Non-operative Treatment with Sling Immobilization
For a mildly displaced greater tuberosity fracture with preserved joint spaces and unremarkable soft tissues, non-operative treatment with sling immobilization for 3 weeks followed by staged rehabilitation is the recommended approach, as 97% of patients with minimally displaced fractures (1-5 mm) achieve good to excellent outcomes without surgery 1.
Treatment Protocol
The optimal management follows a three-phase rehabilitation protocol 2:
Phase 1: Immobilization (0-3 weeks)
- Immobilize in a Gilchrist bandage or Mitella sling for 3 weeks
- This initial immobilization period allows early fracture healing and pain control
Phase 2: Early Mobilization (3-6 weeks)
- Begin pendular exercises and active-assisted range of motion exercises
- Gradual progression based on pain tolerance
Phase 3: Active Strengthening (6+ weeks)
- Commence active exercises starting at 6 weeks post-injury
- Progress to full functional rehabilitation
Evidence Supporting Non-operative Management
The threshold for non-operative treatment is well-established at <5 mm displacement 1, 2, 3. Key outcome data demonstrates:
- 97% good to excellent functional results with non-operative treatment of minimally displaced fractures 1
- Average Constant score improvement from 40 to 95 points at 31-month follow-up 2
- Even fractures with 3-5 mm displacement show no statistically significant difference in outcomes compared to <3 mm displacement 1
Important Caveats
Set realistic expectations: Full recovery typically takes an average of 8 months, not weeks 2. Patients should be counseled that pain and decreased range of motion may persist for this duration despite excellent ultimate outcomes.
Monitor for secondary displacement: While uncommon, secondary displacement can occur, particularly if there is associated shoulder instability 3. Consider follow-up radiographs at 1-2 weeks to ensure fracture stability.
When Surgery Would Be Indicated
Surgery is reserved for fractures with >5 mm displacement 4, 3, as displaced fractures compromise rotator cuff biomechanics and lead to weakness, loss of motion, and subacromial impingement 3. Your case with "mild displacement" and preserved joint spaces does not meet surgical criteria.
Clinical Pitfall to Avoid
The most recent scoping review 4 emphasizes that the 5 mm threshold, while widely used clinically, has not been validated in randomized controlled trials. However, given the consistently excellent outcomes with non-operative treatment in the <5 mm range across multiple studies 1, 2, this remains the standard of care in real-world practice.