What is the management for an elderly patient with a greater tubercle fracture of the humerus, presenting with swelling and pain after a fall?

Management of Greater Tubercle Fracture of the Humerus in an Elderly Patient

For an elderly patient with a greater tubercle fracture presenting with swelling and pain after a fall, immediate management should include appropriate analgesia, assessment of fracture displacement on imaging, and determination of surgical versus conservative treatment based on displacement criteria, followed by systematic evaluation for osteoporosis and future fracture risk. 1

Immediate Assessment and Pain Management

• Provide appropriate pain relief as soon as possible before completing diagnostic investigations. 1, 2 Start with regular acetaminophen unless contraindicated, adding opioids as needed for adequate pain control. 2

• Avoid NSAIDs until renal function is assessed, as approximately 40% of trauma patients have moderate renal dysfunction and NSAIDs are relatively contraindicated in impaired kidney function. 2

• Document pain scores at rest and with movement before and after analgesia administration. 2

Diagnostic Imaging and Displacement Assessment

• Obtain standard radiographs (AP and lateral views) to assess fracture displacement and morphology. 3

• Surgical treatment is indicated if there is ≥3-5 mm of superior displacement of the greater tubercle, as this degree of displacement adversely affects rotator cuff biomechanics and leads to subacromial impingement in active patients. 3

• Consider advanced imaging (CT or MRI) if fracture pattern is unclear or to assess for associated injuries, particularly in elderly patients where occult fractures may be present. 3

Treatment Algorithm Based on Displacement

Non-Displaced or Minimally Displaced Fractures (<3-5 mm)

• Conservative management with immobilization in a sling for comfort, followed by early mobilization as pain allows. 2, 3 Most greater tuberosity fractures can be successfully treated non-surgically. 3

• Begin gentle range-of-motion exercises as pain permits to prevent stiffness. 2

Displaced Fractures (≥3-5 mm)

• Surgical fixation is recommended to restore rotator cuff biomechanics and prevent subacromial impingement. 3

• Surgical options include open or arthroscopic techniques using suture anchors, transosseous sutures, tension bands, or plates/screws, tailored to fracture morphology. 3

• Arthroscopic fixation with W-shaped suture technique has demonstrated excellent outcomes with healing times of 10-12 weeks and high functional scores (Constant-Murley scores averaging 92.33). 4

• For comminuted fractures, stabilization with absorbable sutures through extended surgical approach allows anatomical repositioning and sufficient stabilization. 5

Multidisciplinary Perioperative Care (If Surgery Required)

• Ensure comprehensive preoperative assessment including chest X-ray, ECG, full blood count, clotting studies, renal function, and cognitive baseline function assessment. 1 This is critical in elderly patients who often have pre-existing chronic diseases affecting management and outcomes. 1

• Perform systematic admission assessment for modifiable variables: malnutrition, electrolyte or volume disturbances, anemia, cardiac or pulmonary diseases, dementia and delirium control. 1

• Provide surgery within 48 hours of injury when indicated, as this significantly reduces short-term and mid-term mortality rates and reduces complications from immobility. 1

• Consider orthogeriatric comanagement for elderly patients, as this has been shown to improve functional outcomes, reduce length of hospital stay, and reduce mortality. 1

Critical Secondary Prevention Measures

• All elderly patients with fragility fractures require systematic investigation for future fracture risk and osteoporosis evaluation. 1, 6 This is a strong recommendation with high-level evidence. 1

• Order outpatient DEXA scan, vitamin D level, calcium level, and parathyroid hormone level during hospitalization or at follow-up. 6, 7

• High-risk patients should receive appropriate pharmacological treatment to decrease risk of subsequent fracture, as proximal humerus fractures are among the most common fragility fractures associated with increased morbidity and mortality. 1

• Ensure calcium supplementation (1000-1200 mg/day) and vitamin D (800 IU/day), which is associated with 15-20% reduction in non-vertebral fractures and falls in elderly patients. 2

Common Pitfalls to Avoid

• Do not delay pain management while waiting for imaging or specialist consultation. 1, 2 Pain control should be initiated immediately upon presentation.

• Do not assume minimal displacement on initial radiographs means no surgical intervention needed—measure displacement carefully, as even 3-5 mm warrants surgical consideration in active patients. 3

• Do not discharge elderly patients without arranging systematic osteoporosis evaluation and fracture prevention measures, as this represents a critical opportunity to prevent subsequent fractures. 1, 6

• Avoid prolonged immobilization in elderly patients, as this increases risk of complications including pneumonia, decubitus ulcers, and deconditioning. 1