respectively. Furthermore, all malunion patients were compliant with their treatment protocol.

Radiographs were assessed at time of final follow-up to confirm healing and to document malunion. Varus malunion was found in 13 patients (mean, 24°; range, 20.5°-35.5°), and shortening was documented in the other 2 patients (mean, 4 cm; range, 3-5 cm). Patients were immobilized a mean of 10 weeks (range, 6-13 weeks). Initial fracture management consisted of coaptation splinting for 1 to 2 weeks (12 patients), hanging arm cast for 1 week (1 patient), and posterior splint for 1 week (1 patient). Patients were then transitioned to Sarmiento fracture bracing for the duration of their treatment (range, 5-12 months). One patient, followed initially at an outside institution, was managed in a sling throughout the duration of treatment (12 weeks) (Table 1). All 15 patients were neurovascularly intact at time of final clinical examination, with return of full upper extremity ROM in all but 3 patients. Only 1 of these 3 patients reported residual pain and functional limitations 4 months after injury (Table 2). Twelve patients were evaluated for return to work, with all successfully returning to work without restrictions at time of final follow-up. The 1 minor complication noted during the treatment period involved medial-sided elbow skin breakdown from brace wear, which resolved with local wound care. No patient required or requested surgical intervention for their residual malunion.

Of the 15 patients, 8 (53%) were reached for in-person examination (6 patients) or telephone interview (2 patients) for follow-up assessment by means of DASH form and self-reported questionnaire a mean of 47 months (range, 12-99 months) after initial injury. The 6 patients who had a physical examination were neurovascularly intact, lacked focal tenderness to palpation, and demonstrated full (5/5) strength within the deltoid, biceps, triceps, pronator, and supinator musculature. Each patient had equal ROM compared with the contralateral uninjured extremity on shoulder forward flexion and abduction, elbow flexion and extension, and forearm pronation and supination. Three patients (50%) had mild residual loss of ROM, with 2 demonstrating decreased shoulder external rotation of 10° and 15°, respectively, and 1 demonstrating decreased shoulder internal rotation of 10°.

Mean DASH score was 10.4 (range, 0-49.2). Evaluation of the self-reported questionnaire revealed a mean pain score of 1.1 (range, 0-7), with only 2 patients reporting any ongoing pain. In addition, 2 patients reported functional limitations, both related to overhead activities. However, 6 (75%) of the 8 patients reported noticeable cosmetic deformity, most commonly varus angulation (4 patients), as well as palpable bony prominence (2) and muscle atrophy (1). The majority of patients were satisfied with the outcome of their treatment (mean, 4; range, 2-5), with 6 patients reporting being satisfied or very satisfied, and all 6 indicating they would undergo nonoperative management again if presented with the same injury. Two patients reported being dissatisfied with their outcome, 1 because of cosmetic appearance and 1 because of cosmetic appearance and functional limitations. Both patients indicated they would choose operative management if presented with the same injury. There was no apparent relationship between outcome and degree of residual deformity, as both patients with varus angulation of more than 30° reported no residual pain or functional limitation and were very satisfied with the outcome of their treatment (Table 2).

Of the 7 patients who could not be reached for final follow-up, 2 on initial contact expressed overall satisfaction with their outcome and denied functional limitations. However, both asked to complete the study at a later date. Subsequently, these 2 patients could not be reached to complete the formal follow-up.

Discussion

Humeral shaft fractures are usually managed nonoperatively. One of the most commonly cited disadvantages of nonoperative management is its higher incidence of residual angular deformity, up to 13% in previous studies.⁴ Our study found a slightly higher incidence, 16%, on review of 91 nonoperatively managed humeral shaft fractures treated over an 11.5 year period. Although previous studies have reported acceptable functional and cosmetic outcomes with residual angular deformity of less than 20°,^2,3,5,8,9 only observational reports have suggested acceptable function in patients with a documented malunion.⁸

To our knowledge, ours is the first study to correlate malunion with functional parameters and subjective patient-reported outcomes. We found that malunion was not associated with significant pain or functional limitation after nonoperative management of humeral shaft fractures. Furthermore, 75% of patients were satisfied or very satisfied with the outcome of their treatment and indicated they would undergo nonoperative management if presented with the same injury again. However, 75% of patients reported a noticeable cosmetic deformity, and one-third of these patients cited it as a major reason for dissatisfaction with their overall outcome. Regarding function, all patients returned to full strength and ROM of the affected extremity, aside from small losses of internal or external shoulder rotation on the magnitude of 10° to 15° in 50% of those patients tested. In addition, 75% of patients returned to regular activity without functional limitations; the other 25% reported trouble with overhead activities. There were no significant complications during the treatment or follow-up period, once the fracture had healed.

The major limitation of this study was its small patient population. (Obtaining a larger series of patients with malunion after nonoperative treatment of humeral shaft fractures likely would require a multicenter study.) Some of our study findings, such as lack of correlation between degree of malunion and subsequent functional or subjective outcomes, would require a larger sample size for verification and more definitive conclusions. Another limitation is that the study was not designed to evaluate the cause of malunion. Therefore, we cannot draw any definitive conclusions regarding what may have contributed to the development of malunion in our study population. However, all our malunion patients were compliant with their treatment protocol, and they showed no significant difference in incidence of potential risk factors (eg, obesity, comorbidities) compared with the patients who healed without malunion.

Conclusion

Malunion after nonoperative management of humeral shaft fractures does not appear to result in significant pain, dissatisfaction, or functional limitation as measured on physical examination and with validated objective outcome measures in the majority of patients. Furthermore, no patients in this study required surgical intervention for any residual limitations or complications after malunion. The majority of patients reported a noticeable cosmetic deformity, which left a small subset of patients dissatisfied. Overall, our study findings can be used to help counsel patients before and during nonoperative management—particularly patients who appear to be healing with some malunion. Our findings suggest that operative intervention to prevent malunion is not necessary, as it likely would not result in any overall improvement in patient function or satisfaction, but patients should be counseled regarding the high likelihood of cosmetic deformity, which may or may not be bothersome.

Humeral shaft fractures account for about 1% of all fractures.¹ With the exception of the few absolute indications for surgical intervention, such as the presence of an open fracture, the current teaching on treatment of these fractures is that the majority can be successfully managed nonoperatively.^1-3 These conservative measures consist of bandages, abduction splints, U-casts, hanging arm casts, and, most commonly, functional bracing, which is considered the gold standard for treatment of humeral shaft fractures by many authors.^1-3 One of the most often cited disadvantages of nonoperative management over surgical treatment is the higher incidence of residual deformity, the most common of which is varus angulation.⁴

The incidence of malunion (>20° of angulation in any plane or shortening of ≥2.5 cm) after nonoperative treatment varies in the literature from 0% to 13%,^2,4-9 with a recent literature review documenting a mean incidence of 4.4% within the frontal plane and 2% within the sagittal plane across all studies.² As reported initially by Sarmiento and colleagues^3,9 and echoed by other authors,^2,5,8 angular deformity of less than 20° is thought to be both cosmetically and functionally acceptable. Whether angular deformities or malunion of more than 20° actually leads to functional limitations is unknown. Although some observational reports suggest that the degree of radiographic malalignment does not necessarily correlate with functional outcome,⁸ no studies have specifically evaluated patient outcomes of humeral shaft fracture malunions.

We conducted a study to determine the overall incidence and long-term clinical and functional outcomes of patients with malunion after nonoperative management of humeral shaft fractures. Long-term outcomes were assessed with current symptoms, physical examination findings, need for subsequent operative intervention, DASH (Disabilities of the Arm, Shoulder, and Hand) scores, and a self-reported questionnaire. We hypothesized that patients who develop a malunion after nonoperative treatment of a closed humeral shaft fracture will have satisfactory functional outcomes based on subjective reports, physical examination findings, and DASH scores.

Methods

After obtaining institutional review board approval for the study, we selected patients from a retrospective medical record review of all those 18 years or older with a humeral shaft fracture managed nonoperatively at our institution between January 1, 2001, and June 30, 2012, with a minimum 1-year follow-up. We identified 156 patients with nonoperatively managed midshaft humerus fractures. Study exclusion criteria included fracture associated with a tumor (3 patients), ipsilateral upper extremity injury (9), open/ballistic injury (18), nonunion (9), underlying cognitive disability or psychiatric illness (4), and insufficient follow-up to clinical or radiographic healing (22). Ninety-one patients were eligible for study inclusion. Radiographs at time of final clinical visit were reviewed to assess for evidence of malunion at the fracture site, as defined by previously reported criteria³ (>20° angulation in anterior/posterior or varus/valgus plane of motion or shortening of ≥2.5 cm). Fifteen patients met all the inclusion criteria for further evaluation.

Medical records were retrospectively reviewed for information on age at injury, sex, comorbidities (eg, diabetes, osteoporosis, smoking), body mass index, type and duration of immobilization, complications, return to work, cosmetic perception, time to final clinical follow-up, and symptoms at final clinical follow-up. Incidence of potential risk factors associated with malunion—obesity, noncompliance, and comorbidities such as smoking and diabetes—was compared between the 15 patients with malunion and the other study patients, who healed without malunion.

For long-term postoperative follow-up, patients were contacted to be seen in clinic to complete an updated physical examination, self-reported questionnaire, and the DASH form. Physical examination included measurements of range of motion (ROM) and strength involving the shoulder, elbow, and forearm, with ROM reported as the difference between the injured and contralateral upper extremities. Neurovascular status and focal tenderness to palpation were also assessed on examination. When in-person examination was not possible, the questionnaire and DASH form were completed over the telephone. The self-reported questionnaire asked for information on smoking status, pain, functional limitations, cosmetic perception, satisfaction, and whether or not the patient would still opt for nonoperative management if presented with the same injury again. Pain and satisfaction were measured on numerical scales: Pain scores ranged from 0 (no pain) to 10 (worst possible pain), and satisfaction scores ranged from 1 (not satisfied) to 5 (very satisfied). Data are presented as mean values.

Results

Of the 91 study-eligible patients, 15 (16%) met the radiographic criteria for the diagnosis of malunion. Retrospective data were available for all 15 patients from time of injury to final clinical follow-up (mean, 19 weeks; range, 7-53 weeks). Mean age at injury was 39 years (range, 20-79 years). Additional demographics are listed in Table 1. Incidence of potential risk factors, such as body mass index (26.5 vs 25.4), smoking (33% vs 33%), and diabetes (0% vs 8%), was not significantly different between the malunion and healed-without-malunion groups, respectively. Furthermore, all malunion patients were compliant with their treatment protocol.

Radiographs were assessed at time of final follow-up to confirm healing and to document malunion. Varus malunion was found in 13 patients (mean, 24°; range, 20.5°-35.5°), and shortening was documented in the other 2 patients (mean, 4 cm; range, 3-5 cm). Patients were immobilized a mean of 10 weeks (range, 6-13 weeks). Initial fracture management consisted of coaptation splinting for 1 to 2 weeks (12 patients), hanging arm cast for 1 week (1 patient), and posterior splint for 1 week (1 patient). Patients were then transitioned to Sarmiento fracture bracing for the duration of their treatment (range, 5-12 months). One patient, followed initially at an outside institution, was managed in a sling throughout the duration of treatment (12 weeks) (Table 1). All 15 patients were neurovascularly intact at time of final clinical examination, with return of full upper extremity ROM in all but 3 patients. Only 1 of these 3 patients reported residual pain and functional limitations 4 months after injury (Table 2). Twelve patients were evaluated for return to work, with all successfully returning to work without restrictions at time of final follow-up. The 1 minor complication noted during the treatment period involved medial-sided elbow skin breakdown from brace wear, which resolved with local wound care. No patient required or requested surgical intervention for their residual malunion.

Of the 15 patients, 8 (53%) were reached for in-person examination (6 patients) or telephone interview (2 patients) for follow-up assessment by means of DASH form and self-reported questionnaire a mean of 47 months (range, 12-99 months) after initial injury. The 6 patients who had a physical examination were neurovascularly intact, lacked focal tenderness to palpation, and demonstrated full (5/5) strength within the deltoid, biceps, triceps, pronator, and supinator musculature. Each patient had equal ROM compared with the contralateral uninjured extremity on shoulder forward flexion and abduction, elbow flexion and extension, and forearm pronation and supination. Three patients (50%) had mild residual loss of ROM, with 2 demonstrating decreased shoulder external rotation of 10° and 15°, respectively, and 1 demonstrating decreased shoulder internal rotation of 10°.

Mean DASH score was 10.4 (range, 0-49.2). Evaluation of the self-reported questionnaire revealed a mean pain score of 1.1 (range, 0-7), with only 2 patients reporting any ongoing pain. In addition, 2 patients reported functional limitations, both related to overhead activities. However, 6 (75%) of the 8 patients reported noticeable cosmetic deformity, most commonly varus angulation (4 patients), as well as palpable bony prominence (2) and muscle atrophy (1). The majority of patients were satisfied with the outcome of their treatment (mean, 4; range, 2-5), with 6 patients reporting being satisfied or very satisfied, and all 6 indicating they would undergo nonoperative management again if presented with the same injury. Two patients reported being dissatisfied with their outcome, 1 because of cosmetic appearance and 1 because of cosmetic appearance and functional limitations. Both patients indicated they would choose operative management if presented with the same injury. There was no apparent relationship between outcome and degree of residual deformity, as both patients with varus angulation of more than 30° reported no residual pain or functional limitation and were very satisfied with the outcome of their treatment (Table 2).

Of the 7 patients who could not be reached for final follow-up, 2 on initial contact expressed overall satisfaction with their outcome and denied functional limitations. However, both asked to complete the study at a later date. Subsequently, these 2 patients could not be reached to complete the formal follow-up.

Discussion

Humeral shaft fractures are usually managed nonoperatively. One of the most commonly cited disadvantages of nonoperative management is its higher incidence of residual angular deformity, up to 13% in previous studies.⁴ Our study found a slightly higher incidence, 16%, on review of 91 nonoperatively managed humeral shaft fractures treated over an 11.5 year period. Although previous studies have reported acceptable functional and cosmetic outcomes with residual angular deformity of less than 20°,^2,3,5,8,9 only observational reports have suggested acceptable function in patients with a documented malunion.⁸

To our knowledge, ours is the first study to correlate malunion with functional parameters and subjective patient-reported outcomes. We found that malunion was not associated with significant pain or functional limitation after nonoperative management of humeral shaft fractures. Furthermore, 75% of patients were satisfied or very satisfied with the outcome of their treatment and indicated they would undergo nonoperative management if presented with the same injury again. However, 75% of patients reported a noticeable cosmetic deformity, and one-third of these patients cited it as a major reason for dissatisfaction with their overall outcome. Regarding function, all patients returned to full strength and ROM of the affected extremity, aside from small losses of internal or external shoulder rotation on the magnitude of 10° to 15° in 50% of those patients tested. In addition, 75% of patients returned to regular activity without functional limitations; the other 25% reported trouble with overhead activities. There were no significant complications during the treatment or follow-up period, once the fracture had healed.

The major limitation of this study was its small patient population. (Obtaining a larger series of patients with malunion after nonoperative treatment of humeral shaft fractures likely would require a multicenter study.) Some of our study findings, such as lack of correlation between degree of malunion and subsequent functional or subjective outcomes, would require a larger sample size for verification and more definitive conclusions. Another limitation is that the study was not designed to evaluate the cause of malunion. Therefore, we cannot draw any definitive conclusions regarding what may have contributed to the development of malunion in our study population. However, all our malunion patients were compliant with their treatment protocol, and they showed no significant difference in incidence of potential risk factors (eg, obesity, comorbidities) compared with the patients who healed without malunion.

Conclusion

Malunion after nonoperative management of humeral shaft fractures does not appear to result in significant pain, dissatisfaction, or functional limitation as measured on physical examination and with validated objective outcome measures in the majority of patients. Furthermore, no patients in this study required surgical intervention for any residual limitations or complications after malunion. The majority of patients reported a noticeable cosmetic deformity, which left a small subset of patients dissatisfied. Overall, our study findings can be used to help counsel patients before and during nonoperative management—particularly patients who appear to be healing with some malunion. Our findings suggest that operative intervention to prevent malunion is not necessary, as it likely would not result in any overall improvement in patient function or satisfaction, but patients should be counseled regarding the high likelihood of cosmetic deformity, which may or may not be bothersome.

Anatomical total shoulder arthroplasty (TSA) is an effective treatment for advanced osteoarthritis (OA) of the glenohumeral joint.^1-4 Over the past 40 years, since the early reports appeared, the implants have evolved from the early monoblock humeral component to modular components, variable neck angled components with eccentric heads, and components that can provide variable neck angles, version angles, and dual eccentricity to match the anatomy of the proximal humerus. The goal of the new implants is to replicate the individual patient’s native anatomy using a combination of modularity, multiple neck and version angles, and dual eccentricity of the neck and head. The flexibility of the implant system is made possible by a replicator plate. There are few reports on outcomes of using these new implants for OA.

In this article, we report outcomes of using a dual eccentric, variable neck angle, variable version angle implant with a replicator plate for the treatment of OA of the shoulder at 4 centers.

Materials and Methods

The Western Institutional Review Board approved this study, and consent was prospectively obtained and retrospectively reviewed.

The data banks of a 4-center consortium were queried. Only primary TSA patients treated for OA with a fourth-generation Exactech Equinoxe implant (Exactech, Inc.) were included. For the center to be included, it had to have an 80% patient follow-up rate at a minimum of 2 years. Four centers qualified for inclusion: University of Florida, Medical College of Georgia, New York University, and Bordeaux-Merignac Clinic. Data were obtained on surgeries sequentially performed between August 1, 2006, and December 31, 2010. All data were obtained prospectively using a common data collection format.

The Equinoxe anatomical TSA allows for independent adaptation of neck angle and humeral version and provides 2 variable offset times (1 on replicator plate, 1 on humeral head) for matching the native anatomy in more than 99% of cases⁵ (Figure). The replicator plate is eccentric and can be angled 7.5° in any direction and rotated 360° to provide humeral head coverage. Once its optimal position is obtained, the plate is permanently fixed to the humeral stem using a breakaway screw. Some contemporary implants have similar features.

There were 218 primary shoulder arthroplasties performed on 201 patients (98 male, 103 female). Mean age at time of surgery was 67 years (range, 31-87 years), and mean follow-up was 36 months (range, 24-72 months). The collective follow-up rate at the 3-year mean follow-up and 2-year minimal follow-up was 81%. Eleven shoulders had a cemented stem, and 207 had an uncemented stem. Forty-eight shoulders used the 1.5-mm replicator plate, and 170 used the 4.5-mm offset replicator plate. The patients in this study were typically not very healthy: mean American Society of Anesthesiologists (ASA) score was 2.57 (range, 1-3).

Five outcome scores were calculated from the prospectively obtained data: Constant normalized, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), UCLA Shoulder Rating Scale (UCLA), and American Shoulder and Elbow Surgeons Shoulder Assessment (ASES). Before initiating data collection, we developed the Metric Form⁶ so we could calculate multiple scores while asking the minimal possible number of questions. This could be done for all 5 outcome scores, as their questions have significant overlap.

Objective outcomes included active external rotation, active scaption, active abduction, and active internal rotation. Complications, including revisions, were noted and analyzed. We focus on functional outcomes and do not present radiographic outcomes.

Results

A 2-tailed unpaired t test was used to compare preoperative values with final outcome values (P < .05). Four objective outcomes were significantly improved over preoperative levels: active external rotation (preoperative, 15°; postoperative, 42°), active scaption (pre, 92°; post, 137°), active abduction (pre, 80°; post, 121°), and active internal rotation (pre, S3; post, L2). The functional outcome scores that were significantly (P < .05) improved at final follow-up were Constant normalized (pre, 39; post, 79), SPADI (pre, 86; post, 20), SST (pre, 3.3; post, 10), UCLA (pre, 13; post, 31), and ASES (pre, 33; post, 85).

The outcome improvements at latest follow-up were active external rotation (+28), active scaption (+45), active abduction (+42), active internal rotation (+6 anatomical segments), Constant normalized (+40), SPADI (–66), SST (+6.7), UCLA (+18), and ASES (+52).

There were 32 complications in 25 shoulders. There were no bilateral complications. Seven shoulders had multiple complications, of which many were not independent events. For example, rotator cuff deficiency was associated with instability, and infection was associated with glenoid loosening. One patient had 2 procedures, the first an arthroscopic release and the second a revision shoulder arthroplasty for glenoid loosening. The most common postoperative complication was rotator cuff failure (RCF) or suspected RCF (13 shoulders, including 8 treated with revision arthroplasty). RCF occurred most commonly at the rotator cuff interval, followed by the subscapularis and the supraspinatus. RCF location was based on computed tomography scan or intraoperative observation. The few subscapularis failures occurred with both subscapularis tendon repair and osteotomy. The high RCF rate may derive from scrutinizing postoperative radiographs and was not necessarily confirmed with repeat surgery. We think this represents a more realistic estimate of true postoperative rotator cuff dysfunction, rather than including only reoperated cases. The second most common complication was infection (6 shoulders, 1 with a superficial suture abscess and 5 with deep infections). Other complications were instability (4, with 2 caused by rotator cuff insufficiency), glenoid loosening (4, with 2 caused by infection), stiffness (3), nerve issue (1), and hematoma evacuation (1).

In 21 shoulders, these complications were treated with revision shoulder arthroplasty (16 shoulders), arthroscopic capsular release (3), evacuation of postoperative hematoma (1), and débridement of suture abscess (1). The 16 revision shoulder arthroplasties performed were conversion to reverse shoulder arthroplasty (11 shoulders) and placement of an antibiotic spacer for infection (5). The stem was left in place for all revisions, excluding those for infection. This is a significant advantage of the modular platform stem. Details of the complications and treatments are listed in the Table. There was no difference in health status between patients with a complication (ASA, 2.57) and those without one (ASA, 2.56).

Discussion

The implant described in this article consists of a metaphyseal press-fit stem, a replicator plate, multiple eccentric humeral heads, and a glenoid of multiple sizes with 2 radii of curvatures used to match the patient’s native anatomy and still maintain the appropriate radius of curvature mismatch between the humeral head and the glenoid. Between the eccentricity in the replicator plate and the eccentricity in the humeral head, almost any humeral head cut can be covered, more than 99% of the time.¹ However, it remains to be seen if a versatile implant that comes close to matching the patient’s native anatomy will make a difference clinically.

The objective and functional outcomes in this study compare well with those of other, large TSA studies using older prostheses.^1-4 There are few reports on contemporary implants with sufficient follow-up numbers for the single diagnosis of OA. Norris and Iannotti² reported on a multicenter study of 176 patients with a Depuy Global TSA. The design of their study comes closest to that of our clinical outcome study. Nineteen surgeons were involved in their study. The follow-up rate is not clear. Their outcomes (with ours in parentheses for comparison) were active external rotation of 45° (42°), active elevation of 138° (137°), ASES of 84 (85), and SST of 9.2 (10). Norris and Iannotti² noted an overall complication rate of 13% (12% in our series). Their most common postoperative complications were RCF and glenoid loosening; ours were RCF and infection. Another multicenter study with short-term results using a contemporary prosthesis included 268 shoulders followed for a minimum of 12 months.¹ At final follow-up, Constant score was 97, active elevation was 145°, and the complication rate was 8.6%. Godenèche and colleagues¹ also noted a glenoid lucent-line rate of 58% and reported that rotator cuff pathology adversely affected outcome.

Although the overall clinical outcome results are encouraging and the complication rate is in the reported range, we believe that a focus on the major complication categories may have a significant positive impact on our patients. The present article places significant importance on reporting complications prospectively, which is more accurate than retrospective reporting. The rates of both RCF and infection, the most common complications in our study, need to be decreased. Aldinger and colleagues⁷ reported a 12% complication rate in 485 primary shoulder arthroplasties—a rate identical to ours here. In their study, nerve injuries and humeral fractures were both more common than rotator cuff tears. We think that rotator cuff deficiency after TSA is underreported because it is often based on revision surgery alone. It is also interesting that the majority of the cuff deficiencies were through the upper subscapularis rotator interval and were not a complete failure of the subscapularis repair. Not all these patients will undergo revision surgery. In the future, the RCF rate may drop with the increasingly common use of reverse shoulder arthroplasty for substandard rotator cuffs.

Use of this contemporary variable neck angle, variable version angle, dual eccentric shoulder arthroplasty with a replicator plate provides satisfying short-term clinical outcomes. Patients with less than optimal health (mean ASA, 2.57) seem to tolerate the procedure well. Continued focus on RCF and infection will have the greatest impact on the overall complication rate.

Anatomical total shoulder arthroplasty (TSA) is an effective treatment for advanced osteoarthritis (OA) of the glenohumeral joint.^1-4 Over the past 40 years, since the early reports appeared, the implants have evolved from the early monoblock humeral component to modular components, variable neck angled components with eccentric heads, and components that can provide variable neck angles, version angles, and dual eccentricity to match the anatomy of the proximal humerus. The goal of the new implants is to replicate the individual patient’s native anatomy using a combination of modularity, multiple neck and version angles, and dual eccentricity of the neck and head. The flexibility of the implant system is made possible by a replicator plate. There are few reports on outcomes of using these new implants for OA.

In this article, we report outcomes of using a dual eccentric, variable neck angle, variable version angle implant with a replicator plate for the treatment of OA of the shoulder at 4 centers.

Materials and Methods

The Western Institutional Review Board approved this study, and consent was prospectively obtained and retrospectively reviewed.

The data banks of a 4-center consortium were queried. Only primary TSA patients treated for OA with a fourth-generation Exactech Equinoxe implant (Exactech, Inc.) were included. For the center to be included, it had to have an 80% patient follow-up rate at a minimum of 2 years. Four centers qualified for inclusion: University of Florida, Medical College of Georgia, New York University, and Bordeaux-Merignac Clinic. Data were obtained on surgeries sequentially performed between August 1, 2006, and December 31, 2010. All data were obtained prospectively using a common data collection format.

The Equinoxe anatomical TSA allows for independent adaptation of neck angle and humeral version and provides 2 variable offset times (1 on replicator plate, 1 on humeral head) for matching the native anatomy in more than 99% of cases⁵ (Figure). The replicator plate is eccentric and can be angled 7.5° in any direction and rotated 360° to provide humeral head coverage. Once its optimal position is obtained, the plate is permanently fixed to the humeral stem using a breakaway screw. Some contemporary implants have similar features.

There were 218 primary shoulder arthroplasties performed on 201 patients (98 male, 103 female). Mean age at time of surgery was 67 years (range, 31-87 years), and mean follow-up was 36 months (range, 24-72 months). The collective follow-up rate at the 3-year mean follow-up and 2-year minimal follow-up was 81%. Eleven shoulders had a cemented stem, and 207 had an uncemented stem. Forty-eight shoulders used the 1.5-mm replicator plate, and 170 used the 4.5-mm offset replicator plate. The patients in this study were typically not very healthy: mean American Society of Anesthesiologists (ASA) score was 2.57 (range, 1-3).

Five outcome scores were calculated from the prospectively obtained data: Constant normalized, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), UCLA Shoulder Rating Scale (UCLA), and American Shoulder and Elbow Surgeons Shoulder Assessment (ASES). Before initiating data collection, we developed the Metric Form⁶ so we could calculate multiple scores while asking the minimal possible number of questions. This could be done for all 5 outcome scores, as their questions have significant overlap.

Objective outcomes included active external rotation, active scaption, active abduction, and active internal rotation. Complications, including revisions, were noted and analyzed. We focus on functional outcomes and do not present radiographic outcomes.

Results

A 2-tailed unpaired t test was used to compare preoperative values with final outcome values (P < .05). Four objective outcomes were significantly improved over preoperative levels: active external rotation (preoperative, 15°; postoperative, 42°), active scaption (pre, 92°; post, 137°), active abduction (pre, 80°; post, 121°), and active internal rotation (pre, S3; post, L2). The functional outcome scores that were significantly (P < .05) improved at final follow-up were Constant normalized (pre, 39; post, 79), SPADI (pre, 86; post, 20), SST (pre, 3.3; post, 10), UCLA (pre, 13; post, 31), and ASES (pre, 33; post, 85).

The outcome improvements at latest follow-up were active external rotation (+28), active scaption (+45), active abduction (+42), active internal rotation (+6 anatomical segments), Constant normalized (+40), SPADI (–66), SST (+6.7), UCLA (+18), and ASES (+52).

There were 32 complications in 25 shoulders. There were no bilateral complications. Seven shoulders had multiple complications, of which many were not independent events. For example, rotator cuff deficiency was associated with instability, and infection was associated with glenoid loosening. One patient had 2 procedures, the first an arthroscopic release and the second a revision shoulder arthroplasty for glenoid loosening. The most common postoperative complication was rotator cuff failure (RCF) or suspected RCF (13 shoulders, including 8 treated with revision arthroplasty). RCF occurred most commonly at the rotator cuff interval, followed by the subscapularis and the supraspinatus. RCF location was based on computed tomography scan or intraoperative observation. The few subscapularis failures occurred with both subscapularis tendon repair and osteotomy. The high RCF rate may derive from scrutinizing postoperative radiographs and was not necessarily confirmed with repeat surgery. We think this represents a more realistic estimate of true postoperative rotator cuff dysfunction, rather than including only reoperated cases. The second most common complication was infection (6 shoulders, 1 with a superficial suture abscess and 5 with deep infections). Other complications were instability (4, with 2 caused by rotator cuff insufficiency), glenoid loosening (4, with 2 caused by infection), stiffness (3), nerve issue (1), and hematoma evacuation (1).

In 21 shoulders, these complications were treated with revision shoulder arthroplasty (16 shoulders), arthroscopic capsular release (3), evacuation of postoperative hematoma (1), and débridement of suture abscess (1). The 16 revision shoulder arthroplasties performed were conversion to reverse shoulder arthroplasty (11 shoulders) and placement of an antibiotic spacer for infection (5). The stem was left in place for all revisions, excluding those for infection. This is a significant advantage of the modular platform stem. Details of the complications and treatments are listed in the Table. There was no difference in health status between patients with a complication (ASA, 2.57) and those without one (ASA, 2.56).

Discussion

The implant described in this article consists of a metaphyseal press-fit stem, a replicator plate, multiple eccentric humeral heads, and a glenoid of multiple sizes with 2 radii of curvatures used to match the patient’s native anatomy and still maintain the appropriate radius of curvature mismatch between the humeral head and the glenoid. Between the eccentricity in the replicator plate and the eccentricity in the humeral head, almost any humeral head cut can be covered, more than 99% of the time.¹ However, it remains to be seen if a versatile implant that comes close to matching the patient’s native anatomy will make a difference clinically.

The objective and functional outcomes in this study compare well with those of other, large TSA studies using older prostheses.^1-4 There are few reports on contemporary implants with sufficient follow-up numbers for the single diagnosis of OA. Norris and Iannotti² reported on a multicenter study of 176 patients with a Depuy Global TSA. The design of their study comes closest to that of our clinical outcome study. Nineteen surgeons were involved in their study. The follow-up rate is not clear. Their outcomes (with ours in parentheses for comparison) were active external rotation of 45° (42°), active elevation of 138° (137°), ASES of 84 (85), and SST of 9.2 (10). Norris and Iannotti² noted an overall complication rate of 13% (12% in our series). Their most common postoperative complications were RCF and glenoid loosening; ours were RCF and infection. Another multicenter study with short-term results using a contemporary prosthesis included 268 shoulders followed for a minimum of 12 months.¹ At final follow-up, Constant score was 97, active elevation was 145°, and the complication rate was 8.6%. Godenèche and colleagues¹ also noted a glenoid lucent-line rate of 58% and reported that rotator cuff pathology adversely affected outcome.

Although the overall clinical outcome results are encouraging and the complication rate is in the reported range, we believe that a focus on the major complication categories may have a significant positive impact on our patients. The present article places significant importance on reporting complications prospectively, which is more accurate than retrospective reporting. The rates of both RCF and infection, the most common complications in our study, need to be decreased. Aldinger and colleagues⁷ reported a 12% complication rate in 485 primary shoulder arthroplasties—a rate identical to ours here. In their study, nerve injuries and humeral fractures were both more common than rotator cuff tears. We think that rotator cuff deficiency after TSA is underreported because it is often based on revision surgery alone. It is also interesting that the majority of the cuff deficiencies were through the upper subscapularis rotator interval and were not a complete failure of the subscapularis repair. Not all these patients will undergo revision surgery. In the future, the RCF rate may drop with the increasingly common use of reverse shoulder arthroplasty for substandard rotator cuffs.

Use of this contemporary variable neck angle, variable version angle, dual eccentric shoulder arthroplasty with a replicator plate provides satisfying short-term clinical outcomes. Patients with less than optimal health (mean ASA, 2.57) seem to tolerate the procedure well. Continued focus on RCF and infection will have the greatest impact on the overall complication rate.

Anatomical total shoulder arthroplasty (TSA) is an effective treatment for advanced osteoarthritis (OA) of the glenohumeral joint.^1-4 Over the past 40 years, since the early reports appeared, the implants have evolved from the early monoblock humeral component to modular components, variable neck angled components with eccentric heads, and components that can provide variable neck angles, version angles, and dual eccentricity to match the anatomy of the proximal humerus. The goal of the new implants is to replicate the individual patient’s native anatomy using a combination of modularity, multiple neck and version angles, and dual eccentricity of the neck and head. The flexibility of the implant system is made possible by a replicator plate. There are few reports on outcomes of using these new implants for OA.

In this article, we report outcomes of using a dual eccentric, variable neck angle, variable version angle implant with a replicator plate for the treatment of OA of the shoulder at 4 centers.

Materials and Methods

The Western Institutional Review Board approved this study, and consent was prospectively obtained and retrospectively reviewed.

The data banks of a 4-center consortium were queried. Only primary TSA patients treated for OA with a fourth-generation Exactech Equinoxe implant (Exactech, Inc.) were included. For the center to be included, it had to have an 80% patient follow-up rate at a minimum of 2 years. Four centers qualified for inclusion: University of Florida, Medical College of Georgia, New York University, and Bordeaux-Merignac Clinic. Data were obtained on surgeries sequentially performed between August 1, 2006, and December 31, 2010. All data were obtained prospectively using a common data collection format.

The Equinoxe anatomical TSA allows for independent adaptation of neck angle and humeral version and provides 2 variable offset times (1 on replicator plate, 1 on humeral head) for matching the native anatomy in more than 99% of cases⁵ (Figure). The replicator plate is eccentric and can be angled 7.5° in any direction and rotated 360° to provide humeral head coverage. Once its optimal position is obtained, the plate is permanently fixed to the humeral stem using a breakaway screw. Some contemporary implants have similar features.

There were 218 primary shoulder arthroplasties performed on 201 patients (98 male, 103 female). Mean age at time of surgery was 67 years (range, 31-87 years), and mean follow-up was 36 months (range, 24-72 months). The collective follow-up rate at the 3-year mean follow-up and 2-year minimal follow-up was 81%. Eleven shoulders had a cemented stem, and 207 had an uncemented stem. Forty-eight shoulders used the 1.5-mm replicator plate, and 170 used the 4.5-mm offset replicator plate. The patients in this study were typically not very healthy: mean American Society of Anesthesiologists (ASA) score was 2.57 (range, 1-3).

Five outcome scores were calculated from the prospectively obtained data: Constant normalized, Shoulder Pain and Disability Index (SPADI), Simple Shoulder Test (SST), UCLA Shoulder Rating Scale (UCLA), and American Shoulder and Elbow Surgeons Shoulder Assessment (ASES). Before initiating data collection, we developed the Metric Form⁶ so we could calculate multiple scores while asking the minimal possible number of questions. This could be done for all 5 outcome scores, as their questions have significant overlap.

Objective outcomes included active external rotation, active scaption, active abduction, and active internal rotation. Complications, including revisions, were noted and analyzed. We focus on functional outcomes and do not present radiographic outcomes.

Results

A 2-tailed unpaired t test was used to compare preoperative values with final outcome values (P < .05). Four objective outcomes were significantly improved over preoperative levels: active external rotation (preoperative, 15°; postoperative, 42°), active scaption (pre, 92°; post, 137°), active abduction (pre, 80°; post, 121°), and active internal rotation (pre, S3; post, L2). The functional outcome scores that were significantly (P < .05) improved at final follow-up were Constant normalized (pre, 39; post, 79), SPADI (pre, 86; post, 20), SST (pre, 3.3; post, 10), UCLA (pre, 13; post, 31), and ASES (pre, 33; post, 85).

The outcome improvements at latest follow-up were active external rotation (+28), active scaption (+45), active abduction (+42), active internal rotation (+6 anatomical segments), Constant normalized (+40), SPADI (–66), SST (+6.7), UCLA (+18), and ASES (+52).

There were 32 complications in 25 shoulders. There were no bilateral complications. Seven shoulders had multiple complications, of which many were not independent events. For example, rotator cuff deficiency was associated with instability, and infection was associated with glenoid loosening. One patient had 2 procedures, the first an arthroscopic release and the second a revision shoulder arthroplasty for glenoid loosening. The most common postoperative complication was rotator cuff failure (RCF) or suspected RCF (13 shoulders, including 8 treated with revision arthroplasty). RCF occurred most commonly at the rotator cuff interval, followed by the subscapularis and the supraspinatus. RCF location was based on computed tomography scan or intraoperative observation. The few subscapularis failures occurred with both subscapularis tendon repair and osteotomy. The high RCF rate may derive from scrutinizing postoperative radiographs and was not necessarily confirmed with repeat surgery. We think this represents a more realistic estimate of true postoperative rotator cuff dysfunction, rather than including only reoperated cases. The second most common complication was infection (6 shoulders, 1 with a superficial suture abscess and 5 with deep infections). Other complications were instability (4, with 2 caused by rotator cuff insufficiency), glenoid loosening (4, with 2 caused by infection), stiffness (3), nerve issue (1), and hematoma evacuation (1).

In 21 shoulders, these complications were treated with revision shoulder arthroplasty (16 shoulders), arthroscopic capsular release (3), evacuation of postoperative hematoma (1), and débridement of suture abscess (1). The 16 revision shoulder arthroplasties performed were conversion to reverse shoulder arthroplasty (11 shoulders) and placement of an antibiotic spacer for infection (5). The stem was left in place for all revisions, excluding those for infection. This is a significant advantage of the modular platform stem. Details of the complications and treatments are listed in the Table. There was no difference in health status between patients with a complication (ASA, 2.57) and those without one (ASA, 2.56).

Discussion

The implant described in this article consists of a metaphyseal press-fit stem, a replicator plate, multiple eccentric humeral heads, and a glenoid of multiple sizes with 2 radii of curvatures used to match the patient’s native anatomy and still maintain the appropriate radius of curvature mismatch between the humeral head and the glenoid. Between the eccentricity in the replicator plate and the eccentricity in the humeral head, almost any humeral head cut can be covered, more than 99% of the time.¹ However, it remains to be seen if a versatile implant that comes close to matching the patient’s native anatomy will make a difference clinically.

The objective and functional outcomes in this study compare well with those of other, large TSA studies using older prostheses.^1-4 There are few reports on contemporary implants with sufficient follow-up numbers for the single diagnosis of OA. Norris and Iannotti² reported on a multicenter study of 176 patients with a Depuy Global TSA. The design of their study comes closest to that of our clinical outcome study. Nineteen surgeons were involved in their study. The follow-up rate is not clear. Their outcomes (with ours in parentheses for comparison) were active external rotation of 45° (42°), active elevation of 138° (137°), ASES of 84 (85), and SST of 9.2 (10). Norris and Iannotti² noted an overall complication rate of 13% (12% in our series). Their most common postoperative complications were RCF and glenoid loosening; ours were RCF and infection. Another multicenter study with short-term results using a contemporary prosthesis included 268 shoulders followed for a minimum of 12 months.¹ At final follow-up, Constant score was 97, active elevation was 145°, and the complication rate was 8.6%. Godenèche and colleagues¹ also noted a glenoid lucent-line rate of 58% and reported that rotator cuff pathology adversely affected outcome.

Although the overall clinical outcome results are encouraging and the complication rate is in the reported range, we believe that a focus on the major complication categories may have a significant positive impact on our patients. The present article places significant importance on reporting complications prospectively, which is more accurate than retrospective reporting. The rates of both RCF and infection, the most common complications in our study, need to be decreased. Aldinger and colleagues⁷ reported a 12% complication rate in 485 primary shoulder arthroplasties—a rate identical to ours here. In their study, nerve injuries and humeral fractures were both more common than rotator cuff tears. We think that rotator cuff deficiency after TSA is underreported because it is often based on revision surgery alone. It is also interesting that the majority of the cuff deficiencies were through the upper subscapularis rotator interval and were not a complete failure of the subscapularis repair. Not all these patients will undergo revision surgery. In the future, the RCF rate may drop with the increasingly common use of reverse shoulder arthroplasty for substandard rotator cuffs.

Use of this contemporary variable neck angle, variable version angle, dual eccentric shoulder arthroplasty with a replicator plate provides satisfying short-term clinical outcomes. Patients with less than optimal health (mean ASA, 2.57) seem to tolerate the procedure well. Continued focus on RCF and infection will have the greatest impact on the overall complication rate.

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Supracondylar humerus fractures, which are the most common elbow fractures in the pediatric population, account for approximately 3% of all pediatric fractures.¹ Complications of the injury or surgery include pin migration (2%), pin-site infection (1%), malunion, loss of reduction, compartment syndrome, nerve injury, and cubitus varus.¹ A less frequently reported complication is avascular necrosis (AVN) of the trochlea.

First reported in 1948, posttraumatic deformity of the trochlea has appeared sparingly throughout the literature.² This complication has been reported in varying fracture patterns and degrees of injury. The exact incidence is unknown because AVN of the humerus can occur without known trauma. The etiology of the deformity is thought to be interruption of the blood supply of the trochlea. Patterns include type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista along with a metaphyseal portion). Type A necrosis leads to early degenerative joint disease and loss of range of motion (ROM); angular deformities are uncommon. Type B AVN results in a progressive varus deformity of the trochlea.³ The deformities typically worsen as the child ages. Late-onset ulnar neuropathy can be seen, as medial condyle hypoplasia allows the ulnar nerve to move anterior with the medial head of the triceps. Treatment options address the sequelae and include observation, muscle strengthening, supracondylar osteotomy, and ulnar nerve transposition. Arthroscopic joint débridement has been shown, in short-term follow-up, to relieve pain and restore motion.⁴

We present 5 cases of AVN of the trochlea after supracondylar humerus fractures to highlight this unusual complication. Unlike more common complications of supracondylar humerus fractures, AVN of the trochlea can be a late clinical finding. We speculate that, in cases resulting from nondisplaced fractures, tamponade from fracture hematoma may play a role. It is important to keep this complication in the differential diagnosis of patients with a history of a supracondylar humerus fracture and unexplained elbow motion loss or pain. 

Case Reports 

Retrospective data were collected for all patients after approval by the institutional review board at our institution. Patients were identified by a computerized search using the Current Procedural Terminology code for closed reduction percutaneous pinning of supracondylar humerus fracture. The search was limited to patients treated at our institution from 2000 to 2012; 1159 patients were initially identified. Three patients were found to have postoperative AVN of the trochlea; 2 other patients were treated at an outside hospital and were identified by surgeon recall. These 5 cases are presented here.

Case 1

A girl aged 5 years, 3 months sustained a Gartland type III supracondylar humerus fracture. She was originally seen at an outside facility and transferred to our tertiary care facility for definitive management. She underwent closed reduction and fixation with 3 lateral-based pins 1 day after her injury. Her pins and cast were removed 22 days postoperatively. She returned to full elbow function after her fracture care; 6 months later, she returned to the clinic with painless, decreased flexion of her elbow to 95º. Radiographs showed a lucency of the trochlea extending into the metaphysis (Figure 1). Thirteen months postoperatively, her examination was unchanged with motion at 0º to 95º; her radiographs showed a persistent lateral and medial lucency of the trochlea consistent with type B AVN involving the medial crista.

Case 2

An 8-year-old girl sustained a Gartland type III supracondylar humerus fracture that was treated at an outside facility with closed reduction and fixation with lateral pins. She had an uneventful postoperative course with painless return of motion. She presented 6 months after her surgery with progressive decreased ROM. She underwent conservative treatment with therapy and stretching without much improvement. She presented to our institution 4 years postoperatively with painless decreased motion from 40º to 110º. Radiographs showed dissolution of the lateral ossification center of the trochlea with a fishtail deformity consistent with type A AVN. Magnetic resonance imaging (MRI) confirmed AVN of the trochlea (Figure 2). 

Case 3

A girl aged 5 years, 6 months sustained a Gartland type I supracondylar humerus fracture that was treated uneventfully by casting. She did not have a reduction or manipulation and healed without complications. She returned to the clinic 3 years after the injury complaining of intermittent elbow pain, neglect, and loss of motion. Her ROM was 0º to 110º. Radiographs showed dissolution of the lateral trochlea with sclerosis of the metaphysis consistent with a type A deformity (Figure 3). Contralateral radiographs were not obtained. MRI confirmed AVN of the trochlea. 

Case 4

A 10-year-old girl sustained a Gartland type III supracondylar humerus fracture treated with closed reduction and pinning at an outside facility. She experienced full return to function postoperatively until developing stiffness and popping 1 year after surgery. She was evaluated at our institution 5 years postoperatively with elbow popping in full extension. Radiographs showed a type A deformity; MRI confirmed the diagnosis of AVN of the humerus (Figure 4). She underwent elbow arthroscopy with débridement of a posterior cartilage flap and synovial band. After elbow arthroscopy and débridement, she had resolution of symptoms with full elbow ROM.

Case 5

A 5-year-old boy sustained a Gartland III supracondylar humerus fracture that was treated with closed reduction and pinning at our institution. He had full return of painless motion postoperatively. Seven years after surgery, he presented with popping sensation in his elbow. Examination showed a 5º lack of full extension without effusion or crepitus. Radiographs showed a type A deformity with dissolution of the lateral ossification center (Figure 5).

Discussion

Avascular necrosis of the trochlea after supracondylar humerus fractures was first reported by McDonnell and Wilson in 1948.² Four of 53 patients (7.5%) developed AVN of the trochlea. Clinical presentation happened at 2 to 7 years after injury. No causative effect was given; however, 2 cases of AVN were associated with narrowing of joint space and thinning of articular cartilage. One incident was associated with multiple reduction attempts.² The etiology and exact incidence remain unclear, but both vascular insult and idiopathic growth disturbance have been proposed.⁴

Morrissy and Wilkins⁵ in 1984 reported 3 cases of dissolution of the trochlea after supracondylar humerus fractures: 1 fracture was casted, 1 was splinted, and 1 underwent closed reduction and pinning. Radiographic abnormality was noted at 5 years, 1 year, and 9 months, respectively. These authors explained the dissolution as a vascular phenomenon. Interruption of the medial or lateral vessels supplying the cartilage of the trochlea would lead to the central necrosis pattern seen in their 3 cases. In addition, the rapid onset in Morrissy and Wilkin’s second and third cases (both 7 years old) supports a vascular etiology.⁵ 

A more recent study of 6 cases found dissolution of the trochlea occurred as a result of severe displaced supracondylar fractures.⁶ Four of the 6 cases involved nerve injuries. Evidence of fishtail deformity was delayed from fracture time until 7 to 8 years of age, consistent with the ossification of the trochlea. Additionally, MRI findings, as well as loose body formation, added to the plausibility of AVN.⁶

Haraldsson⁷ demonstrated the 2 main sources of blood supply to the medial crista of the trochlea. The lateral vessels are intra-articular and supply the apex and lateral aspect of the trochlea. The medial vessels supply the medial aspect of the medial crista of the trochlea and are extra-articular. The lateral and medial vessels do not have an anastomosis between them (Figure 6).⁷ Disruption of the lateral vessels results in a type A deformity; disruption of the lateral and medial vessels results in a type B deformity. Displaced supracondylar humerus fractures disrupt the periosteum and can result in disruption of the medial and/or lateral vessels, resulting in AVN and deformity.

Another case of AVN of the trochlea after a Gartland type I fracture was reported by Schulte and Ramseier.⁸ Similar to our case 3, the patient developed type A AVN of the distal humerus,⁹ illustrating an interruption of the lateral, intra-articular vessels. The etiology of vascular disruption in these nondisplaced supracondylar humerus fractures is less clear, but we propose that tamponade may play a role. Nondisplaced fractures result in a fracture hematoma contained in an intact capsule, having the potential to increase pressures and lead to occlusion of the lateral, intra-articular vessels. This would result in a type A deformity. Nondisplaced supracondylar humerus fractures are common, and this complication is very rare. Typically, they would be expected to generate modest fracture hematoma. However, patient factors, such as bleeding disorders or anatomic variants, including a constricted capsule, could predispose patients to development of increased intracapsular pressure. In contrast, Gartland type II and III fractures, although higher-energy, presumably tear the surrounding capsule leading to release of the fracture hematoma. We do not have direct evidence to support this theory, but measurement of intracapsular pressures could help support or refute the occurrence of tamponade. Similar studies have been reported in hip fracture and slipped capital femoral epiphysis, in which hematoma has been shown to increase intracapsular pressure.^8,10 This pressure increase can theoretically cause a tamponade of the femoral head blood supply leading to AVN. Additional alternate explanations for AVN of the trochlea after type I fractures may include a rare occurrence of direct trauma to the vessels at the moment of fracture, increased intracapsular pressure from cast positioning, or that they are unrelated events that occurred in the same elbow (because atraumatic AVN has also been reported).

Conclusion

Avascular necrosis of the trochlea is a rare but important complication of supracondylar humerus fractures. Generally, this complication has a late clinical presentation, and its cause is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to Gartland type A or type B deformity. In nondisplaced fractures, the lateral vessels are affected. We propose that the lateral vessels may be interrupted by tamponade caused by encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. Avascular necrosis of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.

Distal biceps tendon ruptures have been reported with increasing frequency, occurring 1.2 times per 100,000 patients per year, representing 3% of tendinous avulsions involving this muscle.^1,2 This injury occurs most commonly in men between the ages of 40 and 60 years, and more often in the dominant extremity after an unexpected or violent eccentric contraction.^2,3 Generally, the patient is performing a task that is more strenuous than usual and only performed occasionally; usually, it is a flexion task. The biceps muscle is the most superficial muscle in the anterior compartment of the arm with the distal tendon passing deep in the antecubital fossa to insert at the radial tuberosity (Figure 1). Pronation of the forearm rotates the radial tuberosity medially and posteriorly, drawing the biceps tendon distally with it (Figures 1-3). The biceps muscle is primarily responsible for supination of the forearm, although it is also important in elbow flexion.^4,5 The bicipital aponeurosis (lacertus fibrosus) arises from the medial aspect of the muscle belly at the junction of the musculotendinous unit and the distal biceps tendon. This passes distally and medially across the antecubital fossa, blending with the fascia overlying the proximal flexor mass of the forearm, and inserts on the subcutaneous border of the ulna.³ A complete rupture of the distal biceps insertion can produce a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow when compared with the contralateral intact extremity.^1,2,4 

Background

Prompt diagnosis of a distal biceps tendon complete rupture increases the ability to perform a primary repair, and to restore motion and strength.³ Patients with acute ruptures of the distal biceps typically present with a history of experiencing a painful “pop” after a violent eccentric load force at the time of injury. Clinical examination of a patient with a distal biceps tendon rupture shows a loss of the normal upper arm contour, pain with flexion and supination of the forearm, ecchymosis, and an inability to palpate the distal biceps tendon in the antecubital fossa.⁵ It is important to note that a false-negative test can be elicited when examining the integrity of the muscle contour if the lacertus fibrosus remains intact when there is a complete rupture of the distal biceps tendon.⁶ This false negative also can occur with examination of the upper arm contour as the elbow flexes. Radiographic studies to evaluate the distal biceps tendon can aid in the diagnosis of ruptures but are not a substitute for a thorough history taking and physical examination.³ Plain radiographs may show hypertrophic bone formation at the radial tuberosity, although they are generally unrevealing.^3,6 After a complete clinical examination of the distal biceps tendon, magnetic resonance imaging (MRI) can be an important tool for evaluation of the distal biceps tendon.³ This article introduces a special test used as a diagnostic tool during the physical examination to isolate the distal biceps tendon from the lacertus fibrosus and to evaluate the integrity of the distal biceps brachii tendon. 

Test Description

To perform the supination-pronation test, the patient is positioned with both shoulders abducted to 90º and the elbows flexed to approximately 60º to 70º (Figures 4, 5). The examiner stands in front of the patient and observes the contour of the biceps muscle; the unaffected arm is used as a comparison. The examiner may either visually observe the contour of the muscle or may place a hand on the muscle belly throughout the test to feel for movement. The patient is asked to actively supinate and pronate the forearms by turning the hands. Through trial and error, we have found that the change in contour is most pronounced when placing the elbow in 60º to 70º of flexion. Additionally, through clinical experience, we have found testing the patient with both shoulders abducted to 90º provides the examiner with a reproducible examination that is easy to demonstrate to the patient; however, this shoulder position is not mandatory and can be modified if the patient struggles to get into testing position. Forearm position will maximize the size of the biceps, so the result is visually easier to appreciate. If the distal biceps tendon is intact, there is a substantial change in the shape of the biceps as the arm is supinated (the biceps moves proximally), then pronated (the biceps moves distally). Lack of migration of the biceps muscle during supination and pronation is considered a positive test, indicating rupture of the distal biceps tendon from its insertion on the radial tuberosity (Figure 6). We have found the anatomic correlations to a distal biceps injury may be clearly observed through the maneuver of the supination-pronation test and, therefore, provide a reliable clinical method to diagnose a complete distal biceps tendon rupture.

We have been using the supination-pronation test in our clinical practice for 2.5 years. In our experience, opportunities to use the supination-pronation test are very limited and specific. This type of tendon avulsion is rare, and the number of patients who warrant clinical examination using the supination-pronation test is small. We have had 5 positive supination-pronation tests in patients with suspected distal biceps tendon ruptures. To confirm if the supination-pronation test correctly demonstrated a full biceps tendon rupture in these 5 patients, we followed their clinical examination with MRI of the involved arm. Only 4 of the 5 patients were able to obtain MRI. Of these 4, all studies showed complete tearing of the distal biceps tendon from its attachment on the radial tuberosity. All 5 patients were taken into the operating room to confirm the clinical diagnosis and then repair it surgically. Through surgical exploration, we observed a full and complete tear of the distal biceps tendon in all patients, and the tears were repaired successfully. Postoperatively, all patients showed a full recovery with no complications, and all were able to regain full range of motion and strength in the involved arm. All 5 patients were discharged with no complaints. 

Although we have not encountered false positive and false negatives using the supination-pronation test in clinical practice, we speculate that there would be a low rate of incidence for these outcomes. There is a possibility of a false-positive test in obese patients in whom the contours of the biceps are difficult to appreciate (although we have not observed this clinically). In these patients, the examiner may not see the migration of the biceps that is occurring. In practice, we have found that, if the contours of the bicep are difficult to appreciate, the test can be performed with the examiner placing his/her hand on the muscle belly during the test to actively feel for movement. This could decrease the risk of a false-positive supination-pronation test. A false negative may occur if the distal biceps tendon is almost completely torn. In this case, enough of the tendon fibers may remain intact to pull the biceps muscle belly distally as the hand is pronated. In our experience, this was not observed but should be noted as a potential risk for a false-negative test. 

If the lacertus fibrosus is intact, and the distal biceps tendon is ruptured, the biceps will still change shape as the elbow is flexed and extended but will not change shape with supination and pronation. The biceps brachii muscle attaches distally to the radial tuberosity of the radius; contraction of the muscle pulls the tuberosity anteriorly, rotating the forearm into supination. When the forearm rotates into pronation, the tendon is pulled distally and the muscle lengthens, which causes the contour to be more elongated. Since the lacertus fibrosus attaches to the proximal ulna, it is not involved in forearm supination and pronation. It does, however, assist with elbow flexion. 

It is very important to isolate the biceps brachii tendon from the lacertus fibrosus and the brachialis because the examiner may miss a distal tendon rupture by not isolating supination and pronation. The supination-pronation test is a novel clinical test that allows the examiner to isolate the biceps brachii tendon in supination and pronation to evaluate for distal biceps tendon rupture. It has been well established that early anatomic repair of distal biceps tendon rupture is advocated for optimal results in returning flexion and supination strength.^3,4,6 Although some patients may choose nonoperative management of complete ruptures, prompt diagnosis of the injury is vital so that the option of surgical management at the time of presentation is not compromised by delay in diagnosis. Clinically, we have found that a delayed diagnosis results in more difficulty performing the surgery, and it may not be possible to obtain enough excursion for the biceps to be reattached with the passage of time. The literature suggests that patients with chronic ruptures (more than 4 weeks) often present with proximal retraction of the biceps muscles and scarring to the brachialis, which can make anatomic repair a difficult challenge.^3,7

It is important to note the differences in treatment of proximal versus distal bicep tendon ruptures. Proximally, there are 2 tendon attachments. The tendon of the short head attaches to the coracoid process of the scapula. The tendon of the long head runs into the shoulder joint, attaching intra-articularly to the superior aspect of the glenoid. This tendon is often involved in degeneration concurrently with the adjacent rotator cuff and is vulnerable to rupture. Rupture of this tendon is usually treated nonoperatively. Because proximal rupture nearly always affects only the tendon to the long head, the muscle preserves 1 proximal attachment and continues to function, both as a supinator and as a flexor. Also, this type of rupture tends to occur in more elderly and less active patients who are less adversely affected by the modest loss of function associated with proximal ruptures.

Conclusion

The supination-pronation test properly isolates the distal biceps tendon and does not cause significant discomfort, which can be a problem with other physical examination tests for acute distal biceps ruptures. The squeeze test involves placing the patient in 60º to 80º of elbow flexion with the forearm pronated. The examiner places 1 hand at the distal myotendinous junction, and the other around the belly of the muscle and squeezes, looking for forearm supination.⁵ We have not found the squeeze test to be optimal because the amount of forearm supination obtained by performing this test can be subtle. Additionally, the patient commonly has significant ecchymosis and pain associated with this rupture, and it may be too painful to squeeze the muscle belly hard enough to have a reliable test. Another test is the hook test, which is performed by the examiner “hooking” an index finger under the intact biceps tendon from the lateral side.⁸ Clinically, we have found this test difficult to administer because it requires palpation of the tendon, which is often painful for the patient with an acute injury.

The supination-pronation test can easily be performed in the acute setting, and confirms attachment of the biceps tendon distally to the bicipital tuberosity of the radius. It will not show an incomplete tear, but in that case, the muscle retains its normal length, alleviating the urgency of surgical management. We have found the supination-pronation test to be a reliable and pain-free test that should be incorporated in the physical examination to evaluate patients for distal biceps injury.

ORLANDO—Surgeries related to overuse elbow injuries are more common among youth athletes than previously believed, according to research presented at the 2015 Annual Meeting of the American Orthopaedic Society for Sports Medicine and published in the July issue of the American Journal of Sports Medicine.

“Our results showed that 15- to 19-year-olds accounted for 56.7% of the ulnar collateral ligament reconstruction (UCLR) or Tommy John surgeries performed in the US between 2007 and 2011. This is a significant increase over time with an average increase of 9.12% per year,” said lead study author Brandon Erickson, MD, of Rush University Medical Center in Chicago, Illinois.

Dr. Erickson and his research team performed a retrospective analysis of a private payer database using the PearlDiver Supercomputer to identify UCLR procedures performed throughout the United States.

The overall average annual incidence of the procedure was 3.96 +/-0.38 per 100,000 patients with an annual overall growth rate of 4.2%. There were 695 males and 95 females involved in the analysis. Twenty to 24-year olds accounted for the second highest incident rate at 22.2%.

Other findings from the study included that the southern region of the US performed significantly more UCLR procedures than any other region with 53%. Most of the surgeries were also performed between April and June. Fifty-eight percent of the procedures were performed in an outpatient hospital setting, 40% were performed at a surgical center, and 3% of procedures were performed in an inpatient hospital setting.

“The research numbers suggest that more young athletes believe that having an UCLR procedure performed earlier in their career may lead to the big leagues or a scholarship, even though only one in 200 kids who play high school baseball will make it to Major League Baseball. This paradigm shift needs to be evaluated further to help prevent overuse injuries in kids from the beginning of the season when most issues arise,” said Dr. Erickson.

ORLANDO—Surgeries related to overuse elbow injuries are more common among youth athletes than previously believed, according to research presented at the 2015 Annual Meeting of the American Orthopaedic Society for Sports Medicine and published in the July issue of the American Journal of Sports Medicine.

“Our results showed that 15- to 19-year-olds accounted for 56.7% of the ulnar collateral ligament reconstruction (UCLR) or Tommy John surgeries performed in the US between 2007 and 2011. This is a significant increase over time with an average increase of 9.12% per year,” said lead study author Brandon Erickson, MD, of Rush University Medical Center in Chicago, Illinois.

Dr. Erickson and his research team performed a retrospective analysis of a private payer database using the PearlDiver Supercomputer to identify UCLR procedures performed throughout the United States.

The overall average annual incidence of the procedure was 3.96 +/-0.38 per 100,000 patients with an annual overall growth rate of 4.2%. There were 695 males and 95 females involved in the analysis. Twenty to 24-year olds accounted for the second highest incident rate at 22.2%.

Other findings from the study included that the southern region of the US performed significantly more UCLR procedures than any other region with 53%. Most of the surgeries were also performed between April and June. Fifty-eight percent of the procedures were performed in an outpatient hospital setting, 40% were performed at a surgical center, and 3% of procedures were performed in an inpatient hospital setting.

“The research numbers suggest that more young athletes believe that having an UCLR procedure performed earlier in their career may lead to the big leagues or a scholarship, even though only one in 200 kids who play high school baseball will make it to Major League Baseball. This paradigm shift needs to be evaluated further to help prevent overuse injuries in kids from the beginning of the season when most issues arise,” said Dr. Erickson.

ORLANDO—Surgeries related to overuse elbow injuries are more common among youth athletes than previously believed, according to research presented at the 2015 Annual Meeting of the American Orthopaedic Society for Sports Medicine and published in the July issue of the American Journal of Sports Medicine.

“Our results showed that 15- to 19-year-olds accounted for 56.7% of the ulnar collateral ligament reconstruction (UCLR) or Tommy John surgeries performed in the US between 2007 and 2011. This is a significant increase over time with an average increase of 9.12% per year,” said lead study author Brandon Erickson, MD, of Rush University Medical Center in Chicago, Illinois.

Dr. Erickson and his research team performed a retrospective analysis of a private payer database using the PearlDiver Supercomputer to identify UCLR procedures performed throughout the United States.

The overall average annual incidence of the procedure was 3.96 +/-0.38 per 100,000 patients with an annual overall growth rate of 4.2%. There were 695 males and 95 females involved in the analysis. Twenty to 24-year olds accounted for the second highest incident rate at 22.2%.

Other findings from the study included that the southern region of the US performed significantly more UCLR procedures than any other region with 53%. Most of the surgeries were also performed between April and June. Fifty-eight percent of the procedures were performed in an outpatient hospital setting, 40% were performed at a surgical center, and 3% of procedures were performed in an inpatient hospital setting.

“The research numbers suggest that more young athletes believe that having an UCLR procedure performed earlier in their career may lead to the big leagues or a scholarship, even though only one in 200 kids who play high school baseball will make it to Major League Baseball. This paradigm shift needs to be evaluated further to help prevent overuse injuries in kids from the beginning of the season when most issues arise,” said Dr. Erickson.

In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.

The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!

As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.

Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”¹ The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.¹

We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.

In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.

The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!

As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.

Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”¹ The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.¹

We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.

In this month’s issue of The American Journal of Orthopedics, Tannenbaum and colleagues present a “5 Points” article on “Measurement of Resource Utilization for Total and Reverse Shoulder Arthroplasty.” This is an excellent article that summarizes the authors’ methodology of determining not only the overall cost of hospital care for shoulder replacement but a detailed analysis of many components contributing to that cost.

The steps are fairly straightforward: identify the various components of the cost, gather the data contributing to those costs, and then analyze what are the major expenditures that contribute to the overall cost. Sounds simple, but, in practice, it is anything but!

As health care expenditures in the United States continue to increase and approach 20% of the gross domestic product, every sector of the health care industry is searching for ways to curtail and eventually decrease the cost of health care. However, one cannot control costs without accurate data that defines those costs. In this article, Tannenbaum and colleagues have provided a methodology to help both hospital administrators and surgeons determine the overall cost of shoulder arthroplasty, but their principles of analysis can be applied to all aspects of hospital care.

Such efforts are gaining the attention of many leaders of the health care industry. For example, in the September 8, 2015, edition of The New York Times, I was very interested to read the article “What are a Hospital’s Costs? Utah System Is Trying to Learn.”¹ The article reviewed the efforts of Dr. Vivian Lee, chief executive at University of Utah Health Care, to determine the actual cost of all care provided by the university hospital, the same goal as the present 5 Points article on shoulder arthroplasty but on a vastly greater scale. Analyzing those costs guided Dr. Lee and her colleagues to alter clinical programs, which led to a decrease of 30% in hospital expenditures and fewer complications.¹

We are all indebted to Mr. Tannenbaum and his coauthors for providing the journal’s readers with a clear map that we can use to both understand and navigate the current maze of hospital costs. Using such a guide, we will be able to gather information that not only saves money, but will improve care by directing resources to services that actually benefit our patients.

Superior labral anteroposterior (SLAP) tears are common labral injuries. They occur at the attachment of the long head of the biceps tendon on the superior glenoid and extend anterior and/or posterior to the biceps anchor. The mechanism of action for SLAP tears is traction on the superior labrum by the long head of the biceps tendon, resulting in “peeling” of the labrum off the glenoid. Such forces may result from repetitive overhead arm motion (pitching) or from direct trauma.

Clinical diagnosis is challenging with SLAP tears, as they often present with nonspecific shoulder pain and may not be associated with an acute injury. A further complication is that they are often associated with other shoulder pathology, such as rotator cuff tears.¹ As physical examination is typically nonspecific, proper diagnostic imaging is essential for diagnosis.

We prefer to assess potential SLAP tears with magnetic resonance arthrography (MRA).² Dilute (1:200) gadolinium contrast material (12-15 mL) is introduced into the glenohumeral joint under sonographic or fluoroscopic guidance. Capsular distention by dilute intra-articular contrast enables superior imaging resolution of the labroligamentous complex. We think the increase in diagnostic confidence enabled by direct arthrography outweighs the additional invasiveness and cost associated with MRA relative to noncontrast magnetic resonance imaging (MRI).

The MRA protocol differs from our routine noncontrast shoulder imaging. We perform a fat-saturated coronal oblique T1 sequence that maximizes the conspicuity of intra-articular contrast in the plane that optimally visualizes the superior labrum. Three planes of intermediate-weighted fast spin echo not only contrast the high-signal intra-articular fluid with the low-signal fibrocartilaginous labrum and the stratified intermediate signal of glenoid articular cartilage, but they also allow optimal assessment of the rotator cuff. In addition, we perform a fat-saturated coronal T2 sequence that highlights all fluid signal structures as well as edema.

SLAP tears appear on MRA as the insinuation of intra-articular contrast between the articular cartilage and the attachment of the superior labrum,³ within the substance of the labrum, or as detachment of the labrum from the glenoid rim⁴ (Figure 1). Findings can range from labral fraying to complete detachment with displacement. Tears can extend into other quadrants of the labrum, extend from a Bankart lesion, or involve the biceps tendon and/or the glenohumeral ligaments (Figures 2–4). Up to 10 types of SLAP tears have been described on arthroscopy. This classification scheme, however, is seldom helpful in the interpretation of SLAP tears on MRI. More important in guiding treatment is having a detailed description of the tear, including location, extent, and morphology, along with associated abnormalities.

Several findings can aid in the diagnosis of SLAP tears. Normal anatomical variants of the anterior-superior labrum do not extend posterior to the biceps anchor—an important finding for discerning normal morphologic variants from tears. Therefore, high signal within the posterior third of the superior labrum or extension of high signal laterally within the labrum and away from the glenoid suggests a SLAP tear.⁵ A paralabral cyst is almost always associated with a labral tear,¹ so signal abnormality of the superior labrum with a paralabral cyst suggests a SLAP tear (Figure 5).

MRA is not the only method for diagnosing SLAP tears. Standard 3-Tesla MRI had 83% sensitivity and 99% specificity for diagnosing SLAP tears in a recent study, though MRA had 98% sensitivity and 99% specificity—a statistically significant sensitivity difference.⁶ In another study, computed tomography arthrography (CTA) had 95% sensitivity and 88% specificity for diagnosing recurrent SLAP tears after surgery.⁷ CTA is associated with ionizing radiation and is limited in its assessment of other structures that may show concomitant abnormalities, such as the articular cartilage and the rotator cuff. Indirect MRA, wherein magnetic resonance sequences are obtained after intravenous injection of gadolinium contrast and exercise of the affected shoulder, had a high sensitivity of detection of labral tears of all types.⁸

MRA is most sensitive and specific for diagnosing SLAP tears; 3-Tesla MRI, indirect MRA, and CTA are useful alternative modalities for cases in which MRA cannot be performed.

Superior labral anteroposterior (SLAP) tears are common labral injuries. They occur at the attachment of the long head of the biceps tendon on the superior glenoid and extend anterior and/or posterior to the biceps anchor. The mechanism of action for SLAP tears is traction on the superior labrum by the long head of the biceps tendon, resulting in “peeling” of the labrum off the glenoid. Such forces may result from repetitive overhead arm motion (pitching) or from direct trauma.

Clinical diagnosis is challenging with SLAP tears, as they often present with nonspecific shoulder pain and may not be associated with an acute injury. A further complication is that they are often associated with other shoulder pathology, such as rotator cuff tears.¹ As physical examination is typically nonspecific, proper diagnostic imaging is essential for diagnosis.

We prefer to assess potential SLAP tears with magnetic resonance arthrography (MRA).² Dilute (1:200) gadolinium contrast material (12-15 mL) is introduced into the glenohumeral joint under sonographic or fluoroscopic guidance. Capsular distention by dilute intra-articular contrast enables superior imaging resolution of the labroligamentous complex. We think the increase in diagnostic confidence enabled by direct arthrography outweighs the additional invasiveness and cost associated with MRA relative to noncontrast magnetic resonance imaging (MRI).

The MRA protocol differs from our routine noncontrast shoulder imaging. We perform a fat-saturated coronal oblique T1 sequence that maximizes the conspicuity of intra-articular contrast in the plane that optimally visualizes the superior labrum. Three planes of intermediate-weighted fast spin echo not only contrast the high-signal intra-articular fluid with the low-signal fibrocartilaginous labrum and the stratified intermediate signal of glenoid articular cartilage, but they also allow optimal assessment of the rotator cuff. In addition, we perform a fat-saturated coronal T2 sequence that highlights all fluid signal structures as well as edema.

SLAP tears appear on MRA as the insinuation of intra-articular contrast between the articular cartilage and the attachment of the superior labrum,³ within the substance of the labrum, or as detachment of the labrum from the glenoid rim⁴ (Figure 1). Findings can range from labral fraying to complete detachment with displacement. Tears can extend into other quadrants of the labrum, extend from a Bankart lesion, or involve the biceps tendon and/or the glenohumeral ligaments (Figures 2–4). Up to 10 types of SLAP tears have been described on arthroscopy. This classification scheme, however, is seldom helpful in the interpretation of SLAP tears on MRI. More important in guiding treatment is having a detailed description of the tear, including location, extent, and morphology, along with associated abnormalities.

Several findings can aid in the diagnosis of SLAP tears. Normal anatomical variants of the anterior-superior labrum do not extend posterior to the biceps anchor—an important finding for discerning normal morphologic variants from tears. Therefore, high signal within the posterior third of the superior labrum or extension of high signal laterally within the labrum and away from the glenoid suggests a SLAP tear.⁵ A paralabral cyst is almost always associated with a labral tear,¹ so signal abnormality of the superior labrum with a paralabral cyst suggests a SLAP tear (Figure 5).

MRA is not the only method for diagnosing SLAP tears. Standard 3-Tesla MRI had 83% sensitivity and 99% specificity for diagnosing SLAP tears in a recent study, though MRA had 98% sensitivity and 99% specificity—a statistically significant sensitivity difference.⁶ In another study, computed tomography arthrography (CTA) had 95% sensitivity and 88% specificity for diagnosing recurrent SLAP tears after surgery.⁷ CTA is associated with ionizing radiation and is limited in its assessment of other structures that may show concomitant abnormalities, such as the articular cartilage and the rotator cuff. Indirect MRA, wherein magnetic resonance sequences are obtained after intravenous injection of gadolinium contrast and exercise of the affected shoulder, had a high sensitivity of detection of labral tears of all types.⁸

MRA is most sensitive and specific for diagnosing SLAP tears; 3-Tesla MRI, indirect MRA, and CTA are useful alternative modalities for cases in which MRA cannot be performed.

Superior labral anteroposterior (SLAP) tears are common labral injuries. They occur at the attachment of the long head of the biceps tendon on the superior glenoid and extend anterior and/or posterior to the biceps anchor. The mechanism of action for SLAP tears is traction on the superior labrum by the long head of the biceps tendon, resulting in “peeling” of the labrum off the glenoid. Such forces may result from repetitive overhead arm motion (pitching) or from direct trauma.

Clinical diagnosis is challenging with SLAP tears, as they often present with nonspecific shoulder pain and may not be associated with an acute injury. A further complication is that they are often associated with other shoulder pathology, such as rotator cuff tears.¹ As physical examination is typically nonspecific, proper diagnostic imaging is essential for diagnosis.

We prefer to assess potential SLAP tears with magnetic resonance arthrography (MRA).² Dilute (1:200) gadolinium contrast material (12-15 mL) is introduced into the glenohumeral joint under sonographic or fluoroscopic guidance. Capsular distention by dilute intra-articular contrast enables superior imaging resolution of the labroligamentous complex. We think the increase in diagnostic confidence enabled by direct arthrography outweighs the additional invasiveness and cost associated with MRA relative to noncontrast magnetic resonance imaging (MRI).

The MRA protocol differs from our routine noncontrast shoulder imaging. We perform a fat-saturated coronal oblique T1 sequence that maximizes the conspicuity of intra-articular contrast in the plane that optimally visualizes the superior labrum. Three planes of intermediate-weighted fast spin echo not only contrast the high-signal intra-articular fluid with the low-signal fibrocartilaginous labrum and the stratified intermediate signal of glenoid articular cartilage, but they also allow optimal assessment of the rotator cuff. In addition, we perform a fat-saturated coronal T2 sequence that highlights all fluid signal structures as well as edema.

SLAP tears appear on MRA as the insinuation of intra-articular contrast between the articular cartilage and the attachment of the superior labrum,³ within the substance of the labrum, or as detachment of the labrum from the glenoid rim⁴ (Figure 1). Findings can range from labral fraying to complete detachment with displacement. Tears can extend into other quadrants of the labrum, extend from a Bankart lesion, or involve the biceps tendon and/or the glenohumeral ligaments (Figures 2–4). Up to 10 types of SLAP tears have been described on arthroscopy. This classification scheme, however, is seldom helpful in the interpretation of SLAP tears on MRI. More important in guiding treatment is having a detailed description of the tear, including location, extent, and morphology, along with associated abnormalities.

Several findings can aid in the diagnosis of SLAP tears. Normal anatomical variants of the anterior-superior labrum do not extend posterior to the biceps anchor—an important finding for discerning normal morphologic variants from tears. Therefore, high signal within the posterior third of the superior labrum or extension of high signal laterally within the labrum and away from the glenoid suggests a SLAP tear.⁵ A paralabral cyst is almost always associated with a labral tear,¹ so signal abnormality of the superior labrum with a paralabral cyst suggests a SLAP tear (Figure 5).

MRA is not the only method for diagnosing SLAP tears. Standard 3-Tesla MRI had 83% sensitivity and 99% specificity for diagnosing SLAP tears in a recent study, though MRA had 98% sensitivity and 99% specificity—a statistically significant sensitivity difference.⁶ In another study, computed tomography arthrography (CTA) had 95% sensitivity and 88% specificity for diagnosing recurrent SLAP tears after surgery.⁷ CTA is associated with ionizing radiation and is limited in its assessment of other structures that may show concomitant abnormalities, such as the articular cartilage and the rotator cuff. Indirect MRA, wherein magnetic resonance sequences are obtained after intravenous injection of gadolinium contrast and exercise of the affected shoulder, had a high sensitivity of detection of labral tears of all types.⁸

MRA is most sensitive and specific for diagnosing SLAP tears; 3-Tesla MRI, indirect MRA, and CTA are useful alternative modalities for cases in which MRA cannot be performed.