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Greater Tuberosity Fractures

- See: Fracture Dislocation

- Discussion:
    - isolated displaced greater tuberosity fractures are thought to occur in less than 2% of proximal humeral frx;
    - greater tuberosity fragments w/ its attached rotator cuff will characteristically have a longitudinal tear in the cuff between the supraspinatus and subscapularis tendons;
          - additionally, displaced fractures are associated w/ longitudinal rotator cuff tears;
    - note that these fractures are often associated w/ anterior shoulder dislocation;
          - in some cases, the magnitude of the fracture defect in the humeral head will be  over-estimated due to the presence of an unrecognized Hill Sachs lesion;
    - nerve injury:
          - in the presentation by A. Garg et al (15 th OTA meeting), the authors noted 16 nerve injuries out of 50 patients w/ greater tuberosity frx;
                 - nerve injuries included: 10 axillary, 3 brachial plexus injuries, 1 median, and 1 ulnar nerve injury;

- Non Operative Treatment:
    - greater tuberosity fractures are usually retracted posteriorly & superiorly, and closed reduction is difficult;
          - this retraction may recur after reduction;
    - if left in this position, impingment will develop against the acromion, limiting elevation and external rotation of the shoulder;
    - if frx is assoc w/ anterior dislocation, closed reduction of glenohumeral dislocation may successfully reduce greater tuberosity fracture;
          - once the tuberosity fragment has healed, recurrent anterior instability is unlikely;

- Indications for Surgery:
    - presence of a mechanical block to reduction;
    - post reduction displacement > 5 - 10 mm in any plane requires ORIF;
          - axillary view usually shows the most significant displaced, but in some cases CT scan may be indicated to accurately determine amount of displacement;
          - note that 5 mm of displacement might end up causing impingement in younger patients;

- Operative Treatment:
    - anterior approach to the shoulder provides the best exposure;
          - remember that the rotator cuff will cover the posterior and superior poritons of the greater tuberosity fragment, which therefore means that only the antero-inferior portion of the fragment is visible for reduction;
          - this antero-inferior portion of the fragment may not be well visualized by deltoid splitting incisions (such as used in rotator cuff repairs);
          - alternatively consider a "rotator cuff" type incision:
                - 5 cm incision is made parallel to the skin creases over the anterosuperior protion of the shoulder;
                - deltoid is split 4 cm along the anterosuperior raphe of the deltoid (further splitting may injure the axillary nerve);
    - fixation:
          - the tuberosity fragment is reduced and secured to its bed using heavy non absorbable sutures, either using a McGowen needle or through drill holes;
                - occassionally, cancellous lag screws with washers may be used to achieve stable fixation;
  - subsequently the longitudinal tear in the rotator cuff is repaired;
                - this tear is characteristically located in the interval between the supraspinatus and the subscapularis muscles;

- Case Example of Frx Dislocation:

    - 27 year old female who sustained a greater tuberosity frx - anterior dislocation during a seizure;
          - she underwent ORIF of the fragment using No 5 Ethibond sutures and two screws;
          - note the large Hill Sachs fragment;

Year Book: Open Reduction and Internal Fixation of Two-Part Displaced  Fractures of the Greater Tuberosity of the Proximal Part of the Humerus.

Anterior traumatic shoulder dislocation associated with displaced greater tuberosity fracture: the necessity of operative treatment.