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Management of Isolated Greater Tuberosity Fractures: A Systematic Review

The American Journal of Orthopedics. 2017 November;46(6):E445-E453
December 27, 2017 | The American Journal of Orthopedics
David M. Levy, MD ; Brandon J. Erickson, MD ; Joshua D. Harris, MD ; Bernard R. Bach Jr, MD ; Nikhil N. Verma, MD ; Anthony A. Romeo, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Harris reports that he serves as a board or committee member for the American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy, Arthroscopy Association of North America, and Frontiers in Surgery; he has received research support from DePuy Synthes and Smith & Nephew, royalties from SLACK Incorporated, and is paid by NIA Magellan, Ossur, and Smith & Nephew. Dr. Bach reports that he has received research support from Arthrex, Inc., CONMED Linvatec, DJ Orthopaedics, Ossur, Smith & Nephew, and Tornier as well as royalties from SLACK Incorporated. Dr. Verma reports that he serves as a board or committee member for the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Arthroscopy Association Learning Center Committee, Journal of Knee Surgery, and SLACK Incorporated; he has received research support from Arthrex, Inc., Arthrosurface, DJ Orthopaedics, Smith & Nephew, Athletico, ConMed Linvatec, Miomed, and Mitek; he has received publishing royalties, financial, or material support from Arthroscopy and Vindico Medical-Orthopedics Hyperguide; he has received stock or stock options from Cymedica, Minivasive, and Omeros and serves as a paid consultant for Orthospace and Smith & Nephew. Dr. Romeo reports that he serves as a board or committee member for the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, Orthopedics, Orthopedics Today, SAGE, and Wolters Kluwer Health—Lippincott Williams & Wilkins; he has received research support from Aesculap/B.Braun, Arthrex, Inc., Histogenics, Medipost, NuTech, Orthospace, Smith & Nephew, and Zimmer Biomet; he has received other financial or material support from AANA, Arthrex, Inc., and Major League Baseball; he has received publishing royalties, financial and/or material support from Saunders/Mosby-Elsevier and SLACK Incorporated. The other authors report no actual or potential conflict of interest in relation to this article. 

As isolated fractures of the greater tuberosity present a therapeutic challenge, we systematically reviewed all studies of greater tuberosity fracture management. Inclusion criteria were level I to IV evidence and 2-year follow-up. Thirteen studies and 429 shoulders were included in our analyses, which compared 3 paired groups: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).

Concomitant anterior glenohumeral instability was documented in 28.1% of patients and was significantly more common in displaced vs nondisplaced fractures (44.3% vs 14.5%; P < .01). Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (48.6% vs 5.2%; P < .01) but increased shoulder stiffness (0.0% vs 5.7%; P < .01). Heterotopic ossification was more common in displaced vs nondisplaced fractures (7.5% vs 0.0%; P < .01). There were no significant differences in outcome between arthroscopic and open surgery, but with screw fixation (vs suture constructs) there were significantly fewer cases of stiffness (0% vs 12.0%; P < .01) and reoperation (0% vs 8.0%; P = .051).

Surgery for displaced fractures is associated with high patient satisfaction and low rates of complications and reoperations, regardless of technique and fixation mode.

Table 3.
Comparisons of treatment type are listed in Table 3. Compared with nonoperative patients, operative patients had significantly fewer radiographic losses of reduction (P < .01) and better patient satisfaction (P < .01). Operative patients had a significantly higher rate of shoulder stiffness (P < .01). Eight operative patients (3.8%) and no nonoperative patients required reoperation during clinical follow-up (P < .01). All 12 reported cases of stiffness were in the operative group, and 3 required revision surgery. One patient required revision ORIF. There were 2 cases of postoperative superficial infection (0.9%) and 4 neurologic injuries (1.9%).
Table 4.
Comparisons of displacement amount are listed in Table 4. Compared with fractures displaced >5 mm, those displaced <5 mm had more radiographic losses of reduction (P < .01) but fewer instances of heterotopic ossification (P < .01). Fractures displaced >5 mm were significantly more likely than not to be managed with surgery (P < .01) and significantly more likely to develop stiffness after treatment (P = .01). One patient (0.4%) with a fracture displaced <5 mm eventually underwent surgery for stiffness, and 6 patients (3.6%) with fractures displaced >5 mm required reoperation (P = .02).
Table 5.
Comparisons of surgery type are listed in Table 5. All open procedures were performed with a deltoid-splitting approach. Screw fixation was used in 4 cases: 2 percutaneous5,21 and 2 open.2,5 The other open and arthroscopic studies described suture fixation, half with anchors (77/156 patients; 49.4%) and half with transosseous tunnels (79/156; 50.6%). There were no statistically significant differences between open/percutaneous and arthroscopic techniques in terms of stiffness, superficial infection, neurologic injury, or reoperation rate.

Fisher exact tests were used to perform isolated comparisons of screws and sutures as well as suture anchors and transosseous tunnels. Patients with screw fixation were significantly (P = .051) less likely to require reoperation (0/56; 0%) than patients with suture fixation (8/100; 8.0%). Screw fixation also led to significantly less stiffness (0% vs 12.0%; P < .01) but trended toward a higher rate of superficial infection (3.6% vs 0%; P = .13). There was no statistical difference in nerve injury rates between screws and sutures (1.8% vs 3.0%; P = 1.0). There were no significant differences in reoperations, stiffness, superficial infections, or nerve injuries between suture anchor and transosseous tunnel constructs.

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