Management of greater tuberosity fracture dislocations of the shoulder

Abstract

Background: Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment.

Methods: A narrative review of the literature was performed.

Results: During glenohumeral reduction, an iatrogenic humeral neck fracture may occur due to the presence of an occult neck fracture or forceful reduction attempts with inadequate muscle relaxation. Minimally displaced GT fragments after shoulder reduction can be successfully treated nonoperatively, but close follow-up is needed to monitor for secondary displacement of the fracture. Surgery is indicated for fractures with >5 mm displacement to minimize the risk of subacromial impingement and altered rotator cuff biomechanics. Multiple surgical techniques have been described and include both open and arthroscopic approaches. Strategies for repair include the use of transosseous sutures, suture anchors, tension bands, screws, and plates. Good-to-excellent radiographic and clinical outcomes can be achieved with appropriate treatment.

Conclusions: GT fracture dislocations of the proximal humerus represent a separate entity from their isolated fracture counterparts in their evaluation and treatment. The decision to employ a certain strategy should depend on fracture morphology and comminution, bone quality, and displacement.

Keywords: Fixation strategies; Fracture dislocation; Greater tuberosity; Iatrogenic fracture; Proximal humerus fracture; Surgical fixation.

Figure 1

Anterior greater tuberosity fracture dislocation with a large greater tuberosity fragment.

Figure 2

Mutch classification of greater tuberosity fractures: (A) depression; (B) avulsion; and (C) split types.

Figure 3

(A) Anterior greater tuberosity fracture dislocation prior to reduction. (B) Iatrogenic neck fracture of humerus during closed reduction resulting in a 3-part proximal humerus fracture.

Figure 4

Reduction algorithm for greater tuberosity fracture dislocations. ORIF, open reduction internal fixation; RTSA, reverse total shoulder arthroplasty.

Figure 5

Three methods of determining greater tuberosity (GT) displacement. (A) Superior displacement of 5.5 mm. (B) The GT ratio is calculated as $\frac{\mathrm{A}+\mathrm{B}}{\mathrm{B}}=\frac{-4+9.3\text{mm}}{9.3\text{mm}}=0.57\text{.}$ (C) The impingement index is calculated as $\frac{{\mathrm{R}}_{\mathrm{T}}-{\mathrm{R}}_{\mathrm{H}}}{{\mathrm{R}}_{\mathrm{A}}-{\mathrm{R}}_{\mathrm{H}}}=\frac{31.5-23.6\text{mm}}{34.7-23.6\text{mm}}=0.71\text{.}$ A GT ratio > 0.50 or an impingement index >0.70 are suggestive of fractures that may benefit from surgery.

Figure 6

(A) A split-type greater tuberosity fracture with minimal superior displacement on Grashey view with arm in external rotation. (B) Axillary lateral radiograph demonstrating 8 mm posterior displacement. (C) 3D CT reconstructions demonstrating 4.8 mm posterior displacement. The patient was managed successfully nonoperatively. CT, computed tomography.

Figure 7

AP view showing suture fixation with a screw post construct used to secure a small greater tuberosity avulsion fracture. The arrow indicates the location of the fracture line. AP, anteroposterior.

Figure 8

AP radiograph demonstrating a suture and proximal humerus locking plate fixation construct that was used to treat a split-type greater tuberosity fracture in a patient with osteoporotic bone. AP, anteroposterior.