Figure 1. Anteroposterior radiograph of the right shoulder.
Figure 2. Coronal computed tomography of the right shoulder.
Figure 3. Axial computed tomography of the right shoulder.
A 66-year-old man presents to the emergency department with pain and deformity in his right shoulder after he was thrown from a snowmobile and landed on his right shoulder. The patient underwent a closed reduction of the shoulder dislocation. Postoperative anteroposterior radiograph of the right shoulder (Figure 1) shows reduction with a displaced greater tuberosity fracture. Coronal and axial computed tomography images are also obtained (Figures 2 and 3).
Submit your diagnosis to see full explanation.
Shoulder dislocations often have associated soft tissue injuries that are not appreciated on radiograph. These include a Hill-Sachs lesion, bony Bankart lesion, labral tear, and rotator cuff tear. Shoulder dislocations can also be accompanied by fracture. Greater tuberosity fractures occur in up to 30% of patients with glenohumeral dislocations.1
The deforming forces on the greater tuberosity include the attached rotator cuff tendons. The supraspinatus, infraspinatus, and teres minor tendons insert onto the greater tuberosity and contribute to rotation and forward flexion of the humerus.
A fracture may displace posteriorly and superiorly from the pull of the supraspinatus and infraspinatus muscles. Active forward flexion or external rotation of the humerus after fracture can cause the rotator cuff to further displace the fragment.
For this reason, treatment involves placing the arm in a sling immobilizer at all times until radiography shows signs of healing. Indications for surgery include >5 mm of superior displacement in patients who are active.2 Older sedentary patients often tolerate significant displacement without compromising a baseline level of function. Significant superior displacement of the fracture fragment is likely to cause shoulder impingement between the fragment and the acromion once the fracture heals. Therefore, active patients who perform repetitive overhead activities are less likely to tolerate fracture displacement. Posterior displacement is difficult to measure on radiograph; therefore, computed tomography is often performed for a 3-dimensional view. Significant posterior displacement can also affect shoulder function, particularly in younger, more active patients.3,4
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants.
1. Schliemann B, Heilmann LF, Raschke MJ, Lill H, Katthagen JC, Ellwein A. Isolated fractures of the greater tuberosity: when are they treated conservatively? A baseline study. Obere Extrem. 2018;13(2):106-111.
2. Doral MN, Karlsson J, Nyland J, Bendetto KP. Intraarticular Fractures. Minimally Invasive Surgery, Arthroscopy. 1st ed. Springer International Publishing; 2019.
3. George MS. Fractures of the greater tuberosity of the humerus. J Am Acad Orthop Surg. 2007;15(10):607-613.
4. Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012;94(1):18-26.