Management of Isolated Greater Tuberosity Fractures: A Systematic Review
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.
For all 13 studies, mean (SD) MCMS was 41.1 (8.6).
Discussion
Five percent of all fractures involve the proximal humerus, and 20% of proximal humerus fractures are isolated greater tuberosity fractures.26,27 In his classic 1970 article, Neer6 formulated the 4-part proximal humerus fracture classification and defined greater tuberosity fracture “parts” using the same criteria as for other fracture “parts.” Neer6 recommended nonoperative management for isolated greater tuberosity fractures displaced <1 cm but did not present evidence corroborating his recommendation. More recent cutoffs for nonoperative management include 5 mm (general population) and 3 mm (athletes).7,17
In the present systematic review of greater tuberosity fractures, 3 separate comparisons were made: treatment type (nonoperative vs operative), fracture displacement amount (<5 mm vs >5 mm), and surgery type (open vs arthroscopic).
Treatment Type. Only 4 studies reported data on nonoperative treatment outcomes.5,12,16,17 Of these 4 studies, 2 found successful outcomes for fractures displaced <5 mm.12,17 Platzer and colleagues17 found good or excellent results in 97% of 135 shoulders after 4 years. Good results were defined with shoulder scores of ≥80 (Constant), <8 (Vienna), and >28 (UCLA), and excellent results were defined with maximum scores on 2 of the 3 systems. Platzer and colleagues17 also found nonsignificantly worse shoulder scores with superior displacement of 3 mm to 5 mm and recommended surgery for overhead athletes in this group. Rath and colleagues12 described a successful 3-phase rehabilitation protocol of sling immobilization for 3 weeks, pendulum exercises for 3 weeks, and active exercises thereafter. By an average of 31 months, patient satisfaction scores improved to 9.5 from 4.2 (10-point scale), though the authors cautioned that pain and decreased motion lasted 8 months on average. Conservative treatment was far less successful in the 2 studies of fractures displaced >5 mm.5,16 Keene and colleagues16 reported unsatisfactory results in all 4 patients with fractures displaced >1.5 cm. In a study separate from their 2005 analysis,17 Platzer and colleagues5 in 2008 evaluated displaced fractures and found function and patient satisfaction were inferior after nonoperative treatment than after surgery. The studies by Keene and colleagues16 and Platzer and colleagues5 support the finding of an overall lower patient satisfaction rate in nonoperative patients.
Fracture Displacement Amount. Only 2 arthroscopic studies and no open studies addressed surgery for fractures displaced <5 mm. Fewer than 16% of these fractures were managed operatively, and <1% required reoperation. By contrast, almost all fractures displaced >5 mm were managed operatively, and 3.6% required reoperation. Radiographic loss of reduction was more common in fractures displaced <5 mm, primarily because they were managed without fixation. Radiographic loss of reduction was reported in only 9 operatively treated patients, none of whom was symptomatic enough to require another surgery.5 Reoperations were most commonly performed for stiffness, which itself was significantly more common in fractures displaced >5 mm. Bhatia and colleagues14 reported the highest reoperation rate (14.3%; 3/21), but they studied more complex, comminuted fractures of the greater tuberosity. Two of their 3 reoperations were biceps tenodeses for inflamed, stiff tenosynovitis, and the third patient had a foreign body giant cell reaction to suture material. Fewer than 1% of patients with operatively managed displaced fractures required revision ORIF, and <2% developed a superficial infection or postoperative nerve palsy.19,22 For displaced greater tuberosity fractures, surgery is highly successful overall, complication rates are very low, and 90% of patients report being satisfied.
Surgery Type. Patients were divided into 2 groups. In the nonarthroscopic group, open and percutaneous approaches were used. All studies that described a percutaneous approach used screw fixation5,21; in addition, 32 patients were treated with screws through an open approach.2,5 The other open and arthroscopic studies used suture fixation. Interestingly, no studies reported on clinical outcomes of fragment excision. There were no statistically significant differences in rates of reoperation, stiffness, infection, or neurologic injury between the arthroscopic and nonarthroscopic groups. Patient satisfaction scores were slightly higher in the nonarthroscopic group (91.0% vs 87.8%), but the difference was not statistically significant.
