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Findings The initial radiographs show no abnormality. The subsequent radiographs show a faint area of bony irregularity adjacent to the lesser tuberosity. The MRI demonstrates bony irregularity of the lesser tuberosity with a complex collection representing a hematoma adjacent to the lesser tuberosity. The subscapularis tendon has sustained recent injury with hyperintensity and slight fissuring. Noted is the anterior inferior labrum and inferior glenohumeral ligament are intact. Also, no edema pattern is present of the humeral head to suggest a Hill Sachs injury.
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Diagnosis: Pediatric Lesser Tuberosity Avulsion/Subscapularis Injury An entity not thought of as frequently as sequelae of instability and one that can be frequently missed. As in this case, it can be very difficult to make the findings on radiographs and frequently only a small sliver of avulsed bone is seen particularly on an axial radiograph. These injuries are most prevalent in boys around 12 to 14 years of age and should especially be thought of in someone who was thought to have had an instability episode but perhaps is not progressing as would be expected. Although diagnosis is frequently delayed, it has been found that even delayed surgical intervention can be helpful as compared to no surgical intervention. If completely missed, large areas of heterotopic ossification can occur causing markedly restricted range of motion and limited function. Most commonly there is an avulsion of the lesser tuberosity apophysis which causes a joint effusion/hematoma. On MRI, the heterogeneous collection particularly with areas of low signal indicates hemorrhagic debris and hematoma. Even in the setting of a lesser tuberosity avulsion, the subscapularis itself does see some load and in this case has sustained low grade injury. Rarely, there is isolated avulsion of the subscapularis tendon in these pediatric patients but again apophyseal injury is much more frequent. Noted in this case were the absence of stigmata of a translation event as no Bankart, Hill Sachs, or IGHL injury is present. Again, a more fervent push has recently been taken for surgical intervention and repair of this avulsion was performed.
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References Subscapularis Tears and Lesser Tuberosity Avulsion Fractures in the Pediatric Patient. Lauren E. LaMont, MD, Daniel W. Green, MD, MS, FAAP, FACS, David W. Altchek, MD, Russell F. Warren, MD, and Thomas L. Wickiewicz, MD. Sports Health. 2015 Mar; 7(2): 110–114. doi: 10.1177/1941738114533657 Subscapularis Avulsion of the Lesser Tuberosity in Adolescents. Garrigues, Grant E. MD; Warnick, Drew E. MD; Busch, Michael T. MD. Journal of Pediatric Orthopaedics: January/February 2013 - Volume 33 - Issue 1 - p 8-13 doi: 10.1097/BPO.0b013e318270d0d6. Lesser Tuberosity Avulsion Fracture. Pamela H. Burdett, M.D. Radsource. MRI Web Clinic — August 2004.
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