title: Treating Subscapularis and Lesser Tuberosity Avulsion Injuries in Skeletally Immature Patients: A Systematic Review.
abstract: To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries.
  
  
  
  We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed.
  
  
  
  We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain.
  
  
  
  Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity.
  
  
  
  Level IV, systematic review of low-quality studies.
authors.affiliation: alphaclinic Zurich, Zurich, Switzerland; Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.. Electronic address: patrick.vavken@childrens.harvard.edu.
authors.forename: Patrick
authors.initials: P
authors.lastname: Vavken
authors.affiliation: Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae
authors.affiliation: Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Waters
authors.affiliation: Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Brett
authors.initials: B
authors.lastname: Flutie
authors.affiliation: Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
authors.forename: Dennis E
authors.initials: DE
authors.lastname: Kramer
mesh_terms: D000293:Adolescent; D001178:Arthroplasty / Q000379:methods*; D001182:Arthroscopy / Q000379:methods*; D002648:Child; D000071562:Fractures, Avulsion / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D006810:Humeral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D010808:Physical Examination; D011183:Postoperative Complications / Q000453:epidemiology; D011859:Radiography; D012399:Rotation; D000070636:Rotator Cuff Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D020069:Shoulder Pain / Q000453:epidemiology; D016896:Treatment Outcome