What is the management of a greater tuberosity humerus fracture?

Management of Greater Tuberosity Humerus Fractures

Most greater tuberosity fractures of the humerus can be treated non-operatively with good functional outcomes, but surgical intervention is recommended when displacement exceeds 3-5 mm. 1, 2

Assessment and Classification

• Thorough radiographic evaluation, including CT scan, is essential to determine:

  • Fracture pattern and displacement
  • Humeral neck angulation
  • Involvement of other structures

• Greater tuberosity fractures are commonly classified using:

  • AO classification
  • Neer classification
  • Morphologic classification 2

Treatment Algorithm

Non-operative Management

• Indicated for:
  • Non-displaced fractures
  • Minimally displaced fractures (<3 mm) 3

Three-phase rehabilitation protocol:

1. Phase 1 (0-3 weeks): Immobilization in a sling
2. Phase 2 (3-6 weeks): Begin pendular and active-assisted exercises
3. Phase 3 (6+ weeks): Progress to active exercises 3

Important: Patients should be counseled that full recovery may take an average of 8 months, despite favorable outcomes with this protocol 3

Surgical Management

• Indicated for:
  • Displacement ≥3-5 mm (especially in active patients)
  • Significant functional impairment 2, 4

Surgical options:

1. Open reduction and internal fixation:

   • Techniques include:
     • Suture anchors
     • Transosseous sutures
     • Tension bands
     • Plates/screws 2

2. Arthroscopic management:

   • Advantages:
     • Excellent visualization
     • Strong suture anchor fixation
     • Minimized soft tissue disruption
     • Reduced blood loss
     • Less radiation exposure 5

3. Hemiarthroplasty (for complex cases):

   • The "sling technique" for tuberosity fixation provides better long-term results than traditional drill-hole techniques
   • Anatomic head-to-tuberosity distance correlates with better functional outcomes 6

Special Considerations

• For elderly patients with pre-existing rotator cuff dysfunction or after failure of first-line treatment, reverse shoulder arthroplasty may provide satisfactory shoulder function 1

• For displaced three-part and four-part fractures, treatment remains controversial:

  • Open reduction with locking plate osteosynthesis has considerable complications
  • Hemiarthroplasty outcomes depend heavily on tuberosity healing 1

Post-treatment Care

• Early controlled mobilization as soon as pain allows to prevent stiffness
• Physical therapy for range of motion exercises is crucial for good functional outcomes

Complications and Prevention

• Potential complications include:

  • Subacromial impingement (due to malunion)
  • Rotator cuff dysfunction
  • Shoulder stiffness
  • Hardware issues (if surgical fixation used)

• Secondary fracture prevention:

  • Patients aged 50+ with fragility fractures should be evaluated systematically for subsequent fracture risk
  • Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation 1