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Figure. Anteroposterior radiograph of the left shoulder.
A 62-year-old woman presents to the office with left shoulder pain after a fall the night before. She tripped and fell with her arm extended. She had immediate pain and was unable to lift her arm after. The figure shows an anteroposterior radiograph of the left shoulder.
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The great tuberosity is a fused apophysis of the posterior lateral proximal humerus that acts as the attachment site for the rotator cuff. An isolated greater tuberosity fracture is a relatively uncommon injury that can occur during a fall with an impact on the shoulder. An avulsion fracture usually occurs when the rotator cuff is suddenly contracted pulling a piece of bone off the greater tuberosity. A larger vertical type fracture is thought to occur during a shoulder instability episode. If the greater tuberosity fracture displaces more than 5 mm, the fragment may cause mechanical impingement at the subacromial space with shoulder abduction and forward elevation. Open and arthroscopic procedures tailored to fracture morphology are recommended in such cases, and strategies for repair include use of suture anchors, transosseous sutures, tension bands, and plates/screws.1,2
Patients with greater tuberosity fracture and less than 5 mm of fracture displacement can be treated conservatively with no arm abduction or forward elevation for 4 to 6 weeks. If the fracture displacement is unclear on initial radiographs, computed tomography (CT) may be warranted to better determine displacement. Rotator cuff injuries generally don’t occur with greater tuberosity fractures (16% incidence of concomitant rotator cuff tears), but magnetic resonance imaging (MRI) may be warranted if weakness and shoulder pain continue after the greater tuberosity fracture has healed.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 Orthopaedics for Physician Assistants.
References
1. White EA, Skalski MR, Patel DB, Gross JS, Tomasian A, Heckmann N, Matcuk GR Jr. Isolated greater tuberosity fractures of the proximal humerus: anatomy, injury patterns, multimodality imaging, and approach to management. Emerg Radiol. 2018;25(3):235-246. doi:10.1007/s10140-018-1589-8
2. Rouleau DM, Mutch J, Laflamme GY. Surgical treatment of displaced greater tuberosity fractures of the humerus. J Am Acad Orthop Surg. 2016;24(1):46-56. doi:10.5435/JAAOS-D-14-00289.
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