64 Greater Tuberosity Fracture Treatment (Open and Arthroscopic)

10.1055/b-0039-167713

64 Greater Tuberosity Fracture Treatment (Open and Arthroscopic)

Ramin Sadeghpour and Mark A. Schrumpf

Abstract

Operative treatment of greater tuberosity fractures is recommended when displacement may result in shoulder impairment. While most greater tuberosity fractures can be treated nonoperatively, fractures with greater than 5 mm of displacement have been shown to limit abduction, decrease external rotation, and result in symptomatic subacromial impingement. The primary goal of treatment is to prevent impingement and ensure normal physiologic function of the rotator cuff. Several surgical techniques have been described for greater tuberosity fracture fixation. These include open reduction and internal fixation via a deltopectoral or deltoid splitting approach and arthroscopic techniques. The ideal surgical approach and method of fixation are guided by several factors including patient characteristics, fracture pattern, and surgeon skill level.

64.1 Goals of Procedure

Operative treatment of displaced greater tuberosity fractures is recommended to prevent pain, stiffness, malunion, and alteration of shoulder function. Goals of surgery include restoration of bony anatomy, preservation of rotator cuff function, and early range of motion. ¹ The type of procedure performed depends on the size and degree of comminution of the tuberosity fragment. Large tuberosity fragments in nonosteopenic patients are amenable to fixation with partially threaded cannulated screws and washers ( Fig. 64.1a, b). In comminuted fractures, screw fixation is not recommended. In these instances, a small locking plate and/or primary rotator cuff–type repair through drill holes with heavy nonabsorbable sutures or suture anchors is preferred. Current operative treatment options include open reduction and internal fixation and arthroscopic fixation. Each technique has its own advantages and surgeons should always choose an operation within their own comfort zone.

**Fig. 64.1 (a)** This figure illustrates a large tuberosity fragment amenable to screw fixation. **(b)** Postoperative x-ray demonstrating the final fixation with the cannulated screws.

64.2 Advantages

Open reduction and internal fixation may be performed via a deltopectoral or an anterolateral deltoid splitting approach. The deltopectoral approach is a more familiar and extensile approach that avoids damage to the deltoid muscle. Access to a posteriorly displaced tuberosity fragment may prove more difficult with this approach. An anterolateral deltoid splitting approach ² affords the surgeon with a more direct view of the displaced tuberosity fragment, but places the axillary nerve at an increased risk of injury at the inferior margin of the surgical field. Arthroscopic fixation of these fractures affords the surgeon with the benefits of arthroscopy including a smaller incision, better intra-articular visualization, and identification and treatment of any associated intra-articular pathologies. While associated soft-tissue injuries, (i.e., rotator cuff tears, tears of rotator interval, and labral tears), are commonly identified at the time of greater tuberosity fixation, the exact benefit of soft-tissue repair has not been definitively established. Current literature is unclear whether concomitant soft-tissue injury has any influence on long-term clinical outcome following these injuries. ³ ^, ⁴ Studies have also shown better range of motion and the American Shoulder and Elbow Surgeons (ASES) scores with arthroscopic fixation of greater tuberosity fractures compared with open techniques; however, these differences were small and of questionable clinical importance. ⁵

64.3 Indications

Isolated greater tuberosity fractures represent approximately 20% of all proximal humerus fractures and are often associated with glenohumeral dislocations. ⁶ Most isolated greater tuberosity fractures can be treated nonoperatively. While an exact operative threshold remains controversial, most authors agree that 3 to 5 mm of posterosuperior displacement can lead to clinically significant impingement and altered shoulder mechanics. ⁷ Given this, nondisplaced or minimally displaced (<5 mm) fractures of the greater tuberosity are generally treated without surgery, ⁸ while those greater than 5 mm are treated with operative intervention. ¹ ^, ⁷ ^, ⁹ Patient factors (age, comorbidities, functional demand, and hand dominance), bone quality, fracture pattern, and even surgeon experience should all be used to guide treatment decisions. ⁹

64.4 Contraindications

Nondisplaced and/or minimally displaced (<5 mm) greater tuberosity fractures should be treated nonoperatively. While initial displacement of greater tuberosity fractures is important in guiding treatment, between 50 and 60% of minimally displaced greater tuberosity fractures demonstrate increased displacement at follow-up. ⁷ ^, ¹⁰ ^, ¹¹ Weekly serial radiographs for 3 to 4 weeks are of utmost importance if nonoperative treatment is chosen. As with other injuries, active infection at the surgical site and nonideal surgical candidates with significant medical comorbidities are also contraindications to operative intervention.

64.5 Preoperative Preparation/Positioning

General anesthesia with a regional block is the standard of care at our institution. General anesthesia allows for maximal relaxation, which can aid in fracture mobilization and reduction. Open surgery can be performed with the patient in either the beach-chair position or supine on a flat-top radiolucent table. Arthroscopic repair can be performed in the beach-chair or the lateral decubitus position. Prior to prepping and draping, it is important to ensure that a good anteroposterior (AP) and axillary views of the shoulder can be obtained. We prefer to have the C arm coming in from the nonoperative side as this allows for unimpeded work.

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