Simultaneous isolated avulsion fractures of the lesser tuberosities of the humeri: A rare occurrence secondary to alcohol withdrawal seizures

Fractures of the lesser tuberosity of the humerus are typically traumatic in nature, most commonly occurring in association with multi-part fractures of the humeral head, often in the setting of a posterior shoulder dislocation. Isolated fractures of the lesser tuberosity are considerably more rare and are difficult to diagnose on standard shoulder radiographs without an axillary view. These fractures have been associated with 3 main types of injury: acute abduction/external rotation injury, acute injury or repetitive stress injury in adolescent overhead or throwing athletes, and rarely as a seizure associated injury. The mechanism of injury in these cases has been posited to relate to the subscapularis tendon, either resisting forced abduction/external rotation in the setting of trauma, exerting chronic or acute avulsive traction in the setting of adolescent overhead or throwing athletes, or violently contracting and avulsing the lesser tuberosity in the setting of seizures. We present an unusual case of a 27-year-old male with a history of alcohol use disorder with bilateral shoulder pain after minor trauma and observed seizure-like activity. Clinical work-up revealed bilateral isolated avulsion fractures of the lesser tuberosities, which was thought to be on the basis of seizure-related violent contraction of the subscapularis muscles. The clinical relevance of this case is that a high clinical index of suspicion is needed in order to detect lesser tuberosity avulsion fractures and avoid the consequences of untreated injury such as instability or impingement.