Review Question - QID 218969

This patient sustained a minimally displaced greater tuberosity fracture that was appropriately treated non-operatively. Patients who fail to improve 3-6 months after injury should undergo magnetic resonance imaging (MRI) to evaluate for an underlying rotator cuff tear.

Proximal humerus fractures are common injuries sustained in the osteoporotic elderly population following low-velocity trauma (i.e. ground level fall). In contrast, isolated greater tuberosity fractures usually occur in younger patients following high-velocity trauma or shoulder dislocations. There are various fracture patterns and classifications, however, the vast majority (>85%) are minimally displaced and may be treated non-operatively. If patients continue to endorse pain and dysfunction 3-6 months after injury, they should undergo MRI evaluation for an underlying rotator cuff tear (particularly after shoulder dislocation). Surgical indications at the time of injury are dictated by the amount of fracture displacement and the overall functional demands of the patient. In general, fractures displaced more than 5mm and patients with high physical demands are reported to have better functional outcomes when treated operatively. There are a variety of operative techniques described including open reduction with plate and screw fixation, screw fixation alone, and arthroscopic-based approaches. There is no gold standard fixation method as the technique is dependent on fracture morphology.

Rouleau and colleagues provided a comprehensive review article on greater tuberosity fractures and the various surgical treatment options. The authors discuss that even just 3-5mm of superior displacement may adversely affect rotator cuff biomechanics with resultant subacromial impingement in the active population. They provided a treatment algorithm for treater tuberosity fractures (Illustration A) and describe various operative techniques.

Mattaysovszky and colleagues performed a retrospective review of their 30-patient cohort with isolated greater tuberosity fractures. They found that minimally displaced fractures (<5mm) treated nonoperatively, and major displaced fractures (>10mm) treated operatively had similar DASH and Constant scores at 3-year follow-up. They also report that moderately (6-10mm) displaced fractures had equivalent outcomes when treated nonoperatively vs surgically. The authors concluded that minor to moderately displaced (<1cm) greater tuberosity fractures may be treated successfully without surgery.

Figure A shows an AP radiograph displaying a minimally displaced, isolated greater tuberosity fracture. Illustration A shows the greater tuberosity treatment algorithm provided in the Rouleau article.

Incorrect Answers:
Answer 1. Continuing nonoperative treatment despite 4 months of failed improvement would not be appropriate in a highly physically demanding profession (i.e. laborer). Determining the underlying cause of continued dysfunction would be more appropriate.
Answer 3. Providing a corticosteroid injection and manipulation under anesthesia would be appropriate in the setting of adhesive capsulitis (i.e. frozen shoulder). The patient has full passive range of motion which rules out this pathology.
Answer 4. It would be prudent to obtain an MRI prior to undergoing arthroscopic evaluation in order to plan for any implants required. In general, noninvasive diagnostic modalities (i.e. advanced imaging) should be obtained prior to undergoing invasive diagnostic procedures.
Answer 5. An anatomic total shoulder arthroplasty (aTSA) would be considered appropriate in the setting of end-stage osteoarthritis. It is imperative to have a fully functional rotator cuff for long-term implant survival and optimal functional outcomes in aTSA. This patient had a shoulder dislocation which, especially in middle-aged patients, is highly associated with underlying rotator cuff tears.