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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.

With surgical techniques isolated, there were no significant differences between suture anchors and transosseous tunnel constructs, but screws performed significantly better than suture techniques. Compared with suture fixation, screw fixation led to significantly fewer cases of stiffness and reoperation, which suggests surgeons need to give screws more consideration in the operative management of these fractures. However, the number of patients treated with screws was smaller than the number treated with suture fixation; it is possible the differences between these cohorts would be eliminated if there were more patients in the screw cohort. In addition, screw fixation was universally performed with an open or percutaneous approach and trended toward a higher infection rate. As screw and suture techniques have low rates of complications and reoperations, we recommend leaving fixation choice to the surgeon.

Anterior shoulder instability has been associated with greater tuberosity fractures.1,8,19 The supraspinatus, infraspinatus, and teres minor muscles all insert into the greater tuberosity and resist anterior translation of the proximal humerus. Loss of this dynamic muscle stabilization is amplified by tuberosity fracture displacement: Anterior shoulder instability was significantly more common in fractures displaced >5 mm (44.3%) vs <5 mm (14.5%). In turn, glenohumeral instability was more common in patients treated with surgery, specifically open surgery, because displaced fractures may not be as easily accessed with arthroscopic techniques. No studies reported concomitant labral repair or capsular plication techniques.

This systematic review was limited by the studies analyzed. All but 1 study5 had level IV evidence. Mean (SD) MCMS was 41.8 (8.6). Any MCMS score <54 indicates a poor methodology level, but this scoring system is designed for randomized controlled trials,23 and there were none in this study. Physical examination findings, such as range of motion, were underreported. In addition, radiographic parameters were not consistently described but rather were determined by the respective authors’ subjective interpretations of malunion, nonunion, and loss of reduction. Publication bias is present in that we excluded non- English language studies and medical conference abstracts and may have omitted potentially eligible studies not discoverable with our search methodology. Performance bias is a factor in any systematic review with multiple surgeons and wide variation in surgical technique.

Conclusion

Greater tuberosity fractures displaced <5 mm may be safely managed nonoperatively, as there are no reports of nonoperatively managed fractures that subsequently required surgery. Nonoperative treatment was initially associated with low patient satisfaction, but only because displaced fractures were conservatively managed in early studies.5,16 Fractures displaced >5 mm respond well to operative fixation with screws, suture anchors, or transosseous suture tunnels. Stiffness is the most common postoperative complication (<6%), followed by heterotopic ossification, transient neurapraxias, and superficial infection. There are no discernible differences in outcome between open and arthroscopic techniques, but screw fixation may lead to significantly fewer cases of stiffness and reoperation in comparison with suture constructs.

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