What is the best treatment approach for a 78-year-old female patient with a greater tuberosity fracture of the humerus?

Management of Greater Tuberosity Fracture of the Humerus in a 78-Year-Old Female

Most proximal humeral fractures, including greater tuberosity fractures, in elderly patients should be treated non-operatively with good functional outcomes. 1

Initial Assessment and Decision-Making

• Evaluate displacement of the greater tuberosity fracture:

  • Non-displaced or minimally displaced (<3-5 mm): Non-operative management
  • Displaced (>5 mm): Consider surgical options, but non-operative approach still preferred in elderly patients 2, 3

• Consider patient factors that favor non-operative management:

  • Advanced age (78 years)
  • Likely lower functional demands
  • Higher surgical risks
  • Potential for acceptable functional outcomes with conservative treatment

Non-Operative Management Protocol

Immobilization and Pain Control

• Provide a sling for comfort, which may be discarded as early as pain allows 1
• Transition from immobilization to controlled motion at approximately 4 weeks post-injury 1
• Prescribe appropriate analgesics:
  • NSAIDs if not contraindicated
  • Short-term opioids if necessary for severe pain
  • Goal: Minimize opioid use while maintaining comfort 1

Rehabilitation Timeline

1. Weeks 0-4:

   • Sling immobilization for comfort
   • Early pendulum exercises
   • Active range of motion for elbow, wrist, and hand

2. Weeks 4-8:

   • Begin passive and active-assisted range of motion exercises for shoulder
   • Progress to active range of motion as tolerated
   • Avoid overhead activities until fracture healing is evident

3. Weeks 8-12:

   • Advance to strengthening exercises
   • Focus on rotator cuff strengthening
   • Gradually increase functional activities 1

Monitoring and Follow-up

• Clinical and radiographic follow-up at 2-week intervals initially
• Assess:
  • Pain levels
  • Range of motion progress
  • Fracture healing
  • Functional improvement 1

Surgical Considerations

While non-operative management is preferred in this 78-year-old patient, surgical options may be considered if:

• Displacement exceeds 5 mm
• Patient has unusually high functional demands
• Conservative treatment fails

Surgical options include:

• Open reduction and internal fixation with suture anchors or transosseous sutures
• Arthroscopic fixation techniques 3, 4

Prevention of Future Fractures

• Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation
• Fall prevention strategies
• Bone health assessment and possible referral for osteoporosis management 1
• Consider enrollment in a Fracture Liaison Service for systematic evaluation of subsequent fracture risk 5

Pitfalls and Caveats

• Avoid overly aggressive physical therapy as it may increase risk of displacement
• Be aware that non-union rates increase with age (particularly in patients over 70)
• Recognize that some functional limitation may persist but is often acceptable in elderly patients 1, 6
• Do not trivialize isolated greater tuberosity fractures as they can significantly impact shoulder function due to rotator cuff attachment disruption 3