What is the management of a mildly comminuted and mildly displaced fracture of the great tuberosity in the Emergency Department (ED) after a successful reduction of a shoulder dislocation?

From the Guidelines

Management of a reduced shoulder dislocation with a mildly comminuted and displaced greater tuberosity fracture in the emergency department should focus on immobilization, pain control, and appropriate follow-up. The shoulder should be immobilized in a sling or shoulder immobilizer for 2-3 weeks to allow initial healing and reduce pain, as simple immobilization is appropriate when fracture fragments are small, nonarticular, or minimally displaced 1. Pain management should include NSAIDs such as ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily, combined with acetaminophen 1000mg every 6 hours as needed. For moderate to severe pain, a short course of opioids like hydrocodone/acetaminophen 5/325mg every 6 hours for 3-5 days may be prescribed. Ice should be applied for 20 minutes every 2-3 hours for the first 48-72 hours to reduce swelling and pain. Key considerations for management include:

• Immobilization to reduce pain and allow healing
• Pain control with NSAIDs and acetaminophen, with opioids as needed for moderate to severe pain
• Ice application to reduce swelling and pain
• Follow-up with orthopedics within 7-10 days to assess for potential surgical intervention if displacement exceeds 5mm or significant functional impairment is present. The patient should be instructed to return to the emergency department if they experience increased pain, numbness, tingling, or inability to move fingers, which could indicate neurovascular compromise.

From the Research

Management of Mildly Comminuted and Displaced Fracture of the Great Tuberosity

• The patient's condition, with a mildly comminuted and mildly displaced fracture of the great tuberosity, requires careful evaluation and management in the emergency department 2, 3, 4.
• Studies suggest that surgical management is often considered for displaced greater tuberosity fractures, especially when there is displacement of 5 mm or greater 3, 4, 5.
• The choice of surgical approach and method of fixation depends on patient characteristics and fracture pattern, with options including open or arthroscopic techniques, and screw fixation or suture constructs 3, 4, 6, 5.
• Arthroscopic techniques can be beneficial in identifying and addressing coexisting injuries, such as rotator cuff tears or labrum lesions, which are often present in patients with greater tuberosity fractures 3, 6.
• The use of a subacromial spacer on top of double-row suture anchor fixation is a new technique that can be considered for comminuted or eggshell fractures when rigid fixation is not feasible 6.
• Overall, the goal of management is to achieve anatomic reduction and secure fixation, with favorable patient outcomes achievable when fractures with >5 mm of displacement are treated promptly and effectively 3, 4, 5.