SHOULDER AND ELBOW 2022, Jul, 23 | 12:00 am

Greater Tuberosity Fractures افضل دكتور عظام ومفاصل

Greater Tuberosity Fractures

 
 
The greater tuberosity is the prominent area of bone at the top of the humerus and it connects with two large and powerful muscles of the rotator cuff - the supraspinatus and the subspinal muscles.
Greater Tuberosity Fractures The greater tuberosity is the prominent area of bone at the top of the humerus and it connects with two large and powerful muscles of the rotator cuff - the supraspinatus and the subspinal muscles. It may fracture alone, or with other injuries of the shoulder joint (commonly a shoulder dislocation or complex humeral fracture). As with most fractures it may be displaced (out of its normal position) or undisplaced. Greater Tuberosity Fractures without displacement Treatment options Non-surgical-conservative Key indicators Greater Tuberosity Fractures with less than 2 mm removed Supporting indicators The risks of surgery outweigh the benefits Advantages There are no surgical risks. There are no risks of anesthesia. disadvantages Potential risk of displacement See here how non-surgical treatment is done Surgery option Surgery is chosen in the following cases High displacement risk The need for strong fixation for early movement Advantages Reducing the risk of displacement early mobilzation disadvantages Possible need to remove devices Undisplaced Greater Tuberosity Fracture (The 'hidden fracture') I call this the 'hidden fracture' as an undisplaced fracture of the greater tuberosity is common and often does not show up on x-rays. It is common for people to injure their shoulder and x-rays look normal. This is frequently seen in skiing and mountain biking injuries. A diagnosis of 'shoulder sprain' or deltoid injury or rotator cuff injury is given and rest, rehabilitation and painkillers recommended. If your shoulder injury is not settling in a few weeks after a fall and x-rays are normal, then you should suspect a greater tuberosity fracture. It can be very easily seen on an MRI scan and also usually on an ultrasound scan of the shoulder. Surgery is not needed for an undisplaced fracture, but these relatively minor fractures can take a long time to heal and for the pain to settle. Shoulder stiffness and frozen shoulder is also frequent after an undisplaced greater tuberosity fracture. This may require treatment, like a true frozen shoulder. In some cases it can take up to one year to fully recover. Displaced Greater Tuberosity Fracture Isolated displaced greater tuberosity fractures are thought to occur in less than 2% of proximal humeral fractures, and are normally associated with anterior shoulder dislocations. The greater tuberosity fragment detaches with its attached rotator cuff and will characteristically have a longitudinal tear in the cuff between the supraspinatus and subscapularis tendons. The greater tuberosity fragment is pulled superiorly by the supraspinatus and posteriorly by infraspinatus and teres minor. Treatment As greater tuberosity fractures are usually retracted posteriorly and superiorly, a closed reduction is difficult. If left in position, impingement will develop against the acromion, limiting elevation and external rotation of the shoulder. However if the fracture is associated with anterior dislocation then a closed reduction of the glenohumeral dislocation may successfully reduce the greater tuberosity fracture, and once it has healed, recurrent anterior instability is unlikely. The surgical approach to this fracture is much like a rotator cuff repair, anterosuperiorly, often complete with an acromioplasty. An alternative approach is a deltoid-splitting approach, but instead of taking the deltoid off the anterior acromion, it is peeled off the posterior acromion which avoids the acromioplasty and minimizes weakening of the anterior deltoid. This approach is especailly helpful if the fragment is displaced posteriorly. Fixation of smaller fractures can be accomplished with heavy sutures, wire or occasionally, screws. Rotator cuff tears associated with the fracture are also closed. If in the case of a large greater tuberosity fracture, a deltopectoral approach would allow for more adequate exposure for reduction and proper fixation.
 
It may fracture alone, or with other injuries of the shoulder joint (commonly a shoulder dislocation or complex humeral fracture)
 
 
As with most fractures it may be displaced (out of its normal position) or undisplaced.
Greater Tuberosity Fractures The greater tuberosity is the prominent area of bone at the top of the humerus and it connects with two large and powerful muscles of the rotator cuff - the supraspinatus and the subspinal muscles. It may fracture alone, or with other injuries of the shoulder joint (commonly a shoulder dislocation or complex humeral fracture). As with most fractures it may be displaced (out of its normal position) or undisplaced. Greater Tuberosity Fractures without displacement Treatment options Non-surgical-conservative Key indicators Greater Tuberosity Fractures with less than 2 mm removed Supporting indicators The risks of surgery outweigh the benefits Advantages There are no surgical risks. There are no risks of anesthesia. disadvantages Potential risk of displacement See here how non-surgical treatment is done Surgery option Surgery is chosen in the following cases High displacement risk The need for strong fixation for early movement Advantages Reducing the risk of displacement early mobilzation disadvantages Possible need to remove devices Undisplaced Greater Tuberosity Fracture (The 'hidden fracture') I call this the 'hidden fracture' as an undisplaced fracture of the greater tuberosity is common and often does not show up on x-rays. It is common for people to injure their shoulder and x-rays look normal. This is frequently seen in skiing and mountain biking injuries. A diagnosis of 'shoulder sprain' or deltoid injury or rotator cuff injury is given and rest, rehabilitation and painkillers recommended. If your shoulder injury is not settling in a few weeks after a fall and x-rays are normal, then you should suspect a greater tuberosity fracture. It can be very easily seen on an MRI scan and also usually on an ultrasound scan of the shoulder. Surgery is not needed for an undisplaced fracture, but these relatively minor fractures can take a long time to heal and for the pain to settle. Shoulder stiffness and frozen shoulder is also frequent after an undisplaced greater tuberosity fracture. This may require treatment, like a true frozen shoulder. In some cases it can take up to one year to fully recover. Displaced Greater Tuberosity Fracture Isolated displaced greater tuberosity fractures are thought to occur in less than 2% of proximal humeral fractures, and are normally associated with anterior shoulder dislocations. The greater tuberosity fragment detaches with its attached rotator cuff and will characteristically have a longitudinal tear in the cuff between the supraspinatus and subscapularis tendons. The greater tuberosity fragment is pulled superiorly by the supraspinatus and posteriorly by infraspinatus and teres minor. Treatment As greater tuberosity fractures are usually retracted posteriorly and superiorly, a closed reduction is difficult. If left in position, impingement will develop against the acromion, limiting elevation and external rotation of the shoulder. However if the fracture is associated with anterior dislocation then a closed reduction of the glenohumeral dislocation may successfully reduce the greater tuberosity fracture, and once it has healed, recurrent anterior instability is unlikely. The surgical approach to this fracture is much like a rotator cuff repair, anterosuperiorly, often complete with an acromioplasty. An alternative approach is a deltoid-splitting approach, but instead of taking the deltoid off the anterior acromion, it is peeled off the posterior acromion which avoids the acromioplasty and minimizes weakening of the anterior deltoid. This approach is especailly helpful if the fragment is displaced posteriorly. Fixation of smaller fractures can be accomplished with heavy sutures, wire or occasionally, screws. Rotator cuff tears associated with the fracture are also closed. If in the case of a large greater tuberosity fracture, a deltopectoral approach would allow for more adequate exposure for reduction and proper fixation.

Greater Tuberosity Fractures without displacement

Treatment options

Non-surgical-conservative

Key indicators

Greater Tuberosity Fractures with less than 2 mm removed

Supporting indicators

The risks of surgery outweigh the benefits

Advantages

  • There are no surgical risks.
  • There are no risks of anesthesia.

Disadvantages

  • Potential risk of displacement
  • See here how non-surgical treatment is done

 

Surgery option

 Surgery is chosen in the following cases

  • High displacement risk
  • The need for strong fixation for early movement

Advantages

 

  • Reducing the risk of displacement
  •  Early mobilization

Disadvantages

Possible need to remove devices

.
Greater Tuberosity Fractures The greater tuberosity is the prominent area of bone at the top of the humerus and it connects with two large and powerful muscles of the rotator cuff - the supraspinatus and the subspinal muscles. It may fracture alone, or with other injuries of the shoulder joint (commonly a shoulder dislocation or complex humeral fracture). As with most fractures it may be displaced (out of its normal position) or undisplaced. Greater Tuberosity Fractures without displacement Treatment options Non-surgical-conservative Key indicators Greater Tuberosity Fractures with less than 2 mm removed Supporting indicators The risks of surgery outweigh the benefits Advantages There are no surgical risks. There are no risks of anesthesia. disadvantages Potential risk of displacement See here how non-surgical treatment is done Surgery option Surgery is chosen in the following cases High displacement risk The need for strong fixation for early movement Advantages Reducing the risk of displacement early mobilzation disadvantages Possible need to remove devices Undisplaced Greater Tuberosity Fracture (The 'hidden fracture') I call this the 'hidden fracture' as an undisplaced fracture of the greater tuberosity is common and often does not show up on x-rays. It is common for people to injure their shoulder and x-rays look normal. This is frequently seen in skiing and mountain biking injuries. A diagnosis of 'shoulder sprain' or deltoid injury or rotator cuff injury is given and rest, rehabilitation and painkillers recommended. If your shoulder injury is not settling in a few weeks after a fall and x-rays are normal, then you should suspect a greater tuberosity fracture. It can be very easily seen on an MRI scan and also usually on an ultrasound scan of the shoulder. Surgery is not needed for an undisplaced fracture, but these relatively minor fractures can take a long time to heal and for the pain to settle. Shoulder stiffness and frozen shoulder is also frequent after an undisplaced greater tuberosity fracture. This may require treatment, like a true frozen shoulder. In some cases it can take up to one year to fully recover. Displaced Greater Tuberosity Fracture Isolated displaced greater tuberosity fractures are thought to occur in less than 2% of proximal humeral fractures, and are normally associated with anterior shoulder dislocations. The greater tuberosity fragment detaches with its attached rotator cuff and will characteristically have a longitudinal tear in the cuff between the supraspinatus and subscapularis tendons. The greater tuberosity fragment is pulled superiorly by the supraspinatus and posteriorly by infraspinatus and teres minor. Treatment As greater tuberosity fractures are usually retracted posteriorly and superiorly, a closed reduction is difficult. If left in position, impingement will develop against the acromion, limiting elevation and external rotation of the shoulder. However if the fracture is associated with anterior dislocation then a closed reduction of the glenohumeral dislocation may successfully reduce the greater tuberosity fracture, and once it has healed, recurrent anterior instability is unlikely. The surgical approach to this fracture is much like a rotator cuff repair, anterosuperiorly, often complete with an acromioplasty. An alternative approach is a deltoid-splitting approach, but instead of taking the deltoid off the anterior acromion, it is peeled off the posterior acromion which avoids the acromioplasty and minimizes weakening of the anterior deltoid. This approach is especailly helpful if the fragment is displaced posteriorly. Fixation of smaller fractures can be accomplished with heavy sutures, wire or occasionally, screws. Rotator cuff tears associated with the fracture are also closed. If in the case of a large greater tuberosity fracture, a deltopectoral approach would allow for more adequate exposure for reduction and proper fixation.