Treatment of Diastatic Vertical Fracture of Greater Tuberosity
For a diastatic vertical fracture of the greater tuberosity, surgical fixation is recommended if displacement exceeds 3-5 mm, as this degree of displacement adversely affects rotator cuff biomechanics and leads to subacromial impingement 1.
Initial Imaging Assessment
CT is the preferred imaging modality to fully characterize the fracture pattern and displacement 2. Radiographs frequently underestimate the extent of proximal humeral fractures, and CT provides superior delineation of fracture planes. Three-dimensional volume-rendered CT images can better characterize complex fracture patterns 2.
Treatment Algorithm Based on Displacement
Non-displaced or Minimally Displaced (<3-5 mm)
- Conservative management is appropriate 3
- Critical caveat: Close radiographic follow-up is mandatory to monitor for secondary displacement 4
- Secondary displacement occurs in approximately 18.64% of cases 5
Displaced (≥3-5 mm)
Surgical fixation is indicated to prevent:
- Subacromial impingement
- Altered rotator cuff biomechanics
- Chronic pain and range of motion limitations 1, 4
Surgical Technique Options
Multiple approaches exist with good-to-excellent outcomes:
Arthroscopic Techniques (Preferred for most cases)
- Suture bridge technique using multiple suture anchors for comminuted fragments 6
- Transosseous augmented technique for avulsion-type fractures 3
- Parachute technique specifically designed for split-type vertical fractures 7
- Advantages: Less soft tissue disruption, ability to address concomitant pathology
Open Reduction Internal Fixation
- Screw and washer fixation through minimal incision 8
- Plates/screws for complex patterns 1
- Warning: Prolonged immobilization (4 weeks) after open fixation resulted in 31% incidence of postoperative stiffness requiring arthroscopic release 8
Risk Factors for Secondary Displacement
Monitor closely for these independent risk factors 5:
- Comminuted fracture pattern
- Osteoporosis/poor bone quality
- Associated shoulder dislocation
- Poor initial reduction quality
Key Clinical Pitfalls
Occult neck fractures: During reduction of associated dislocations, iatrogenic humeral neck fractures can occur 4. Ensure adequate muscle relaxation and avoid forceful manipulation.
Underestimation on radiographs: Poor inter-observer agreement exists for grading these fractures on plain films 2. Always obtain CT for surgical planning.
Delayed rotator cuff assessment: Up to 40% of proximal humerus fractures have associated rotator cuff tears 2. However, delays in rotator cuff repair up to 4 months show no adverse outcomes 2, so immediate soft tissue diagnosis is not urgent.
Prolonged immobilization: Avoid extended immobilization periods as this significantly increases stiffness risk 8.