A 43-year-old woman presents to the office with left shoulder pain after a fall 2 days ago. She was ice skating and fell with her arm extended. She is now having difficulty lifting the arm overhead. A Grashey view radiograph is shown in Figure 1.
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The patient presents with a minimally displaced greater tuberosity fracture. The patient’s radiographs were read as normal in the emergency room, and she was unaware that she had a fracture. The greater tuberosity is an attachment site for the supraspinatus and infraspinatus tendons. The greater tuberosity can fracture with a direct blow to the shoulder (an impaction injury) or from a fall on an outstretched hand causing an avulsion injury. A greater tuberosity fracture can also occur in up to 30% of shoulder dislocations.1,2
A nondisplaced fracture may be subtle on radiograph and is often missed. Nondisplaced and minimally displaced fractures can be treated in a sling immobilizer to avoid active abduction for 4 to 6 weeks. Displacement of fractures greater than 5 mm should be fixed with open reduction and internal fixation. Displaced fractures can result in impingement on the undersurface of the acromion and a poor functional outcome. Displaced fractures retract posteriorly and superiorly causing impingement in abduction and external rotation. Standard radiographs, including Grashey anteroposterior, outlet view, and axillary view, are usually adequate to determine the amount of displacement and indicated treatment. MRI may be used for suspected occult fractures not visible on radiograph.1,2
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 (JOPA).
- Wilcox RB 3rd, Arslanian LE, Millett PJ. Management of a patient with an isolated greater tuberosity fracture and rotator cuff tear. J Orthop Sports Phys Ther. 2005;35:521-530.
- Parsons BO, Klepps SJ, Miller S, Bird J, Gladstone J, Flatow E. Reliability and reproducibility of radiographs of greater tuberosity displacement: a cadaveric study. J Bone Joint Surg Am. 2005;87:58-65.