You are on page 1of 9

Clinical Communication 341

Outcome of Supraglenoid Tubercle Fractures


in 12 Dogs
Elvin R. Kulendra1 Andrew J. C. Beer2 George C. A. Hockley3 Derniese Goh4 Pilar Lafuente5
Karen L. Perry6

1 North Downs Specialist Referrals, Bletchingley, United Kingdom Address for correspondence Elvin R. Kulendra, BVetMed, MVetMed,
2 Charter Veterinary Hospital, Roundswell, Barnstaple, Devon, CertVDI, PgCert(VetEd), DipECVS, FHEA, MRCVS, North Downs
United Kingdom Specialist Referrals, 3 & 4 The Brewerstreet Dairy Business Park,
3 Framlingham Vets, Framlingham, Suffolk, United Kingdom Brewer Street, Bletchingley, RH1 4QP, United Kingdom
4 Peninsula Vet Care Emergency and Referral Hospital, Mornington, (e-mail: ekulendra@ndsr.co.uk).
Victoria, Australia
5 Clinical Sciences and Services Department, The Royal Veterinary
College, Hatfield, Herts, United Kingdom
6 Michigan State University, Veterinary Medical Center, East Lansing,
Michigan, United States

Vet Comp Orthop Traumatol 2019;32:341–350.

Downloaded by: Uppsala University. Copyrighted material.


Abstract Objective The aim of this study was to report the outcome and complications of
surgical stabilization following fracture of the supraglenoid tubercle in dogs.
Materials and Methods Data from three referral centres (Queen Mother Hospital for
Animals, Michigan State University and Veterinary Referral Hospital Hallam) were
reviewed retrospectively for cases of supraglenoid tubercle fracture (n ¼ 12).
Results Overall success rate was 9/12. Major complication rate was 2/12 and minor
complication rate was 9/12. All fractures that had major complications were comminuted.
Methods of stabilization included pin and tension band wire (n ¼ 5), lag screw (n ¼ 2),
Keywords plate fixation (n ¼ 2), fragment removal (n ¼ 2) and conservative management (n ¼ 1).
► fracture Clinical Significance Good outcomes can be achieved following fractures of the
► scapula supraglenoid tubercle, although cases with comminution have a higher complication
► supraglenoid tubercle rate. Further research into the optimal method of fixation and postoperative manage-
► dog ment is required.

Introduction supraglenoid tubercle are a fraction of these and are infre-


quently encountered. Supraglenoid tubercle fractures are
The supraglenoid tubercle is located on the craniodistal aspect articular and classified as type III fractures.3
of the scapula, on the craniodorsal aspect of the glenoid cavity Hyperflexion of the shoulder results in increased tension
and is the point of origin of the biceps brachii muscle. It has a on the biceps tendon and a supraphysiological force is
separate centre of ossification from the rest of the scapula and exerted on the supraglenoid tubercle resulting in fracture.
does not fuse with the body of the scapula until between In skeletally immature, large breed dogs this can be caused by
12 weeks and 6 months of age in dogs, depending on breed.1,2 a hard fall, although it is reported that due to the weakness of
Fractures of the scapula represent 0.5 to 2.4% of all fractures in the physis even minor trauma can result in avulsion.5 In
small animals and 2.4% of fractures in dogs.3,4 Fractures of the skeletally mature dogs, fracture of the tubercle does occur;
however, a greater traumatic force is required.
Andrew J. C. Beer's ORCID is https://orcid.org/0000-0002-3179- Acutely these fractures often cause a high-grade lame-
1509. ness. The severity of the lameness resolves rapidly, but a

received © 2019 Georg Thieme Verlag KG DOI https://doi.org/


September 21, 2018 Stuttgart · New York 10.1055/s-0039-1688777.
accepted after revision ISSN 0932-0814.
March 19, 2019
342 Supraglenoid Tubercle Fractures Kulendra et al.

lower grade lameness can persist chronically as a result of Animal and Fracture Description
osteoarthritis, malunion or non-union.5,6 Data collected included breed, age at presentation, chroni-
Due to forces that the biceps brachii attachment is city of fracture, lameness at presentation, weight, fracture
exposed to, flexion of the shoulder following fracture of type (simple or comminuted), presence of concurrent ortho-
the supraglenoid tubercle will further displace the fragment. paedic injuries, method of fixation, use of postoperative
Typically fracture displacement is not more than 10 mm coaptation, physical rehabilitation, intraoperative complica-
distally due to the transverse humeral ligament.7 Sponta- tions, postoperative complications, whether biceps tenot-
neous healing is unlikely as the fragment distraction and omy was performed, fracture reduction, follow-up physical
constant pull from the biceps prevents secondary bone examination and subjective outcome from the owner or
healing and open reduction and internal fixation is often referring veterinary surgeon.
indicated.5 Lameness was defined using a modified equine scale,
Several methods for surgical stabilization of supragle- ranging in severity from mild (1–3/10 lame), moderate (4–
noid tubercle fractures are described: fixation using a pin 6/10 lame), severe (7–9/10 lame) to non-weight bearing (10/
and tension band wire; an interfragmentary screw in a lag 10 lame).15 Postoperative complications were defined as
fashion; excision of the fragment combined with perform- complications occurring in the 3 months post-treatment.16
ing a biceps brachii tenodesis or tenotomy.8 Recommenda- Complications were divided into major (defined as requiring
tion for the management of acute injuries is open reduction surgical or medical treatment to resolve) and minor (did not
and internal fixation, and, for chronic injuries, fragment receive any treatment).16 All cases were re-examined at least
removal with or without concurrent biceps tenodesis.2 For once by the referral hospitals. Follow-up radiographs were
comminuted fractures plate application may be more obtained for all dogs that had surgical fixation of the fracture
appropriate than a pin and tension band wire or interfrag- to assess implant position and fracture healing. Where

Downloaded by: Uppsala University. Copyrighted material.


mentary screw, when load sharing across the fracture is not possible, all dogs had their lameness, shoulder range of
achievable. motion and pain assessed on each revisit.
The supraglenoid tubercle can be approached by either an Success was defined as radiographic union postopera-
osteotomy of the greater humeral tubercle, via a cranial tively, the patient having no or mild lameness (1–3/10), with
approach, or a longitudinal myotomy of the supraspinatus no long-term analgesia necessary. Failure was defined as an
muscle from its midbelly to its insertion onto the greater unresolved lameness following surgical intervention, or the
tubercle of the humerus; the latter allows avoidance of an patient requiring long-term non-steroidal anti-inflamma-
osteotomy.9 Avoiding an osteotomy may be beneficial in tory drug medication (non-steroidal anti-inflammatory
skeletally immature animals, preventing disruption of the drugs).
proximal humeral physis.10 There is a paucity of information
on the management and outcome of fractures of the supra- Case Follow-Up
glenoid tubercle in dogs. Where possible, the referring vets or owners were contacted
The advice on postoperative care is controversial. Some for longer term follow-up. The owners were asked to com-
studies advise an early return of weight-bearing, whereas plete a questionnaire, based on the Canine Brief Pain Index
others prefer a Velpeau or non-weight bearing sling for (CBPI), to determine outcomes.17 Additional questions deter-
2 weeks, exercise restriction and 6 to 8 weeks for gradual mined if long-term non-steroidal anti-inflammatory drug
return to exercise.6,11,12 therapy was required, and whether further surgery was
A programme of physical rehabilitation is recommended required to obtain a satisfactory outcome.
postoperatively to prevent fibrosis and decreased range of
movement.13,14 Data Analysis
The objective of this study was to report the outcomes and Due to low case number descriptive analysis was performed.
complications encountered following surgical stabilization All tables and median values were produced using Microsoft
of fractures of the supraglenoid tubercle with different Excel.
fixation methods.

Results
Materials and Methods
Animal and Fracture Description
Inclusion Criteria Twelve cases met the inclusion criteria (►Table 1). Eleven
Cases were recruited from the Queen Mother Hospital for cases had surgery performed, with one managed conserva-
Animals, Michigan State University and Veterinary Referral tively. All 12 cases were closed fractures. Dog breeds
Hospital Hallam between 2002 and 2016. Dogs with both included Bernese Mountain Dog (n ¼ 1), Briard (n ¼ 1),
simple and comminuted fractures of the scapula involving Cavalier King Charles Spaniel (n ¼ 1), Cocker Spaniel
the supraglenoid tubercle were included. Cases with incom- (n ¼ 2), Jack Russell Terrier (n ¼ 1), Newfoundland
plete medical records, lack of preoperative or postoperative (n ¼ 1), Siberian Husky (n ¼ 2), Staffordshire Bull Terrier
radiographs, or follow-up re-examination were excluded (n ¼ 1), Weimaraner (n ¼ 1) and mixed breed (n ¼ 1).
from the study. Medical records and radiographs of affected Median age was 41 months (4–108 months) and median
cases were reviewed. body weight was 22.4 kg (11.5–38.6 kg). The duration of the

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019


Table 1 Summary of the 12 cases of dog’s with supraglenoid tubercle fractures and their management

Case Breed Sex Age Chronicity Lameness Fracture type Concurrent Fixation Coaptation Physical Intraopera- Postoperative Follow-up physi- Follow-up Successful
number (months) (days) at orthopaedic and time (w) therapy tive compli- radiographs cal examination radiographs outcome
presenta- injuries cations (time [post-op] (time [post-
tion and findings) op] and find-
ings)

1 Mixed 84 1 Non-weight Comminuted N 2x plates, pin Carpal flexion Y N Satisfactory frac- 2w- mild decrease 6w- implants Y
bearing and tension bandage (2w) ture reduction and in ROM of shoulder stable, frac-
band wire implant 6w- 2/10 lame- ture line
positioning ness, normal ROM reduced
of shoulder 6mo-
5mo- no lameness, implants
normal ROM of stable, frac-
shoulder ture healed
1y- pain on
shoulder manipu-
lation and biceps
tendon palpation
(bicipital tenosy-
novitis diagnosed
arthroscopically)

2 Cocker FN 60 1 Severe Comminuted N Pin and ten- Velpeau sling Y N Satisfactory frac- 6w- 3/10 lameness 6w- implants Y
Spaniel sion band (2w) ture reduction and and decreased stable, frac-
wire and K implant ROM of shoulder, ture line visi-
wires positioning muscle atrophy ble, bony
12w- no lameness, remodelling
slight decreased of fracture
ROM of shoulder, 12w- implants
muscle atrophy stable, frac-
5y- acute 3/10 ture healed
lameness, 5y- migration
decreased ROM of of pins under
shoulder (mana- supraspinatus
ged conservatively
and resolved,
implants left in
place)

3 Bernese M 15 1 Non-weight Comminuted Y T plate and Carpal flexion N Regurgitation Near anatomic 2w- no crepitus on 2w- implant N
Mountain bearing pin and ten- bandage (4w) alignment shoulder manipu- failure, frac-
Dog sion band lation but some ture displace-
wire pain ment and
non-union

4 Stafford- 83 2 Non-weight Comminuted N Pin and ten- None N N Good fracture 2w- 3/10 lame- 8w- implants Y
shire Bull bearing sion band reduction and ness, mild pain on stable, frac-
Terrier wire implant shoulder manipu- ture line visi-
positioning lation ble but
8w- 3/10 lame- reduced
ness, no pain on
shoulder manipu-
lation
12w- no lameness,
Supraglenoid Tubercle Fractures

normal ROM of

Veterinary and Comparative Orthopaedics and Traumatology


shoulder

5 Siberian 5 3 Moderate Simple N Lag screw and Velpeau sling N N Satisfactory frac- 2w- no pain on 4w- implants Y
Husky anti-rotation (4w) ture reduction and shoulder manipu- stable, frac-

Vol. 32
wire implant lation, normal ture line visi-
positioning ROM of shoulder, ble but
mild muscle atro- reduced
phy
Kulendra et al.

No. 4/2019
(Continued)
343

Downloaded by: Uppsala University. Copyrighted material.


344

Table 1 (Continued)

Case Breed Sex Age Chronicity Lameness Fracture type Concurrent Fixation Coaptation Physical Intraopera- Postoperative Follow-up physi- Follow-up Successful
number (months) (days) at orthopaedic and time (w) therapy tive compli- radiographs cal examination radiographs outcome
presenta- injuries cations (time [post-op] (time [post-
tion and findings) op] and find-
ings)

4w- 3/10 lame-


ness, normal ROM
of shoulder joint,
moderate muscle
wastage
10w- 2/10 lame-
ness, normal ROM
of shoulder

6 Briard F 6 3 Moderate Simple N Pin and ten- Velpeau sling N N Satisfactory frac- 6w- 1/10 lame and 6w- implants Y
sion band (2w) ture reduction and discomfort on stable, frac-
Supraglenoid Tubercle Fractures

wire implant flexion of shoulder ture line visi-


positioning with elbow ble
extended, muscle 10w- implants
atrophy stable, frac-

Veterinary and Comparative Orthopaedics and Traumatology


10w- no lameness ture line visi-
or pain ble but
16w- no lameness reduced

Vol. 32
or pain
Kulendra et al.

7 Cavalier FN 93 3 Moderate Comminuted N Pin and ten- Velpeau sling N N Satisfactory frac- 1w- 8/10 lameness 1w- implants N
King sion band and carpal ture reduction and 6w- 4/10 lameness stable but
Charles wire and K bandage tried implant 11w- acute severe increased
Spaniel wires but not positioning pain, suspected fracture gap

No. 4/2019
tolerated implant failure,
euthanasia

8 Weimaraner F 108 4 Severe Comminuted Y Lag screw None N N Good fracture 8w- 3/10 lame, 8w- implants Y
reduction and normal ROM of stable, frac-
implant shoulder, muscle ture line
positioning atrophy visible

9 Cocker M 4 8 Variable Simple N Pin and ten- Velpeau sling Y N Satisfactory frac- 2w- accessory car- 2w- implants Y
Spaniel sion band (2w) ture reduction and pal pad sloughed, stable, frac-
wire implant normal ROM of ture healing
positioning shoulder 4w- fracture
4w- 2/10 lame- healed
ness, normal ROM
of shoulder

10 Siberian 22 21 Mild Simple N None None N N/A N/A 4w- no lameness, None Y
Husky normal ROM of
shoulder

11 Newfound- 7 91 Moderate Simple Y Fragment None N N None 2w- 2/10 lame- None Y
land removal and ness, normal ROM
biceps of shoulder
tenotomy 6w- no lameness,
normal ROM of
shoulder

12 Jack Russell FN 60 1642 Severe Simple N Fragment None N N Severe osteoar- 2w- 4/10 lame- None N
Terrier removal thritic changes of ness, decrease
shoulder joint, ROM of shoulder
complete removal 4w- 4/10 lame-
of fragment ness, decrease
ROM of shoulder

Abbreviations: F, female; FN, female neutered; M, male; mo, months; N, no; post-op, postoperative; ROM, range of motion; w, weeks; Y, yes; y, years.

Downloaded by: Uppsala University. Copyrighted material.


Supraglenoid Tubercle Fractures Kulendra et al. 345

Fig. 1 Preoperative (A) and postoperative (B) lateral radiographs of a patient (case 9) with a simple fracture of the supraglenoid tubercle
repaired using a pin and tension band wire. Two weeks postoperative radiographs (C) show the implants are stable and fracture is healing.

fracture ranged from 1 day to 1,642 days, with the median placed in a Velpeau sling; three for 2 weeks, one for 4 weeks
being 3 days. Lameness varied from mild to completely non- and another initially placed in a Velpeau sling, but it was
weight bearing. The median lameness grade was moderate. removed as the dressing was not tolerated, two cases had the

Downloaded by: Uppsala University. Copyrighted material.


Six fractures were simple, with the other six being com- limb placed in a carpal flexion bandage; one for 2 weeks and
minuted. Three of the cases had concurrent orthopaedic one for 4 weeks. Three cases had physical therapy post-
injuries including one case each of humeral luxation, scap- operatively and nine did not.
ular spine fracture and acromial avulsion. Of the skeletally Ten out of 11 surgically treated cases had no intraopera-
immature dogs (4/12), all four had simple fractures. The tive complications, with one case suffering from regurgita-
supraglenoid tubercle, a separate centre of ossification, had tion. Postoperatively all surgically treated cases incurred
not yet fused in these four dogs resulting in physeal fractures. complications, two major (cases 3 and 7) and nine minor
The fractures were treated as follows: 5/12 with a pin and (cases 1, 2, 4, 5, 6, 8, 9, 11 and 12).
tension band wire (►Fig. 1A–C); 2/12 with screws placed in a
lag fashion (one with an anti-rotational wire and one with- Outcome
out) (►Fig. 2A–C); 2/12 with plates and screws in addition to Five out of six of the dogs with simple fractures had a
a pin and tension band wire (►Fig. 3A–D); 2/12 had a salvage successful outcome and four out of the six of the dogs with
procedure consisting of fragment removal; 1/12 case was comminuted fractures had a successful outcome. Implant
managed conservatively (►Fig. 4). Immediate postoperative failure was seen in one dog with and one dog without
radiographs were assessed in all cases with surgical fixation concurrent injuries (cases 3 and 7 respectively) (►Table 1).
(n ¼ 9). Fracture reduction and implant positioning was Both cases of lag screw fixation (n ¼ 2) had a successful
classified as either satisfactory (n ¼ 6), good (n ¼ 2) or outcome (cases 5 and 8). Of the five dogs treated using a pin
near anatomic (n ¼ 1). and tension band wire, four had successful outcomes (cases
The cases were managed postoperatively with a range of 2, 4, 5 and 9); however, one dog suffered from implant failure
coaptation methods. Five had no coaptation, five had the limb 11 weeks postoperatively (case 7). One of the two cases

Fig. 2 Preoperative (A) and postoperative (B) lateral radiographs of a patient (case 5) with a simple fracture of the supraglenoid tubercle
repaired using a lag screw and an anti-rotation wire. Four weeks postoperative radiographs (C) show the implants are stable and fracture gap is
reduced but still visible.

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019


346 Supraglenoid Tubercle Fractures Kulendra et al.

Downloaded by: Uppsala University. Copyrighted material.


Fig. 3 Preoperative (A) and postoperative (B) lateral radiographs of a patient (case 1) with a comminuted fracture of the supraglenoid tubercle
repaired using two string of pearls plates and a pin and tension band wire. Six weeks postoperative radiographs (C) show the implants are stable
and fracture gap is reduced. Six months postoperative radiographs (D) show the implants are stable and the fracture healed; note the irregular
proliferative bone changes and increase in mineral opacity of the intertubercular groove.

repaired with a plate and a pin and tension band wire had a Postoperative Complications
successful outcome, but the other suffered from implant The major complications diagnosed were one case with
failure 2 weeks postoperatively (cases 1 and 3 respectively). implant failure, fracture displacement and non-union of
Of the two dogs treated with fragment removal, one had a the fracture 2 weeks postoperatively (case 3) and one case
successful outcome; the other had a 4/10 lameness 4 weeks with severe acute pain and suspected implant failure
postoperatively (cases 11 and 12 respectively). The latter 11 weeks postoperatively leading to euthanasia (case 7).
case was reported to still have issues with mobility 2 years The minor complications seen were seven cases of mild
after initial case management likely due to the extensive lameness (cases 1, 4, 5, 6, 8, 9 and 11), one case of moderate
osteoarthritic changes evident when the case presented; lameness (case 12), three cases of decreased range of move-
however, follow-up radiographs were not obtained. The ment of the shoulder (cases 1, 2 and 12) and one bandage-
one case managed conservatively (n ¼ 1) had a successful related injury (case 9). Both cases that suffered implant
outcome (case 10). This case presented 21 days after the failure were skeletally mature (2/2) (cases 3 and 7). For
fracture occurred and remodelling of the fracture was one case with implant failure (case 3), revision surgery
already evident radiographically. Lameness had resolved was discussed with the owners but they were reluctant so
by 4 weeks; however, no longer term follow-up was opted to attempt conservative management. One case (case
available. 1) represented with pain on palpation of biceps tendon and

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019


Supraglenoid Tubercle Fractures Kulendra et al. 347

Of the two failed cases (cases 3 and 12), the median score
for average pain and pain at its least was 5/10, with pain at its
worst having a median score of 8.5/10. It was found that pain
interfered with both dog’s activity, enjoyment, rising and
running (cases 3 and 12). Only one owner felt that the pain
interfered with the dogs walking and climbing (case 3).

Discussion
There is a distinct paucity of information in the peer-
reviewed literature regarding outcome following supragle-
noid tubercle fractures with the vast majority of the infor-
mation available existing in textbooks and review
articles.2–9,11,12
All four of the skeletally immature dogs in this study
(n ¼ 4) were large breeds and had simple avulsion fractures,
supporting previous observations recorded in the litera-
ture.11 Simple fractures had a higher success rate and lower
major and minor complication rates compared with the
comminuted fractures. This is perhaps not unexpected as
fixation of simple fractures has a lower reported complica-

Downloaded by: Uppsala University. Copyrighted material.


tion rate than fixation of comminuted fractures.18 This is
speculated to be due to the fact that simple fractures are
easier to reconstruct anatomically compared with commin-
uted fractures which permit greater load sharing between
the bone and implant.
Fig. 4 Lateral radiograph of a patient (case 10) with a simple fracture
Due to the limited case number, it is difficult to determine
of the supraglenoid tubercle. This case presented 21 days after the
which method of fracture fixation resulted in a better out-
trauma and the radiograph shows the fracture already remodelling.
This case was managed conservatively and lameness resolved after come. The method of fixation is influenced by multiple
4 weeks. factors including fragment size, degree of comminution
and surgeon preference.
It has been reported that a high success rate can be
shoulder manipulation 1 year postoperatively. Radiographs achieved when repairing supraglenoid tubercle fractures
revealed irregular proliferative bone changes and increase in with a 2.0 mm T plate.19 It was shown to provide a robust
mineral opacity of the intertubercular groove; bicipital fixation with a very few complications; however, plate
tenosynovitis was diagnosed arthroscopically. fixation can only be used if the fragment is of sufficient
size to allow implant placement.
Follow-Up Current literature recommends to place a screw, remove
The owner response to the questionnaire was 5/12. Of the the fragment or place a pin and tension band wire for simple
five respondents, three cases were deemed a success (cases 1, fractures with limited information in the literature on the
2 and 8) and two cases were deemed a failure (cases 3 and treatment of comminuted fractures.2,5,6,9 To place a screw,
12). Median follow-up time was 2 years, six months post- the fragment must be large enough to ensure that it does not
surgery (11 weeks–8 years). fracture. If the fragment is too small to accommodate an
In the three successful cases, a median pain score of 2/10 appropriately sized lag screw, a pin and tension band wire
(range, 0–4) was reported. In all three successful cases, pain would be indicated. However, for very small fragments
was not seen to be interfering with enjoyment of life. Pain conservative management or fragment removal may be
was not seen to interfere with walking and running in two indicated as was done in 3/12 dogs in this series.
cases (cases 2 and 8), with one case being 1/10 affected for Chronically lame cases were treated by fragment removal,
walking and 2/10 affected for running (case 1). All three in line with the current recommendations in the literature.2
successful cases were viewed to have an excellent quality of Although the initial lameness associated with these fractures
life and required no further surgery or long-term non- is severe, this resolves rapidly and many patients may not be
steroidal anti-inflammatory drugs. presented by their owner until the lameness is chronic,
One of the three successful cases (case 2) was reported to possibly due to osteoarthritis associated with malunion or
have some interference with rising (3/10) and difficulties non-union of the fracture.5
climbing upstairs (7/10). The median scores for the three Only one case was managed conservatively in this study so
successful cases for interference with activity, enjoyment of it is difficult to establish the success of this as an option for
life, rising, walking, running, and climbing were all 0/10 fracture management. Fragment removal could have been
(range, 0–7). considered in this case if lameness and pain progressed due

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019


348 Supraglenoid Tubercle Fractures Kulendra et al.

to osteoarthritic changes of the shoulder joint. Current injuries will be more likely to have extended periods of cage
literature states that surgical management of these cases is rest, preventing complications such as implant failure or
required to achieve a satisfactory outcome; however, it is non-union. The presence of concurrent injuries can impact
possible that conservative management may be appropriate on the ability of a surgeon to use external coaptation. A
in some cases.5,6,20 If anatomic reconstruction is not possible Velpeau sling or carpal flexion bandage, which do not allow
and rigid fixation of these fractures cannot be achieved, then weight bearing, is more difficult to use in patients with
a salvage option may be required. Further investigation of severe injuries affecting other limbs that may be non-weight
fragment removal as a potential treatment option is war- bearing for a period of time.
ranted in cases of chronic fractures or where the fragment is Unfortunately, there was limited follow-up for all cases.
too small for reattachment. One case was diagnosed with bicipital tenosynovitis 1 year
Fractures of the supraglenoid tubercle in the horse have postoperatively; a complication that has previously been
been reported to be stabilized with a distal femoral locking reported after fixation of supraglenoid tubercle frac-
plate cranial to the scapular spine or one or two transversely tures.19,24 Due to the articular nature of the fracture, an
placed locking compression plates, although these pieces of increased incidence of osteoarthritis of the shoulder joint is
literature involved small case numbers.21,22 It would appear expected.3 One case that presented around 4.5 years after the
that plate fixation is a robust method of fixation if the fracture occurred was found to have severe osteoarthritic
fragment size is large enough in dogs and has been shown changes of the shoulder.
in one study to have a high successful outcome.19 Limitations of this study include the retrospective nature
Of the two cases that had implant failure, one was fixed and small sample size. There is a heterogeneity in the
with a combination of T plate and a pin and tension band fracture types, timing of intervention and therapies chosen
wire. The plate was used due to the severely comminuted that make it difficult to draw firm conclusions from the

Downloaded by: Uppsala University. Copyrighted material.


fracture and was necessary to reconstruct the fragments. The study.
implant is speculated to have failed due to excess force being The lameness score at presentation was a subjective
applied to the implants; this was likely due to suboptimal assessment method applied by multiple different surgeons;
reduction, preventing load sharing and excessive force on a standardized lameness assessment or force plate analysis
relatively weak implants. could be used for more objective measures.25
In the other case of implant failure, a pin and tension Although a validated questionnaire, the response rate of
band wire were used in conjunction with Kirschner wires. the owners to the CBPI was poor. Another limitation of study
The size of the fragments only allowed for pin placement. design was that the time between surgery and questionnaire
As this fracture was comminuted, the implant probably completion varied greatly potentially allowing a greater time
failed due to tension on the repair placed by the biceps’ for osteoarthritis and other postoperative complications
tendon. It can be speculated that in both cases performing a such as implant migration to occur in some patients com-
tenodesis or tenotomy of the biceps brachii may have pared with others.
eliminated the pull of the tendon on the repair, potentially
preventing implant failure. For both cases of implant failure
Conclusion
arthrodesis of the scapulohumeral joint was recommended
but declined by the clients in both instances. Arthrodesis This study has found a variety of options exist for repair of
has been reported to eliminate lameness caused by mal- supraglenoid tubercle fractures; however, the limited num-
union or severe degenerative osteoarthritis secondary to a ber of cases in this series makes interpretation difficult. The
fracture.7 study has highlighted a collective lack of knowledge in the
Given the limited case number, it is difficult to make any small animal orthopaedic field regarding fractures of the
definitive conclusion about the effects of postoperative supraglenoid tubercle and indicates that further research is
coaptation in this case series. The aim of postoperative needed into this area to confirm the optimal fixation method
coaptation is to decrease the tension on the biceps tendon to minimize complications and ultimately reduce fixation
by keeping the elbow in flexion, in turn reducing tension on failures.
the fracture fixation.23 Postoperative coaptation varied
greatly between cases based on surgeon preference. Unfor- Author Contribution
tunately, due to the retrospective nature of this multi- Elvin R. Kulendra contributed to conception of study,
centre study, an inherent limitation of the study was the study design, acquisition of data and data analysis and
variability of fixation and postoperative management tech- interpretation. Andrew J. C. Beer contributed to study
niques. The low incidence of this fracture type necessitated design, acquisition of data and data analysis and inter-
a retrospective multi-centre study to achieve sufficient pretation. George C. A. Hockley, Derniese Goh, Pilar
numbers. Lafuente, and Karen Perry contributed to acquisition of
Cases with no concurrent injuries were shown to have a data and data analysis and interpretation. All authors
higher success rate than cases with concurrent injuries, drafted, revised and approved the submitted manuscript.
although the cases with no concurrent injuries had a higher
minor and total complication rate. This could be due to the Funding
small sample size or the fact that patients with concurrent None.

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019


Supraglenoid Tubercle Fractures Kulendra et al. 349

Conflict of interest 13 Millis D, Levine D. Responses of musculoskeletal tissues to disuse


None declared. and remobilization. In: Millis D, Levine D, eds. Canine Rehabilita-
tion and Physical Therapy. 2nd ed. Philadelphia: Elsevier; 2013:
92–153
14 Henderson AL, Latimer C, Millis DL. Rehabilitation and physical
References therapy for selected orthopedic conditions in veterinary patients.
1 von Pfeil DJ, DeCamp CE. The epiphyseal plate: physiology, Vet Clin North Am Small Anim Pract 2015;45(01):91–121
anatomy, and trauma. Compend Contin Educ Vet 2009;31(08): 15 May SA, Wyn-Jones G. The diagnosis of the causes of lameness. In:
E1–E11, quiz E12 Wyn-Jones G, ed. Equine Lameness. Oxford: Blackwell Scientific
2 Rayward R. The scapula. In: Gemmill TJ, Clements DN, eds. BSAVA Publications; 1988:5
Manual of Canine and Feline Fracture Repair and Management. 16 Cook JL, Evans R, Conzemius MG, et al. Proposed definitions and
2nd ed. Quedgeley: British Small Animal Veterinary Association; criteria for reporting time frame, outcome, and complications for
2016:188–197 clinical orthopedic studies in veterinary medicine. Vet Surg 2010;
3 Cook JL, Cook CR, Tomlinson JL, et al. Scapular fractures in dogs: 39(08):905–908
epidemiology, classification, and concurrent injuries in 105 cases 17 Brown DC, Boston RC, Coyne JC, Farrar JT. Development and
(1988-1994). J Am Anim Hosp Assoc 1997;33(06):528–532 psychometric testing of an instrument designed to measure
4 Harari J, Dunning D. Fractures of the scapula in dogs: a retro- chronic pain in dogs with osteoarthritis. Am J Vet Res 2007;68
spective review of 12 cases. Vet Comp Orthop Traumatol 1993;06 (06):631–637
(02):105–108 18 Aron DN, Johnson AL, Palmer RH. Biologic strategies and a
5 DeCamp CE, Johnston SA, Déjardin LM, et al. Fractures of the scapula. balanced concept for repair of highly comminuted long bone
In: DeCamp CE, Johnston SA, Déjardin LM, Schaefer SL, eds. Brinker, fractures. Comp Cont Edu Small Anim 1995;17:35–47
Piermattei, and Flo’s Handbook of Small Animal Orthopedics and 19 Brunnberg L, Waibl H, Meyer-Lindenberg A. Zur operativen
Fracture Repair. 5th ed. St Louis: Elsevier; 2016:251–259 Versorgung der Fraktur des Tuberculum supraglenoidale scapulae
6 Perry KL, Woods S. Fractures of the scapula. Companion Anim (Surgical management of supraglenoid tubercle fractures of the

Downloaded by: Uppsala University. Copyrighted material.


2017;22(06):340–348 scapula). Kleintierprax 1993;38:425–432
7 Newton CD. Fractures of the scapula. In: Newton CD, Nunamaker 20 Johnson AL, Dunning D. Supraglenoid tuberosity fractures. In:
DM, eds. Textbook of Small Animal Orthopaedics. Philadelphia: Atlas of Orthopaedic Surgical Procedures of the Dog and Cat. St
Lippincott; 1985:333–342 Louis: Elsevier; 2005:144–145
8 Peck JN, Leasure J. Scapula fractures. In: Johnson SA, Tobias KM, 21 Frei S, Fürst AE, Sacks M, Bischofberger AS. Fixation of supragle-
eds. Veterinary Surgery: Small Animal. 2nd ed. St Louis: Elsevier; noid tubercle fractures using distal femoral locking plates in three
2017:794–799 Warmblood horses. Vet Comp Orthop Traumatol 2016;29(03):
9 Johnson KA. Piermattei’s Atlas of Surgical Approaches to the 246–252
Bones and Joints of the Dog and Cat. 5th ed. St Louis: Elsevier; 22 Ahern BJ, Bayliss IPM, Zedler ST, Getman LM, Richardson DW.
2014:118–159 Supraglenoid tubercle fractures repair with transverse locking
10 Gill PJ, Lippincott CL, Anderson SM. Longitudinal myotomy of the compression plates in 4 horses. Vet Surg 2017;46(04):507–514
supraspinatus muscle: a new approach to the supraglenoid tubercle 23 Schaaf OR, Eaton-Wells R, Mitchell RA. Biceps brachii and bra-
of the scapula. J Am Anim Hosp Assoc 1996;32(03):243–246 chialis tendon of insertion injuries in eleven racing greyhounds.
11 DeCamp CE, Johnston SA, Déjardin LM, et al. The shoulder joint. In: Vet Surg 2009;38(07):825–833
DeCamp CE, Johnston SA, Déjardin LM, Schaefer SL, eds. Brinker, 24 Davidson EB, Griffey SM, Vasseur PB, Shields SL. Histopathologi-
Piermattei, and Flo’s Handbook of Small Animal Orthopedics and cal, radiographic, and arthrographic comparison of the biceps
Fracture Repair. 5th ed. St Louis: Elsevier; 2016:260–297 tendon in normal dogs and dogs with biceps tenosynovitis. J Am
12 Scott HW, McLaughlin RM. Fractures and disorders of the fore- Anim Hosp Assoc 2000;36(06):522–530
limb. In: Scott HW, McLaughlin RM, eds. Feline Orthopedics. Boca 25 Carr BJ, Dycus DL. Canine gait analysis. Recovery & Rehab Today’s
Raton: Taylor & Francis; 2007:107–114 Veterinary Practice 2016:93–100

Veterinary and Comparative Orthopaedics and Traumatology Vol. 32 No. 4/2019

You might also like