Treatment of Avulsion Fracture of Greater Tuberosity of Humerus
For minimally displaced fractures (<3-5 mm), treat conservatively with sling immobilization followed by staged rehabilitation; for displaced fractures (≥3-5 mm), perform surgical fixation to prevent subacromial impingement and restore rotator cuff biomechanics. 1
Initial Assessment and Treatment Decision
The critical threshold for surgical intervention is 3-5 mm of superior displacement, as even this minimal displacement adversely affects rotator cuff biomechanics and leads to subacromial impingement in active patients 1. This displacement measurement should be carefully assessed on standard radiographs, with axillary views being essential for accurate diagnosis 2. Consider CT or MRI if displacement is unclear on plain films 2.
Non-Operative Treatment (Displacement <3 mm)
Use a three-phase rehabilitation protocol for minimally displaced or non-displaced fractures: 3
- Phase 1 (0-3 weeks): Immobilize in a sling for 3 weeks 3
- Phase 2 (3-6 weeks): Begin pendular and active-assisted exercises 3
- Phase 3 (6+ weeks): Commence active exercises 3
Important counseling points for non-operative management:
- Patients achieve excellent outcomes with average Constant scores improving from 40 to 95 points 3
- Full recovery typically requires 8 months on average (range 1-24 months), so set realistic expectations 3
- All minimally displaced fractures in one series achieved favorable outcomes without surgery 3
Surgical Treatment (Displacement ≥3-5 mm)
Multiple surgical techniques are available, tailored to fracture morphology: 1
Open reduction with screw and washer fixation:
- Achieves 100% bone union within 3 months 4
- Performed through a small incision with minimally invasive approach 4
- Results in excellent functional outcomes: mean UCLA score 31.2, ASES score 92.6 4
- Critical caveat: 31% of patients developed postoperative stiffness requiring arthroscopic release due to prolonged immobilization 4
Arthroscopic transosseous augmented technique:
- Provides advantages of both transosseous fixation and arthroscopic approach 5
- Particularly useful for displaced or comminuted fractures 5
- May reduce stiffness complications compared to open techniques 5
Other surgical options include:
- Suture anchors, transosseous sutures, tension bands, or plates/screws depending on fracture pattern 1
Post-Surgical Protocol
After surgical fixation, immobilize in a brace for 4 weeks, then begin rehabilitation 4. However, be aware that this prolonged immobilization contributes to the relatively high stiffness rate 4.
Critical Pitfalls to Avoid
- Do not underestimate minimal displacement: Even 3 mm can cause significant functional impairment in active patients 1
- Do not rely solely on AP radiographs: Obtain axillary views to accurately assess displacement 2
- Do not delay surgery for displaced fractures: Operating within the first 8 days allows optimal reduction and fixation 2
- Warn patients about prolonged recovery: Even with optimal treatment, expect 8 months for full recovery in non-operative cases 3
- Anticipate postoperative stiffness: Consider earlier mobilization protocols or arthroscopic techniques to reduce this 31% complication rate 4