Can you interpret the right shoulder X‑ray showing an acute nondisplaced fracture of the greater tuberosity of the humerus with mild osteoarthritis of the acromioclavicular and glenohumeral joints and advise initial management?

X-Ray Interpretation and Initial Management

X-Ray Interpretation

This X-ray demonstrates an acute nondisplaced fracture of the greater tuberosity of the right humerus with mild degenerative changes in both the acromioclavicular and glenohumeral joints, but no evidence of dislocation. 1

Key Findings:

• Fracture: Acute nondisplaced greater tuberosity fracture of the right humerus 1
• Joint alignment: No glenohumeral or acromioclavicular dislocation 1
• Degenerative changes: Mild osteoarthritis affecting both the AC and glenohumeral joints 1
• Bone quality: Normal mineralization 1
• Soft tissues: No acute abnormalities 1
• Lung fields: Clear (incidentally visualized) 1

Initial Management Approach

Immediate Treatment for Nondisplaced Fracture

Nondisplaced or minimally displaced greater tuberosity fractures (≤5 mm) should be managed nonoperatively with immobilization in a sling for 4-6 weeks followed by structured physical therapy. 2

• Immobilize the shoulder in a simple sling for 4-6 weeks 3
• Provide adequate analgesia for pain control 2
• Arrange orthopedic follow-up within 1-2 weeks to reassess fracture position 2

Critical Decision Point: Assess for Displacement

Measure the degree of superior displacement carefully on the radiographs, as displacement >5 mm may require surgical intervention to prevent subacromial impingement and rotator cuff dysfunction. 4

• Displacement ≤5 mm: Nonoperative management with excellent outcomes (mean Constant score 71) 2
• Displacement 6-10 mm: Either operative or nonoperative treatment can yield good results (mean Constant score 72) 2
• Displacement >10 mm: Surgical fixation recommended (mean Constant score 69) 2

Consider Advanced Imaging

Obtain a CT scan with three-dimensional reconstruction if there is any uncertainty about fracture displacement, comminution, or associated injuries, as CT changes clinical management in up to 41% of proximal humerus fractures. 5, 6

Indications for CT:

• Uncertainty about degree of displacement on plain films 5
• Suspected fracture comminution 5
• Need to characterize humeral neck angulation 6
• Planning for potential surgical intervention 5

Evaluate for Associated Injuries

Screen for rotator cuff tears, which occur in up to 40% of proximal humerus fractures, particularly in patients over 40 years old or those with persistent weakness after initial healing. 6

• Clinical examination for rotator cuff strength and impingement signs 6
• Consider MRI without contrast if rotator cuff tear is suspected and patient is unlikely to undergo immediate surgical fixation 6
• MRI is preferred over MR arthrography in acute trauma because hemarthrosis provides natural joint distention 1

Rehabilitation Protocol

Initiate early passive range-of-motion exercises after the initial immobilization period to prevent stiffness, progressing to active motion as fracture healing permits. 3

• Weeks 0-4: Immobilization in sling, pendulum exercises only 3
• Weeks 4-6: Begin passive range-of-motion exercises 3
• Weeks 6-12: Progress to active-assisted and active range-of-motion 3
• Months 3-6: Strengthening exercises as tolerated 3

Common Pitfalls to Avoid

Beware that subacromial impingement syndrome is the most common complication, occurring in both operatively and nonoperatively treated patients, so maintain a low threshold for reassessment if symptoms persist beyond expected healing time. 2

• Impingement can develop even with appropriate initial treatment 2
• Nonunion is rare (only 1 case in 30 patients in one series) 2
• Axillary or scapular-Y views are essential to rule out occult dislocation that may be missed on AP views alone 1

Surgical Indications

Refer for orthopedic surgical evaluation if displacement exceeds 5 mm in active patients, as even 3-5 mm of superior displacement can adversely affect rotator cuff biomechanics and lead to impingement. 4

• Arthroscopic fixation with suture bridge technique is increasingly preferred over open reduction, especially in elderly patients with comminuted fractures 3
• Three cannulated screws with washers provide excellent fixation for isolated greater tuberosity fractures 7
• Arthroscopic approach allows concurrent treatment of associated labral or rotator cuff injuries 8