Management of Minor Displaced Greater Tuberosity Avulsion Fractures
For avulsion fractures of the greater tuberosity with less than 5 mm displacement, non-operative treatment with immobilization for 3 weeks followed by intensive rehabilitation is recommended, as 97% of patients achieve good or excellent functional outcomes. 1
Initial Assessment and Imaging
- Obtain standard radiographs including anteroposterior and axillary views to accurately measure displacement and assess fracture morphology 2
- Displacement should be measured carefully on quality radiographs, as the threshold for surgical consideration differs based on patient activity level 3, 4
- Advanced imaging (CT or MRI) is generally not required for fractures with clearly <5 mm displacement 4
Non-Operative Management Protocol
For displacement <5 mm in most patients:
- Immobilize with a Gilchrist bandage or Mitella sling for 3 weeks, which produces the best functional outcomes 1
- Begin intensive rehabilitation immediately after the 3-week immobilization period to prevent stiffness 1
- This approach yields good or excellent results in 97% of patients, with mean Constant scores of 71 and DASH scores of 13 1, 5
Patient-Specific Surgical Considerations
Despite <5 mm displacement, surgical intervention should be considered in specific populations:
- Young, active patients with displacement >3 mm may benefit from surgical fixation 3
- Athletes and heavy laborers involved in overhead activities should be considered for surgery if displacement exceeds 3 mm, as even minimal displacement can adversely affect rotator cuff biomechanics and lead to subacromial impingement 3, 4
- Patients with 3-5 mm displacement represent a gray zone where operative treatment may provide better functional outcomes than conservative management 2
The evidence shows that surgically treated patients with displaced fractures had significantly better shoulder function scores compared to those treated non-operatively (p < 0.05) 2. However, this benefit must be weighed against surgical risks in lower-demand patients.
Monitoring During Non-Operative Treatment
- Watch for development of impingement syndrome, which is the most common complication occurring in both operative and non-operative patients 5
- Assess for loss of reduction on follow-up radiographs, though minimal superior migration (<5 mm) typically does not significantly affect function 2
- Non-union is rare (occurring in only 1 of 18 non-operatively treated patients in one series) 5
Critical Pitfalls to Avoid
- Do not underestimate displacement in overhead athletes or laborers—the 5 mm threshold should be lowered to 3 mm in these populations 3, 4
- Avoid prolonged immobilization beyond 3 weeks without starting rehabilitation, as this increases stiffness risk 1
- Female patients and those under 70 years old tend to have better outcomes with conservative treatment 1
- Male patients and those in their eighth and ninth decades have significantly worse outcomes regardless of treatment method 1