What is the recommended treatment for a complex humeral tuberosity fracture?

Treatment for Complex Humeral Tuberosity Fractures

For complex humeral tuberosity fractures, surgical treatment with open reduction and internal fixation is recommended when displacement exceeds 3-5 mm, particularly in active patients. 1

Diagnostic Evaluation

• Initial standard radiographs to confirm diagnosis and fracture pattern
• CT is the preferred imaging study for characterizing complex fracture patterns and humeral neck angulation 2
• MRI without contrast can detect associated rotator cuff tears, which occur in up to 40% of humeral head fractures 3
• 3D volume-rendered CT images may help better characterize fracture patterns 2

Treatment Algorithm

Non-operative Management

• Appropriate for minimally displaced fractures (<3-5 mm)
• Treatment includes:
  • Analgesics
  • Activity modification
  • Bracing or immobilization
  • Early mobilization when appropriate

Surgical Management

• Indicated for:

  • Displacement ≥3-5 mm (especially in active patients) 1
  • Fracture-dislocations
  • Substantial tuberosity involvement with >1 cm displacement
  • Disengagement of the head from the shaft
  • Severe varus or valgus deformity 4

• Surgical techniques include:

  • Open reduction and internal fixation using:
    • Suture anchors
    • Transosseous sutures
    • Tension bands
    • Plates/screws 1
  • Arthroscopic options for specific fracture morphologies

Greater Tuberosity Fractures

• Displacement of as little as 3-5 mm can adversely affect rotator cuff biomechanics 1
• Open reduction and internal fixation with heavy non-absorbable sutures and careful repair of the rotator cuff allows for early passive motion 5
• Anterosuperior deltoid-splitting approach with rotation of the humerus provides adequate exposure of retracted tuberosity 5

Lesser Tuberosity Fractures

• Isolated fractures are rare but should be considered when anterior shoulder pain follows trauma 6
• For displaced lesser tuberosity fractures (>5 mm), surgical fixation with cancellous bone screws is effective 7
• Early functional training can begin as soon as two days after surgery 6

Associated Injuries and Complications

• Up to 40% of humeral head fractures have an associated complete tear of at least one rotator cuff tendon 3
• Potential complications of surgical treatment include:
  • Postoperative stiffness (23.6%)
  • Fixation failure/nonunion (6.8%)
  • Late osteonecrosis/posttraumatic osteoarthritis (4.3%) 4
  • Axillary nerve injury (rare) 5

Rehabilitation

• Early passive motion can be initiated after secure fixation 5
• Delay in repair of associated rotator cuff tears by up to 4 months has not been shown to have adverse outcomes 3
• Follow-up radiographs at 1-2 weeks to ensure no further displacement 3

Long-term Outcomes

• Surgical treatment with ORIF shows good to excellent long-term outcomes for pain, function, and patient satisfaction 4
• 10-year survivorship until any reoperation is 74%, but improves to 90% when reoperations for stiffness are excluded 4