Greater Tuberosity Fracture of the Humerus: Arthroscopic Fixation

Abstract

Isolated fractures of the greater tuberosity are a relatively uncommon pathology and can lead to issues in strength, range of motion, and pain if not adequately reduced and fixed. Treatment decision mainly depends on the displacement of the fragment but most of the time it requires surgery because of the mechanics of the cuff that pulls on the fragment, making it unstable. If mistreated or unrecognized, the patients could develop chronic pain and limitations in range of motion that can lead to diminished function of the shoulder. Surgical alternatives include close reduction and percutaneous fixation, open or arthroscopic-assisted reduction, and internal fixation. In recent years, the advancements in shoulder arthroscopy have yielded arthroscopically assisted fixation techniques with encouraging results. The purpose of this Technical Note is to describe a suture bridge arthroscopic technique for treating a comminuted fracture of the greater tuberosity using multiple suture anchors. This technique has been found to be helpful in cases of greater tuberosity comminution to bridge the bony fragments.

Fig 1

Preoperative magnetic resonance imaging of a left shoulder including coronal T2 fat suppressed (A) and sagittal proton density fat-suppressed sequences (B), demonstrating the avulsion fracture of the greater tuberosity with multiple fragments (arrow). (G, glenoid; HH, humeral head.)

Fig 2

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope. (A) Clear visualization of the fracture site and the fragments is critical before fixation. (B) An arthroscopic shaver is used to accurately debride the fracture site from any scar tissue or initial callus formations present. (FB, fracture bed; FG, fragment.)

Fig 3

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope, an arthroscopic grasper is introduced from the accessory anterolateral portal. The mobility and reduction of the fracture fragments and rotator cuff are tested. (FB, fracture bed; FG, fragment; GT, greater tuberosity.)

Fig 4

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) The first medial anchor is positioned medially within the fracture site. (B) Using a Scorpion suture passer (Arthrex, Naples, FL) the 2 limbs of the suture tape are passed through the rotator cuff, just medial to the fragment. (C) Next, one of the suture limbs is passed through a lateral anchor positioned posteriorly in the greater trochanter thus keeping the fragments reduced. (FB, fracture bed; FG, fragment; GT, greater tuberosity.)

Fig 5

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) The remaining 2 medial anchors are positioned, and the suture tapes are passed through the rotator cuff in the same fashion previously described. Then the suture limbs are separated with an arthroscopic suture retriever and passed through 2 lateral anchors in the following order: one limb of each medial anchors is passed to the second lateral anchor (B) and one limb from the second and third medial anchors is passed to the third lateral anchor (C). ∗Second lateral anchor; ∗∗third lateral anchor. (AM, articular margin [medial-row fixation]; LR, lateral row fixation; RC, rotator cuff; SL, SwiveLock anchor [Arthrex]; SP, suture passer.)

Fig 6

Viewing in the beach-chair position through the anterolateral portal of a left shoulder with a 30° arthroscope: (A) Fixation is completed as the remaining anterior deformity of the fracture (∗) is addressed. (B) After passing a suture tape through the deformity, the repair is competed with a final knotless suture anchor. (C) The final construct was probed and noted to achieve an excellent anatomic reduction and compression of the fracture fragments. ∗∗∗Fourth lateral anchor. (FB, fracture bed; RC, rotator cuff; SL, SwiveLock anchor [Arthrex]; SP, suture passer.)