Greater Tuberosity Fracture: Expert Diagnosis and Treatment Strategies

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A 35-year-old woman fell from a ladder, injuring her right shoulder. These are her radiographs. 1. What do the radiographs show? This is an AP and ‘Y’ lateral view of the shoulder. It shows a fracture of the greater tuberosity which is undisplaced. 2. How would you manage this patient? I would take a careful history from this woman and perform a full examination. Assuming this is an isolated injury, I would look carefully for an associated undis- placed fracture of the surgical neck or proximal humerus. If there was any doubt then I would arrange a CT scan. The greater tuberosity fracture fragment may have a tendency to retract due to the pull of supraspinatus and infraspinatus. The CT would allow me to judge the true amount of displacement. Healing in a retracted position could result in impingement and defunctioning of the rotator cuff. Fracture fragment displacement greater than 5 mm is a relative indication for surgery.
If the CT confirms the apparent injury of an undisplaced greater tuberosity fracture only then would I treat this patient in a sling for comfort and follow up clinically and radiographically at 1 week. I would allow her to start a programme of
shoulder physiotherapy from the 3-week point, starting with active pendular move- ments and gentle passive range of movement.
If significant displacement is confirmed on CT or if subsequent displacement is noticed at follow-up then I would offer surgery. I would approach the fracture through a deltoid-splitting approach. For a large fracture fragment, as shown here, I would use 4 mm cannulated cancellous screws. Non-absorbable suture fixation would be an alternative should this not be possible. 3. What degree of displacement would make you consider operative fixation?
There is debate about this. I would consider operative fixation for a greater tuberos- ity fracture displaced by 5 mm or more or where the fracture fragment is in a posi- tion likely to cause impingement should it heal there.