Is a rotator cuff tear obligatory with a fracture of the surgical neck of the humerus?

Rotator Cuff Tears and Proximal Humeral Fractures

No, a rotator cuff tear is not obligatory with a fracture of the surgical neck of the humerus, but they are present in up to 40% of humeral head fractures. 1, 2

Incidence and Association

• According to the American College of Radiology guidelines, a complete tear of at least one rotator cuff tendon can be seen in up to 40% of humeral head fractures 1, 2
• Research studies have found varying incidence rates:
  • 8.1% incidence of full-thickness rotator cuff tears in patients with proximal humerus fractures 3
  • In a cohort study of 76 patients, 22 rotator cuff tears were diagnosed at the time of injury, with 10 additional tears developing within one year 4

Clinical Significance

• Rotator cuff integrity significantly correlates with functional outcomes after proximal humeral fractures 5
• Both partial and full-thickness tears impact functional results 4
• Functional loss at one year significantly corresponds to rotator cuff tears present at the time of injury 4

Diagnostic Approach

When evaluating a patient with a surgical neck fracture of the humerus:

1. Initial Assessment: Standard radiographs to confirm diagnosis and fracture pattern
2. Advanced Imaging:
   • CT is the preferred study for characterizing proximal humeral fractures 1
   • MRI can detect associated rotator cuff tears but is generally inferior to CT for fracture characterization 1
   • Ultrasound can identify full-thickness rotator cuff tears in ideal conditions but is limited in acute settings due to swelling and decreased patient mobility 1

Management Considerations

• When rotator cuff tears are present with proximal humeral fractures:
  • Significant rotator cuff tears are typically addressed during open reduction and internal fixation of the fracture 1
  • Simultaneous repair of rotator cuff tears does not negatively affect functional outcomes 3
  • Careful rotator cuff repair is recommended to optimize treatment results 5

Important Caveats

• A delay in repair of rotator cuff tears by up to 4 months has not been shown to have adverse outcomes on rotator cuff repair 1
• Varus malunion of the humeral head and displacement of tubercles may have an even greater impact on functional outcomes than rotator cuff tears 4
• Most rotator cuff tears associated with proximal humeral fractures are longitudinal defects located at the rotator interval 5

In summary, while rotator cuff tears frequently accompany proximal humeral fractures, they are not obligatory. However, their presence significantly impacts functional outcomes, making assessment of rotator cuff integrity an important part of the management of these fractures.