Greater and Lesser Tuberosity Fractures


Chapter 29

Greater and Lesser Tuberosity Fractures



Emilio Calvo, Maria Valencia, and Mikel Aramberri Gutiérrez

Introduction


Although the incidence of greater tuberosity fractures of the proximal humerus has been estimated to be 20% of all proximal humerus fractures, lesser tuberosity fractures account for only 2%. Contrary to proximal humerus fractures, the typical patient who sustains this type of injury is a male, younger (between the second and fifth decades of life), and with good bone quality and fewer comorbidities. Greater and lesser tuberosity fractures can both be associated with glenohumeral (GH) dislocation, in an anterior and posterior direction, respectively.

Despite their benign appearance on radiological studies, the reported outcomes of greater and lesser tuberosity fractures are poor when treated inappropriately. The displacement of the fracture is conditioned by the integrity of the tendon insertions. It has been shown that small amounts of displacement of only 5 mm are responsible for a change in force vectors and a subsequent decrease in function. The degree of displacement that is an indication for surgery and how to measure it are still a matter of controversy. Obtaining appropriate x-ray projections or computed tomographic (CT) scans should be advocated in order to avoid misdiagnosis.

A conservative approach has been advocated for nondisplaced and minimally displaced fractures. When displacement is present, surgical treatment is recommended in order to improve functional outcome. A clear understanding of relevant anatomy, fracture patterns, patient characteristics, and associated injuries is mandatory to obtain satisfactory results.

Procedure


Conservative management is indicated for minimally displaced fractures. It should include a period of immobilization followed by a specific rehabilitation program. Patients should be advised that the recovery period might be long and full range of motion might be difficult to achieve, owing to rotator cuff involvement.

Displaced fractures are treated surgically. Several techniques have been described, both open and arthroscopic. When the bony fragment is consistent enough and good bone quality is present, screw fixation might be the preferred option. Suture fixation with or without implants is also an excellent option when there is comminution or poor bone quality. Many different configurations are available. More recently, percutaneous or direct reduction performed in an arthroscopically assisted fashion has also been described.

Patient History


Greater Tuberosity


Lesser Tuberosity



Patient Examination


Greater Tuberosity



Lesser Tuberosity



Imaging



Treatment Options: Nonoperative and Operative



Surgical Anatomy


Greater Tuberosity





  1. • Apophyseal structure of the proximal humerus composed of three facets: superior, middle, and inferior (Fig. 29.3).


  3. image
    FIG. 29.2 Fracture of the greater tuberosity in the context of a glenohumeral dislocation. After reduction of dislocation, the fracture was reduced to its native position and was treated nonsurgically. (A) Anteroposterior x-ray of left shoulder. An anterior glenohumeral dislocation can be seen. There is a comminuted fracture of the greater tuberosity with a minimal superior displacement. (B) Outlet view x-ray of the same shoulder in which posterior displacement of the greater tuberosity fragment can be seen. (C) Anteroposterior x-ray of the same patient after reduction of the anterior glenohumeral dislocation. Fracture of the greater tuberosity was reduced, and conservative treatment was then decided. (D) Outlet view x-ray of the same shoulder in which posterior displacement of the greater tuberosity is also corrected after reduction.

  4. • The supraspinatus tendon was thought to insert on the superior facet and the superior half of the middle facet, whereas the infraspinatus tendon would insert on the entire middle facet, covering a portion of the supraspinatus tendon. However, a recent study described that the supraspinatus insertion was localized in the anteromedial and superior aspect of the tuberosity and that the infraspinatus insertion was located at the same height but in the anterolateral aspect of the superior facet and the entire middle facet.
  5. • Teres minor would occupy the inferior facet.
  6. • The highest point of the articular surface sits 8 ± 3.2 mm above the highest point of the greater tuberosity, preventing impingement against the acromion with arm motion.
  7. • When a fracture occurs as a result of the deforming forces, the tuberosity displaces in a superior direction owing to the supraspinatus and the superior part of the infraspinatus pull and in a posterior direction owing to the lower infraspinatus and teres minor pull.


image
FIG. 29.3 Bony and soft-tissue anatomy of proximal humerus, including lesser and greater tuberosities. Left: Bony landmarks of greater tuberosity and their relation to humeral head height. Right: The rotator cuff insertions on the greater and lesser tuberosities. The long head of the biceps tendon defines the landmark between both tuberosities. 
Courtesy Pau Golano.

Lesser Tuberosity



Surgical Indications


Greater Tuberosity



Lesser Tuberosity



Surgical Technique Setup


Positioning



Equipment


Tags:
Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Greater and Lesser Tuberosity Fractures

Full access? Get Clinical Tree
Get Clinical Tree app for offline access