Arthroscopic Treatment of Shoulder Fractures

Arthroscopic Treatment of Shoulder Fractures

Jesus Rey II

Sumant G. Krishnan

The appropriate management of shoulder fractures remains challenging. Therapeutic options for shoulder fractures include both conservative and surgical treatments. Indications for either treatment remain controversial and are often made based on surgeon experience rather than evidence-based algorithms. In recent years, the treatment of shoulder girdle fractures has evolved from extensive open reduction to minimally invasive surgery. Arthroscopy is increasingly being recognized as an important adjunct in treating periarticular fractures, especially to confirm accurate reduction of articular surfaces. Avoidance of large muscular dissections is attractive for potentially decreasing complications, reducing postoperative pain, enhancing healing potential, and shortening postoperative recovery time. These arthroscopic techniques also allow for complete joint inspection and more accurate assessment of concomitant injuries than conventional methods. Given the high incidence of associated injuries with proximal humerus fractures, arthroscopy may indeed be a useful diagnostic and treatment tool for associated labral lesions, rotator cuff injuries, and traumatic cartilage defects (1). However, the arthroscopic treatment of shoulder fractures requires a learning curve that depends on surgeon experience in shoulder arthroscopy. Long-term outcomes after all-arthroscopic management of shoulder fractures still remain elusive.



Proximal humerus fractures represent 4% to 5% of all fractures and are the most common fractures of the shoulder girdle. Nordqvist and Petersson, (2) in a review of all fractures treated in a single hospital during the course of a year, found that proximal humerus fractures accounted for 53% of all significant shoulder girdle injuries.

Greater and lesser tuberosity fractures can occur as isolated injuries or as a component of comminuted proximal humerus fractures. Despite the disagreement in the literature regarding the magnitude of displacement, when isolated, most authors advocate that 5 mm of posterosuperior displacement of the greater tuberosity can lead to clinically significant impingement. With nondisplaced or minimally displaced (less than 5 mm) fractures, conservative management is an option (3). Management and outcomes for lesser tuberosity fractures are even more controversial since the incidence of this injury is far less common.

Clinical Evaluation

Pertinent History

The clinical history for proximal humerus fractures varies based upon which pattern of fracture is present. Although most of these fractures result from low-energy trauma usually following a fall in an elderly individual, isolated greater or lesser tuberosity fractures occur in younger patients. Tuberosity fractures usually occur in male patients between the second and the fifth decades of life (4) as well as adolescents with open humeral physis (5).

The mechanism of injury plays an important role in the pattern of fracture. It has been shown that over 50% of greater tuberosity fractures occur in the setting of an anterior shoulder dislocation (6). Eccentric loads on the tuberosities sustained by falling onto an outstretched arm can produce an avulsion-type fracture or propagate it with subsequent displacement. Lesser tuberosity fractures represent a rare injury that occurs in younger individuals. The arm is usually placed in an abducted and externally rotated position. Forceful contraction of the subscapularis muscle avulses the tuberosity. Another mechanism for lesser tuberosity fractures is a posterior dislocation of the shoulder.

Physical Examination

Acutely, the shoulder is often extremely swollen after a proximal humeral fracture. Ecchymosis tracks down the arm and into the chest and axilla. As most patients with proximal humeral fractures are elderly, assessment for concomitant injuries is paramount.

Electromyographic evaluation has demonstrated that approximately two-thirds (67%) of all patients with proximal humeral fractures suffer acute neurologic injury from
the violence of the injury. Most commonly, this involves either the axillary nerve (58%) or the suprascapular nerve (48%) (7).

For isolated lesser tuberosity fractures, symptoms include pain with passive external rotation, pain with resisted internal rotation, and tenderness over the lesser tuberosity. Since the subscapularis tendon is attached to the fractured bony structure, insufficiency of the musculotendinous unit of the subscapularis muscle is present and lift-off and belly-press tests can be used to evaluate this pathology.


Imaging is paramount in evaluating the proximal humerus fracture. Initial radiographic evaluation consists of a Neer trauma series with anteroposterior (AP), scapular “Y” and axillary roentgenographic views (Fig. 21.1). Because of the anatomy of the proximal humerus, it may be difficult to appreciate fracture lines and fragment displacement. If plain radiographs do not offer adequate visualization, the use of computed tomographic scans with three-dimensional (3D) reconstructions can be extremely helpful in assessing fracture pattern (Fig. 21.2). For fractures involving the greater tuberosity, it has been demonstrated that the most accurate displacement measurements are determined from the AP view in external rotation and the AP view with 15° caudal tilt (8). Displaced large lesser tuberosity fragments can usually be visualized on the AP images, whereas smaller fragments are better visualized on the axillary view.

MRI can detect occult nondisplaced fractures of the tuberosities. Zanetti et al (9). reported a 38% prevalence of occult fractures of the greater tuberosity in patients suspected of having traumatic rotator cuff tears.

FIGURE 21.1. AP X-ray of a 35-year-old patient with a greater tuberosity fracture.


Neer’s four-part classification system of proximal humerus fractures has endured by virtue of its simplicity. Despite its poor interobserver reliability and intraobserver reproducibility, this classification allows a conceptual understanding of the fracture pattern by defining the fracture into separate parts.

Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Arthroscopic Treatment of Shoulder Fractures

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