Fractures of the greater tuberosity of the humerus

Neglected Anterior Shoulder Dislocation With Greater Tuberosity Fracture Managed With Open Reduction and Latarjet Procedure: A Case Report

Neglected shoulder dislocation is a relatively rare occurrence characterized by structural changes in bone and soft tissue. Surgical intervention is often necessary, yet no universally accepted treatment approach exists, presenting a challenging clinical scenario. A 45-year-old female presented with an eight-month-old neglected anterior shoulder dislocation, compounded by a Hill-Sachs lesion from a previous fall. Treatment comprised open reduction in conjunction with the Latarjet procedure. Regular follow-up evaluations were conducted over three years post-surgery, revealing satisfactory outcomes including good range of motion, bony union, and absence of dislocation episodes. Managing neglected shoulder dislocations, particularly those with significant bone defects, poses unique challenges involving soft tissue contracture, bone loss, and associated fractures. Despite these complexities, open reduction combined with the Latarjet procedure demonstrated a high success rate in preventing further shoulder dislocation, albeit with a persistent risk of shoulder joint osteoarthritis.

Deep-learning-based image quality enhancement of CT-like MR imaging in patients with suspected traumatic shoulder injury

PURPOSE

To evaluate the diagnostic performance of CT-like MR images reconstructed with an algorithm combining compressed sense (CS) with deep learning (DL) in patients with suspected osseous shoulder injury compared to conventional CS-reconstructed images.

METHODS

Thirty-two patients (12 women, mean age 46 ± 14.9 years) with suspected traumatic shoulder injury were prospectively enrolled into the study. All patients received MR imaging of the shoulder, including a CT-like 3D T1-weighted gradient-echo (T1 GRE) sequence and in case of suspected fracture a conventional CT. An automated DL-based algorithm, combining CS and DL (CS DL) was used to reconstruct images of the same k-space data as used for CS reconstructions. Two musculoskeletal radiologists assessed the images for osseous pathologies, image quality and visibility of anatomical landmarks using a 5-point Likert scale. Moreover, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated.

RESULTS

Compared to CT, all acute fractures (n = 23) and osseous pathologies were detected accurately on the CS only and CS DL images with almost perfect agreement between the CS DL and CS only images (κ 0.95 (95 %confidence interval 0.82-1.00). Image quality as well as the visibility of the fracture lines, bone fragments and glenoid borders were overall rated significantly higher for the CS DL reconstructions than the CS only images (CS DL range 3.7-4.9 and CS only range 3.2-3.8, P = 0.01-0.04). Significantly higher SNR and CNR values were observed for the CS DL reconstructions (P = 0.02-0.03).

CONCLUSION

Evaluation of traumatic shoulder pathologies is feasible using a DL-based algorithm for reconstruction of high-resolution CT-like MR imaging.

Evaluation of the relationship between scapula morphology and anterior shoulder dislocation accompanying greater tuberosity fracture

INTRODUCTıON: It is estimated that 5-30% of traumatic anterior shoulder dislocations are accompanied by greater tuberosity fracture (GTF), and the pathomechanism of these fractures is not yet clear. Our hypothesis is to examine the relationship between the scapula morphology and anterior shoulder dislocation (ASD) accompanying GTF. MATERıALS AND METHODS: The patients were divided into two groups according to the accompanying GTF. 40 patients with isolated traumatic ASD and 31 patients with accompanying GTF were included in the study. Critical shoulder angle (CSA), glenoid inclination (GI), acromial index (AI) and greater tuberosity angle (GTA) values were measured in two sessions by two independent observers in the standard antero-posterior radiographs of the patients in both groups. RESULTS: The mean CSA was 40.82°±3.19° and 35.49°±2.19° in accompanying GTF group and the isolated ASD group, respectively. The mean CSA was significantly higher in accompanying GTF group than isolated ASD group(P<0.001). The GI was significantly higher in the isolated ASD than in accompanying GTF group (P = 0.001). The mean GI was 18.7°±6.85° and 10.45°±4.87° in accompanying GTF group and the isolated ASD, respectively. Cut-off value of CSA and GI was 38° (88.2% sensitivity,88.9% specificity) and 14.5° (70.6% sensitivity and 72.2% specificity), respectively. There was no significant difference regarding the mean GTA and AI values between GTF group and the isolated ASD group (P = 0.98, P = 0.63). CONCLUSıONS: Increased CSA and GI values are associated with traumatic anterior shoulder dislocation accompanied by greater tuberosity fracture.

Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome. The mean DASH score improved from 42.3 (SD 9.6) at six weeks post-injury, to 19.5 (SD 14.3) at one-year follow-up (p < 0.001), but outcomes were mixed, with 30 patients having a DASH score > 30 at one year. MRI revealed a range of associated injuries, with a full-thickness rotator cuff tear present in 19 patients (19%). Overall, 11 patients (11%) developed complications requiring further operative intervention; 20 patients (21%) developed post-traumatic secondary shoulder stiffness. Multivariate analysis revealed a high-energy mechanism (p = 0.009), tobacco consumption (p = 0.033), use of mobility aids (p = 0.047), a full-thickness rotator cuff tear (p = 0.002), and the development of post-traumatic secondary shoulder stiffness (p = 0.035) were independent predictors of poorer outcome. The results of nonoperative management of minimally displaced GT fractures are heterogeneous. While many patients have satisfactory early outcomes, a substantial subgroup fare much worse. There is a high prevalence of rotator cuff injuries and post-traumatic shoulder stiffness, and their presence is associated with poorer patient experience. Furthermore, patients who have a high-energy injury, smoke, or use walking aids, have worse outcomes.

Chronic Bilateral Symmetric Anterior Shoulder Dislocation Secondary to Seizures in Chikungunya Encephalitis

Bilateral shoulder dislocations are a rare occurrence and can be categorized as either symmetric (both humeral heads dislocate in the same direction) or asymmetric (wherein the humeral heads dislocate in different directions). Shoulder dislocations may be overlooked if they are the result of systemic injury; if diagnosed >21 days after occurring, they are considered chronic dislocations. We describe the case of a 31-year-old male who presented with an eight-week history of bilateral shoulder pain. His onset of pain coincided with a seizure secondary to Chikungunya encephalitis. Clinical and radiological examination demonstrated bilateral symmetric anterior shoulder dislocation with associated greater tuberosity fractures and extensive callus formation bilaterally. Open surgical management was performed first on the left shoulder via the deltopectoral approach. The callus was removed, the greater tuberosity fragment lifted off, reattached to the original position, and held in place with sutures and proximal humeral locking plates. The right shoulder was reduced six weeks after the left shoulder due to patient preference; the reduction utilized the same approach as with the left shoulder. Post-operatively the patient was immobilized, and physiotherapy commenced. He achieved a satisfactory range of motion four months post-operation. Physicians should be cognizant that shoulder pain after a convulsive seizure may signify shoulder dislocation. Thorough clinical and radiological examinations are warranted in such an instance. There exists no consensus on the treatment of chronic shoulder dislocations, but it is recommended that closed reduction only be attempted up to six weeks post-dislocation due to the high risk of iatrogenic fractures and neurovascular damage beyond this time.

Morphological characteristics and management of greater tuberosity fractures associated with anterior glenohumeral joint dislocation: A single centre 10-year retrospective review

Introduction

Greater tuberosity (GT) fractures associated with anterior gleno-humeral (GH) dislocations are unstable, with inadequate treatment leading to displacement, malunion, stiffness and functional disability. We explored its morphological characteristics to ultimately optimize their management.

Methods

We retrospectively reviewed all shoulder radiographs with GT fractures associated with anterior GH dislocations in a university hospital between December 1, 2009 and December 31, 2019. Special considerations were given to fracture morphology, presence and site of comminution, degree of displacement and need for surgical intervention.

Results

133 patients were identified. Most of the fracture-dislocations were multi-fragmentary (86.5%) and located antero- or postero-superiorly (68.7%). Superiorly comminuted GT fractures were twice as likely to displace compared to other sites of comminution (43% vs. 21%, p = 0.03), and require surgery (p = 0.03). Undisplaced comminuted GT fragments, particularly superior patterns, could undergo secondary migration if conservatively treated (p = 0.01). GT fractures fixed with interfragmentary screw suffered more secondary migration but those treated with double-row suture anchors (DRSA) did not on follow-up x-rays at two months.

Conclusion

GT fractures with anterior GH dislocations are frequently comminuted. Those with superiorly situated comminution should have a low threshold for surgical fixation, particularly with DRSA which can prevent secondary fragment migration.

A Mid-Scapular Portal for Arthroscopic-Assisted Fixation of Severe Retraction Greater Tuberosity Avulsion Fracture

Chronic displaced greater tuberosity avulsion fracture of the humerus causes severe retraction of the rotator cuff and resorption of the avulsion fragment. Many treatment options can be considered to solve this problem and return the patient to function. The arthroscopic technique is very challenging to achieve a reduction of the rotator cuff and fixation of greater tuberosity with minimized soft-tissue damage. This Technical Note describes a portal for arthroscopic-assisted reduction and fixation in severe retracted greater tuberosity avulsion fracture. The technique is easy to release and fix chronic displaced greater tuberosity and could avoid unnecessary open surgery.

Biomechanical comparisons of hook plate and screw fixations in split-type greater tuberosity fractures of the humerus

BACKGROUND

Screws and plate are commonly utilized for the fixation of split-type humeral greater tuberosity (GT) fractures. However, the mechanical properties of these 2 types of fixation methods have not been compared directly. The aim of the present study was to evaluate the classic 2 screws fixation with hook locking plate from a mechanical perspective.

METHODS

Sixteen synthetic humerii (Sawbones Pacific Research Laboratories, Vashon, WA, USA) were divided into 2 groups. An osteotomy was performed to simulate a split-type GT fracture. Group A (n = 8) was fixed with 2 standard parallel screws. Group B (n = 8) was fixed with a hook plate. Each specimen was tested with traction force at 45° shoulder abduction. Following the 20-N preload, a 500-cycle loading test was applied with a force ranging from 20 to 200 N (valley/peak), and the interfragmental displacement was measured periodically at intervals of 100 cycles. Finally, all the specimens were pulled with destructive force at a rate of 5 mm/min until catastrophic failure.

RESULTS

The hook plate exhibited greater construct stiffness than the screw fixation (63.2 ± 6.1 N/mm vs. 40.9 ± 3.4 N/mm, P < .001). All of the specimens completed the entire cyclic loading test without catastrophic failure, and the fragment displacement after 500 cycles was 0.4 ± 0.2 mm for the hook plate and 2.1 ± 0.3 mm for screw fixation, which was statistically lower in the plate group (P < .001). In terms of failure load, the hook plate group exhibited a significantly greater value than the screw group (770.6 ± 94.6 vs. 427.5 ± 45.1 N/mm, P < .001). The failure modes of both fixation methods were distinct.

CONCLUSION

In humeral GT fracture fixation, hook plate fixation appears to offer greater construct stiffness and failure load while maintaining fragment stability to resist a physiological traction force. The current study provides support from a mechanical perspective for the clinical application of the hook plate.

Minimally invasive open reduction of greater tuberosity fractures by a modified suture bridge procedure

BACKGROUND

Most greater tuberosity fractures can be treated without surgery but some have a poor prognosis. The surgical procedures for avulsion fractures of the humeral greater tuberosity include screw fixation, suture anchor fixation, and plate fixation, all of which have treatment-associated complications. To decrease surgical complications, we used a modified suture bridge procedure under direct vision and a minimally invasive small incision to fix fractures of the greater tuberosity of the humerus.

AIM

To investigate the clinical efficacy and outcomes of minimally invasive modified suture bridge open reduction of greater tuberosity evulsion fractures.

METHODS

Sixteen patients diagnosed between January 2016 and January 2019 with an avulsion-type greater tuberosity fracture of the proximal humerus and treated by minimally invasive open reduction and modified suture bridges with anchors were studied retrospectively. All were followed up by clinical examination and radiographs at 3 and 6 wk, 3, 6 and 12 mo after surgery, and thereafter every 6 mo. Outcomes were assessed preoperatively and postoperatively by a visual analog scale (VAS), the University of California Los Angeles (UCLA) shoulder score, the American Shoulder and Elbow Surgeon score (ASES), and range of motion (ROM) for shoulders.

RESULTS

Seven men and nine women, with an average age of 44.94 years, were evaluated. The time between injury and surgery was 1-2 d, with an average of 1.75 d. The mean operation time was 103.1 ± 7.23 min. All patients achieved bone union within 3 mo after surgery. VAS scores were significantly decreased (P = 0.002), and the mean degrees of forward elevation (P = 0.047), mean degrees of abduction (P = 0.035), ASES score (P = 0.092) were increased at 3 wk. The UCLA score was increased at 6 wk (P = 0.029) after surgery. The average degrees of external rotation and internal rotation both improved at 3 mo after surgery (P = 0.012 and P = 0.007, respectively). No procedure-related deaths or incision-related superficial or deep tissue infections occurred.

CONCLUSION

Modified suture bridge was effective for the treatment of greater tuberosity evulsion fractures, was easier to perform, and had fewer implants than other procedures.

Imaging of traumatic shoulder injuries – Understanding the surgeon’s perspective

Imaging plays a key role in the assessment and management of traumatic shoulder injuries, and it is important to understand how the imaging details help guide orthopedic surgeons in determining the role for surgical treatment. Imaging is also crucial in preoperative planning, the longitudinal assessment after surgery and the identification of complications after treatment. This review discusses the mechanisms of injury, key imaging findings, therapeutic options and associated complications for the most common shoulder injuries, tailored to the orthopedic surgeon’s perspective.

A new biomechanical classification system for split fractures of the humeral greater tuberosity: guidelines for surgical treatment

Background

Split fractures of the humeral greater tuberosity (HGT) are common injuries. Although there are numerous surgical treatments for these fractures, no classification system combining clinical and biomechanical characteristics has been presented to guide the choice of fixation method.

Methods

We created a standardised fracture of the HGT in 24 formalin-fixed cadavers. Six were left as single-fragment fractures (Group A), six were further prepared to create single-fragment with medium size full-thickness rotator cuff tear (FT-RCT) fractures (Group B), six were cut to create multi-fragment fractures (Group C), and six were cut to create multi-fragment with FT-RCT fractures (Group D). Each specimen was fixed with a shortened proximal humeral internal locking system (PHILOS) plate. The fixed fractures were subjected to load and load-to-failure tests and the differences between groups analysed.

Results

The mean load-to-failure values were significantly different between groups (Group A, 446.83 ± 38.98 N; Group B, 384.17 ± 36.15 N; Group C, 317.17 ± 23.32 N and Group D, 266.83 ± 37.65 N, P < 0.05). The load-to-failure values for fractures with a greater tuberosity displacement of 10 mm were significantly different between each group (Group A, 194.00 ± 29.23 N; Group B, 157.00 ± 29.97 N; Group C, 109.00 ± 17.64 N and Group D, 79.67.83 ± 15.50 N; P < 0.05). These findings indicate that fractures with a displacement of 10 mm have different characteristics and should be considered separately from other HGT fractures when deciding surgical treatment.

Conclusions

Biomechanical classification of split fractures of the HGT is a reliable method of categorising these fractures in order to decide surgical treatment. Our findings and proposed system will be a useful to guide the choice of surgical technique for the treatment of fractures of the HGT.

Open Reduction and Stable Internal Fixation Using a 3.5-mm Locking Hook Plate for Isolated Fractures of the Greater Tuberosity of the Humerus: A 2-Year Follow-up Study Using an Innovative Fixation Method

Backgroud

The best treatment for isolated greater tuberosity (GT) fractures is still controversial. Although previous studies have suggested surgical options, they are either unable to provide firm fixation or present with a variety of complications.

Methods

We retrospectively studied the records of patients with isolated GT fractures who underwent open reduction and internal fixation using a 3.5-mm locking hook plate between January 2016 and January 2018. The surgical indication was an at least 5-mm displacement of the GT as observed in either simple radiography or three-dimensional computed tomography. Clinical outcomes were assessed using the following five parameters shortly before implant removal and at the final follow-up: visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Shoulder Rating Scale of the University of California, Los Angeles (UCLA), Constant-Murley score, and range of motion.

Results

Twenty-one patients with a mean age of 64 years were included. Bone union was achieved within 12–20 weeks of the first surgery in all patients. Implant removal was performed between 13 and 22 weeks after surgery. At the final follow-up, the mean VAS pain score, forward flexion, abduction, external rotation, internal rotation, ASES score, UCLA score, and Constant-Murley score were significantly better when compared to outcomes shortly before implant removal (p < 0.001, p < 0.001, p < 0.001, p = 0.008, p = 0.003, p < 0.001, p < 0.001, and p < 0.001, respectively).

Conclusions

The 3.5-mm locking hook plate provided sufficient stability and led to satisfactory clinical and radiological outcomes for isolated GT fractures. However, the hook plate may irritate the rotator cuff, and postoperative stiffness may be inevitable. Therefore, second surgery for implant removal is necessary after bone union is achieved.

Augmented cerclage wire improves the fixation strength of a two-screw construct for humerus split type greater tuberosity fracture: a biomechanical study

Background

Poor functional outcome can result from humeral greater tuberosity (GT) fracture if not treated appropriately. A two-screw construct is commonly used for the surgical treatment of such injury. However, loss of reduction is still a major concern after surgery. To improve the biomechanical strength of screw fixation in GT fractures, we made a simple modification of the two-screw construct by adding a cerclage wire to the two-screw construct. The purpose of this biomechanical study was to analyze the effect of this modification for the fixation of GT fractures.

Materials and methods

Sixteen fresh-frozen human cadaveric shoulders were used in this study. The fracture models were arbitrarily assigned to one of two fixation methods. Group A (n = 8) was fixed with two threaded cancellous screws with washers. In group B (n = 8), all screws were set using methods identical to group A, with the addition of a cerclage wire. Horizontal traction was applied via a stainless steel cable fixed directly to the myotendinous junction of the supraspinatus muscle. Displacement of the fracture fixation under a pulling force of 100 N/200 N and loading force to construct failure were measured.

Results

The mean displacements under 100 N and 200 N traction force were both significantly decreased in group B than in group A. (100 N: 1.06 ± 0.12 mm vs. 2.26 ± 0.24 mm, p < 0.001; 200 N: 2.21 ± 0.25 mm vs. 4.94 ± 0.30 mm, p < 0.001) Moreover, the failure load was significantly higher in group B compared with group A. (415 ± 52 N vs.335 ± 47 N, p = 0.01),

Conclusions

The current biomechanical cadaveric study demonstrated that the two-screw fixation construct augmented with a cerclage wire has higher mechanical performance than the conventional two-screw configuration for the fixation of humeral GT fractures.

Trial registration

Retrospectively registered.

Short-term reoperation risk after surgical and nonsurgical management of isolated greater tuberosity fractures

Background

The outcomes and complication rates of patients with isolated greater tuberosity fractures are not well documented. The present study aimed to evaluate the reoperation rates, types of reoperations, and complications for patients undergoing open reduction internal fixation and those undergoing initial nonoperative treatment of isolated greater tuberosity fractures.

Methods

An administrative claims database was queried from 2010 to 2018 for adult patients treated with open reduction internal fixation or initial nonoperative treatment within 6 weeks of sustaining a closed isolated greater tuberosity fracture. Reoperation rates, types of reoperations, local/surgical complications, and systemic complications for two cohorts were collected, and statistical analysis was performed using R statistical software for patients initially treated operatively and nonoperatively. Complication rates were compared using multivariate logistic regression, while demographic data were compared using chi-square analysis.

Results

Of the 8509 patients who were documented to have sustained a closed isolated greater tuberosity fracture, 333 patients underwent operative treatment and 8176 patients received initial nonoperative treatment within the first 6 weeks of diagnosis. The operative cohort had a reoperation rate of 2.7% at 90 days, 5.7% at 6 months, and 7.8% at 1 year, with the majority of reoperations being rotator cuff repair (40.6%). Within the initial nonoperative cohort, 7.3% had an operation within a year, with the majority of operations being open reduction internal fixation (41.3%). The subsequent reoperation rate for those patients was 3.5% at 2 years with the majority of reoperations being rotator cuff repair (32.4%). In the operative cohort, the 90-day infection rate was 3.0%. Nonunion was demonstrated in the operative cohort at a rate of 1.8% at 6 months and 2.7% at 1 year.

Conclusion

When surgical care was provided to patients sustaining isolated greater tuberosity fractures in the first 6 weeks, there was a 7.8% rate of reoperation within the first year. Patients initially treated nonoperatively had a future operation rate of 7.3% within the first year and a 3.5% reoperation rate within the second year. The most common reoperation regardless of initial treatment was rotator cuff repair. With an elevated rate of subsequent operations, education is paramount to provide patients with expectations for the sequelae of this injury especially when presenting with concomitant injuries.

Outcomes of surgical fixation of greater tuberosity fractures: A systematic review

BACKGROUND

Isolated greater tuberosity fractures account for up to a fifth of all proximal humeral fractures. There have been several retrospective cohort studies and case series reporting outcomes after treatment of this pathology. This study aims to report on the clinical outcomes of surgically treated isolated greater tuberosity fractures, as well as diagnostic workup and complications associated with fracture fixation.

METHODS

A systematic review was performed under PRISMA guidelines to identify studies that reported the results or clinical outcomes of isolated greater tuberosity fracture. The searches were performed using MEDLINE through PubMed, the Elsevier Embase database, and the Cochrane Database of Systematic Reviews.

RESULTS

Sixteen studies met inclusion criteria comprising 345 patients and 345 shoulders. The mean age was 52.9 years and mean follow-up was 3.4 months. The mean postoperative American Shoulder and Elbow Surgeon Score, the most frequently utilized patient reported outcome measure across studies, was 90.1% of ideal maximum. All studies used standard shoulder radiographs in their initial workup and most commonly referred to a minimum of 5mm displacement as an indication for surgery. Fifty five percent of patients were treated using open fixation and 35.9 with arthroscopic fixation. Ninety three percent of patients were able to return to work. A total of fifty-two (15.1%) complications were reported in the included studies.

CONCLUSIONS

The current literature describes overall satisfactory functional outcomes and minimal occupational morbidity following either open or arthroscopic fixation of isolated greater tuberosity fractures despite a notable rate of complications.

LEVEL OF EVIDENCE

IV, systematic review.

Biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion without a Hill-Sachs lesion: A case report and review of the literature

Combined injuries of the glenohumeral joint that involve biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion are extremely rare. As per our knowledge, this is the first case report that includes such combined injuries that were treated arthroscopically. We present the case of a 48-year-old male patient who sustained shoulder trauma after being thrown against the rocks by a wave, was found to have biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion.

The operative management resulted in complete restoration of the range of motion of the shoulder, and uneventful healing of the fracture. The patient recovered normal activity including his surfing.

Follow-up radiographs in isolated Greater Tuberosity fractures lead to a change in treatment recommendation; an online survey study

INTRODUCTION

It is common practice to obtain follow-up radiographs of non-operatively treated isolated greater tuberosity (GT) fractures 1 to 2 weeks after trauma. However, the majority of non-operatively treated GT fractures remain stable and do not require reconsideration of the initial treatment decision. Radiological follow-up therefore might be unnecessary. Our primary objective was to study whether radiological folow-up changes the initial treatment recommendation, hypothesizing no change.

MATERIALS AND METHODS

Radiographs of 25 patients diagnosed with an isolated GT fracture were selected from our hospital database and presented on a web-based platform. Sixty-eight trauma- and orthopedic surgeons evaluated these radiographs. First the radiographs directly post-trauma and then, in random order, the radiographs 5-14 days post-trauma alongside the first radiographs. Each observer evaluated each set of radiographs once. The observers answered which treatment they would recommend (non-operative/operative), and how certain they were about their advice (absolutely certain, certain, some doubt, very uncertain). Recommendation-consistency and inter-observer agreement are presented as percentages and intra class correlation coefficients (ICC).

RESULTS

Overall, 84% (95% CI 82.1-85.8) of treatment recommendations was unchanged after evaluation of the second radiograph. Agreement within each observer ranged from 60 to 98%. The mean proportion of patients about whom the observers were (absolutely) certain of their recommendation increased from 70% at the first evaluation to 83% at the second evaluation (12.8; 95% CI 9.8-15.9). Furthermore, the ICC between the surgeons improved from 0.37 (95% CI 0.26-0.54) for the first evaluation to 0.60 (95% CI 0.47-0.74) for the second.

CONCLUSION

In 16% of the patients the treatment recommendation for an isolated GT fracture changed after the evaluation of radiographs 1 to 2 weeks post-trauma. In addition, surgeons were more certain about their recommendation and there was less inter-observer variation. Radiological follow-up of a non-operatively treated isolated GT fracture therefore seems justifiable.

LEVEL OF EVIDENCE

III, diagnostic study.

Utility of MRI in the Evaluation of Acute Greater Tuberosity Proximal Humeral Fractures

Background:

Understanding soft tissue injury patterns associated with greater tuberosity (GT) fractures may help clinicians provide guidance to patients.

Hypothesis:

Evaluating magnetic resonance imaging (MRI) findings in patients with suspected isolated GT fractures will help elucidate the role of MRI in the diagnosis and treatment of these patients.

Study Design:

Case series; Level of evidence, 4.

Methods:

We performed a retrospective review of medical records from 2010 to 2014 for patients presenting with acute isolated GT fractures and MRI. Uncomplicated and delayed recovery groups were established according to the need for delayed procedural intervention or persistent symptoms past last recorded follow-up. Multivariate regression analysis was used to analyze the relationships between MRI findings and delayed recovery.

Results:

A total of 32 patients met the inclusion criteria (mean age, 47 years [range, 24-88 years]; mean follow-up, 30 weeks [range, 33 days–4 years]). There was no significant difference in the estimation of fracture displacement as measured on radiography and compared with MRI (radiography, 2.8 mm; MRI, 3.5 mm; P = .16). There was a high incidence of full-thickness rotator cuff tears (9%), partial-thickness rotator cuff tears (72%), partial biceps tendon tears (41%), and labral tears (50%). Presence of biceps pathology or partial-thickness rotator cuff tear was predictive of delayed recovery in a multivariate model.

Conclusion:

There is a high incidence of soft tissue injury found by MRI following GT fracture. MRI did not appreciably change the measure of displacement of the fracture fragment. In the multivariate analysis, presence of a partial-thickness rotator cuff tear or biceps tendon injury was associated with delayed recovery.

Risk factors for secondary displacement in conservatively treated isolated greater tuberosity fractures: An analysis of 82 cases

INTRODUCTION

The optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed.

HYPOTHESIS

Certain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures.

PATIENTS AND METHODS

All patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity.

RESULTS

82 patients (42 male, 40 female) were eligible for further analyses. Median follow-up was 8.0±39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7±15.5, group 2: 68.3±14.3; p<0.001) and had significantly more shoulder dislocations (p=0.024), whereas gender (p=0.299), side of fracture (p=0.189) and fragment/head ratio (p=0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement.

DISCUSSION

The present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement.

LEVEL OF PROOF

III, Retrospective comparative study.

Displaced isolated greater tuberosity fractures of elder adults treated with plate osteosynthesis

BACKGROUND

We elucidated the effect of open reduction and internal fixation with locking plate for acute isolated displaced greater tuberosity fractures of humerus in elder adults (aged >60 years).

METHODS

From 2009 to 2015, data from 32 patients, aged between 60 and 88 years, who had acute unilaterally displaced greater tuberosity fractures of humerus were collected and evaluated retrospectively. All the fractures were managed with open reduction and internal fixation with locking plate. The follow-up period was 50.8 months on an average (range 22-80 months). Finally, 25 patients were available for final evaluation of radiographic and functional results.

RESULTS

All the 32 fractures had union with the average union time of 14 weeks (range 10-18 weeks) and with no complications. The average of preoperative Visual Analogue Scale (VAS) was 6.2 (range 4-8), ASES was 30.4 (range 13-45), and Constant score was 30.4 (range 20-45). At the last follow-up, the mean VAS was 1.3 (range 0-2.5), the mean ASES score was 90.1 (range 72-100), and the mean Constant score was 90.3 (range 80-100). There were statistically significant differences between preoperative and final follow-up in VAS, ASES, and Constant score. Hundred percent of patients had good or excellent results by Constant score, with excellent results (86-100) in 17 (68%) patients and good result (71-85) in 8 (32%).

CONCLUSION

In conclusion, open reduction and internal fixation with locking plate is an effective treatment for acute displaced greater tuberosity fractures of humerus in elder adults.

Application of pre-contoured anatomic locking plate for treatment of humerus split type greater tuberosity fractures: A prospective review of 68 cases with an average follow-up of 2.5 years

OBJECTIVES

Although various implants exist for 3- and 4-part proximal humerus fractures, few implants are appropriate for humerus split type greater tuberosity fractures. The goal of this study was to assess the efficacy of pre-contoured anatomic locking plate for humerus split type greater tuberosity fractures.

METHODS

A retrospective review of 68 patients with humerus split type greater tuberosity fractures treated with open reduction and internal fixation using anatomic locking plates between January 2014 and October 2016. Postoperatively, patient radiographs, functional results, and complications were reviewed.

RESULTS

All patients got a mean follow-up of 30.5 months (range 14-46 months). Average fracture healing time was 9.4 weeks (range, 8-14 weeks). Overall mean Constant score was 86.8% (range, 70%-96%). The result was rated as excellent in 25 patients (Constant score: 92.1%), good in 38 patients (Constant score: 85.3%) moderate in 5 patients (Constant score: 71.8%) and poor in 0 cases. The excellent-good rate was 92.6%. No recurrence of dislocation occurred in the 30 cases with shoulder dislocation. All fractures healed without the complications of wound infection, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening.

CONCLUSION

Pre-contoured anatomic locking plate is a reliable option in treating humerus split type greater tuberosity fractures as it provides stable fixation with an early return to function. The surgical technique is easy and efficient.

Isolated fractures of the greater tuberosity: When are they treated conservatively?: A baseline study

Background

This study analyzed the indications for conservative management of isolated greater tuberosity (GT) fractures. The rate of secondary interventions for failed conservative treatment was also assessed.

Methods

A retrospective data evaluation of isolated GT fractures was performed from the clinical database of two level-I trauma centers from January 2010 to June 2017. Conservatively treated GT fractures were identified and subdivided according to etiology, morphology, and amount of initial displacement. Secondary surgical interventions were recorded and subcategorized into fracture-associated interventions and interventions for associated soft tissue lesions.

Results

We identified 114 fractures. Nine cases were excluded because patients refused surgery or their comorbidities ruled it out. Only two of the remaining 105 patients had an initial displacement >3 mm. All other GT fractures (n = 103, 98%) were not displaced or only slightly displaced (0–3 mm). The fracture was associated with an anterior shoulder dislocation in 39 cases (37%); 17 patients (16.2%) underwent surgery after primary conservative treatment. Four of these 17 patients presented with a secondary displacement of the GT fragment. In all other cases (76.5%), an associated soft tissue lesion necessitated revision surgery. Young age, anterior shoulder dislocation, and concomitant injuries were risk factors for revision surgery after primary conservative treatment.

Conclusion

Secondary interventions are required more frequently after shoulder dislocation. Surgery is most likely required for associated soft tissue lesions rather than for secondary displacements. Thus, detailed physical examination and magnetic resonance imaging should be used to screen for concomitant soft tissue injuries accompanying GT fractures to prevent revision surgeries.

Isolated greater tuberosity fractures of the proximal humerus: anatomy, injury patterns, multimodality imaging, and approach to management

The greater tuberosity is an important anatomic structure and its integrity is important for shoulder abduction and external rotation. Isolated fractures of the greater tuberosity are often subtle and may not be detected on initial radiographs. Clinically, these patients display symptoms which mimic a full thickness rotator cuff tear. It is important to differentiate these two entities, as their treatment is different (typically nonsurgical management for minimally displaced fractures versus rotator cuff repair for acute full thickness rotator cuff tears). When greater tuberosity fractures are significantly displaced and allowed to heal without anatomic reduction, they can lead to impingement. This article will review greater tuberosity anatomy and function, as well as the clinical presentation and multimodality imaging findings of greater tuberosity fractures. Imaging optimization, pitfalls, and clinical management of these fractures will also be discussed.

Arthroscopic Treatment of Osseous Instability of the Shoulder

BACKGROUND

Bony deficiency of the anteroinferior glenoid rim as a result of a dislocation can lead to recurrent glenohumeral instability. These lesions, traditionally treated by open techniques, are increasingly being treated arthroscopically as our understanding of the pathophysiology and anatomy of the glenohumeral joint becomes clearer. Different techniques for arthroscopic management have been described and continue to evolve. While the success of the repair is surgeon dependent, the recent advances in arthroscopic shoulder surgery have contributed to the growing acceptance of arthroscopic reconstruction of glenoid bone defects to restore stability.

QUESTIONS/PURPOSES

The purpose of this study was to describe arthroscopic surgical management options for patients with glenohumeral osseous lesions and instability.

METHODS

A comprehensive search of PubMed, Cochrane, and Medline was conducted to identify eligible studies. The reference lists of identified articles were then screened. Both technique articles and long-term outcome studies evaluating arthroscopic management of glenohumeral lesions were included.

RESULTS

Studies included for final analysis ranged from Level II to V evidence. Technique articles include suture anchor fixation of associated glenoid rim fractures, arthroscopic reduction and percutaneous fixation of greater tuberosity fractures, arthroscopic filling ("remplissage") of the humeral Hill-Sachs lesion, and an all-arthroscopic Latarjet procedure. The overall redislocation rate varied but was consistently <10% with a low complication rate.

CONCLUSION

Management of glenohumeral instability can be challenging but more recent advances in arthroscopic techniques have provided improved means of treating this diagnosis. This manuscript provides a comprehensive review of the arthroscopic treatment of osseous instability of the shoulder. It provides an in depth look at the various treatment options and describes techniques for each.

Dislocation of the Shoulder Joint - Radiographic Analysis of Osseous Abnormalities

Radiography remains pivotal to the workup of instability lesions of the shoulder, both in the acute as well as the chronic settings. The goal of radiography is to detect osseous abnormalities and locate them in order to determine the direction of instability. In antero-inferior instability, Hill-Sachs lesions are often visible at radiography and should not be confused with various differential diagnoses, which are usually more laterally located. Bankart lesions are more difficult to detect on conventional radiography, but there are less false positives than for Hill-Sachs lesions. The Garth view represents an excellent radiographic view to detect antero-inferior instability impaction fractures at both the humeral and glenoid sides. Accurate quantification of bony abnormalities and detection of lesions to the soft-tissue stabilizers of the shoulder however require advanced cross-sectional imaging techniques.

Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy

BACKGROUND

This is a retrospective prognostic study on soft tissue injury following isolated greater tuberosity (GT) fractures of the proximal humerus with respect to the relationship between rotator cuff tears and GT displacement.

METHODS

Forty-three patients with isolated GT fractures were recruited and evaluated with a standardized interview and physical examination, quality of life and shoulder function questionnaires (Western Ontario Rotator Cuff Index, SF-12 Version 2, Constant, Quick-Disabilities of the Arm, Shoulder and Hand, Visual Analogue Scale), standard shoulder radiographs and an ultrasound. The main outcome measurements were: incidence of rotator cuff tears and atrophy, biceps pathology and sub-acromial impingement; superior displacement of the GT fragment; and questionnaire scores.

RESULTS

Mean age was 57 years (31 years to 90 years) with a follow-up of 2.4 years (0.8 years to 6.8 years). In total, 16% had a full rotator cuff tear and 57% showed subacromial impingement on ultrasound. Full rotator cuff tears and supraspinatus fatty atrophy significantly correlated with decreased function and abduction strength. Significant atrophy (>50%) of the supraspinatus and infraspinatus, without a rotator cuff tear, was correlated with the worst function in the presence of a residual displacement of the greater tuberosity at the last-follow-up (7 mm).

CONCLUSIONS

Residual displacement, full rotator cuff tear and muscle atrophy are associated with the worst outcomes. Soft tissue imaging could benefit patients with an unfavourable outcome after a GT fracture to treat soft tissue injury.

BBilateral Neglected Anterior Shoulder Dislocation with Greater Tuberosity Fractures

INTRODUCTION

Shoulder dislocations are a very common entity in routine orthopaedic practice. Chronic unreduced anterior dislocations of the shoulder are not very common. Neurological and vascular complications may occur as a result of an acute anterior dislocation of the shoulder or after a while in chronic unreduced shoulder dislocation. Open reduction is indicated for most chronic shoulder dislocations. We report a case of neglected bilateral anterior shoulder dislocation with bilateral displaced greater tuberosity fracture. To the best of our knowledge, only a handful cases have been reported in literature with bilateral anterior shoulder dislocation with bilateral fractures. Delayed diagnosis/reporting is a scenario which makes the list even slimmer and management all the more challenging.

CASE REPORT

We report a case of a 35-year-old male who had bilateral anterior shoulder dislocation and bilateral greater tuberosity fracture post seizure and failed to report it for a period of 30 days. One side was managed conservatively with closed reduction and immobilization and the other side with open reduction. No neurovascular complications pre or post reduction of shoulder were seen.

CONCLUSION

Shoulder dislocations should always be suspected post seizures and if found should be treated promptly. Treatment becomes difficult for any shoulder dislocation that goes untreated for considerable period of time.

Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be successfully treated nonsurgically in most patients. However, as little as 3 to 5 mm of superior greater tuberosity displacement may adversely affect rotator cuff biomechanics and lead to subacromial impingement in patients who are active. In these cases, surgical treatment is recommended. Multiple surgical techniques include open and arthroscopic options tailored to fracture morphology, and strategies for repair include the use of suture anchors, transosseous sutures, tension bands, and plates/screws. Three classification systems are commonly used to describe greater tuberosity fractures: the AO, Neer, and morphologic classifications. Several hypotheses have been discussed for the mechanism of greater tuberosity fractures and the deforming forces of the rotator cuff, and the use of advanced imaging is being explored.

Delayed Migration of Greater Tuberosity Fractures Associated With Anterior Shoulder Dislocation

OBJECTIVES

Treatment of greater tuberosity (GT) fractures occurring during anterior shoulder dislocation generally consists of initial closed reduction of the shoulder. Undisplaced fractures are treated conservatively, whereas displaced fractures generally undergo surgical management. Our hypothesis is that many well-reduced GT fractures will migrate. The primary goal of this study is to evaluate the outcomes of GT fractures associated with shoulder dislocation to optimize their management.

DESIGN

Retrospective review with prospective outcomes.

SETTING

Tertiary Level 1 trauma center.

PATIENTS

A total of 55 patients with anterior shoulder dislocation and GT fractures were identified. A matched cohort of isolated GT fractures was also identified.

INTERVENTION

Closed reduction versus open reduction with or without fixation.

OUTCOME MEASUREMENTS

Radiographs were evaluated for initial displacement, reduction, Hill-Sachs lesion, and subsequent displacement. Patients were evaluated using the Constant and quick DASH scores at a minimum of 1 year of follow-up.

RESULTS

A majority of patients received initial closed reduction, with acceptable reduction of the tuberosity in 85%. With closed reduction, migration of the GT was seen in 9 cases (16%). In younger patients (<70 years), the failure rate increased to 26%. Displacement of the GT was 5.6 times more likely with dislocation than without. Patients with migration were only operated on in 33% of cases, mostly because of late presentation.

CONCLUSIONS

Treatment of GT fractures occurring with anterior shoulder dislocation is complex. Although outcomes with nonoperative treatment are generally acceptable, a significant proportion of these patients will have tuberosity migration, which may impact function.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Easily Missed Fractures of the Upper Extremity

Radiographs remain the mainstay for initial imaging of suspected fracture in the emergency setting. Missed fractures potentially have significant negative consequences for patients, referring physicians, and radiologists. Most missed fractures are owing to perceptual errors. In this review, we emphasize knowledge of 3 categories of pitfalls as they pertain to the upper extremity: the common but challenging; the out of mind, out of sight; and those related to satisfaction of search. For specific injuries, emphasis is placed on helpful radiographic signs and important additional radiographic views to obtain.

Effect of shoulder abduction on the fixation of humeral greater tuberosity fractures: a biomechanical study for three types of fixation constructs

BACKGROUND

An abduction brace and abduction exercises are commonly employed after humeral greater tuberosity fracture repair. However, the effects of glenohumeral abduction on the biomechanical strength have seldom been elucidated.

METHOD

We studied 24 pairs of female fresh frozen porcine shoulders randomly divided into 3 groups. After creation of a greater tuberosity fracture on each shoulder, 3 fixation techniques were used for the 3 groups: double-row suture anchor fixation (DR), suture bridge technique (SB), and 2-screw fixation (TS). This biomechanical study was conducted to compare the forces that create 3- and 5-mm displacements and the ultimate failure load at the simulated shoulder abduction angles of 0° and 45° among the 3 groups.

RESULTS

In the DR group, the mean forces to create 3- and 5-mm displacements and the failure load at 0° were higher than those at 45° (P = .036, P = .012, P = .027). By contrast, in the SB group, the mean forces to create 3- and 5-mm displacements at 45° were greater than those at 0° (P = .012, P = .012). There were no significant differences in the forces to create 3- and 5-mm displacements and construct failure between 0° and 45° in the TS group (P = .575, .327, .478).

CONCLUSION

The DR group had greatest initial fixation strength at a low abduction angle, whereas the SB group had the highest initial fixation strength at a high abduction angle. The TS group appeared unaffected by the abduction angle.

Management of recent first-time anterior shoulder dislocations

The management of a first episode of anterior shoulder dislocation starts with an analysis of the causative mechanism and a physical examination to establish the diagnosis. Based on the findings, the case can be classified as simple or accompanied with complications, most notably vascular or nerve injuries. Two radiographs perpendicular to each other should be obtained to confirm the diagnosis then repeated after the reduction manoeuvres. Additional imaging studies may be needed to assess concomitant bony lesions (impaction lesions or fractures). External reduction should always be attempted after premedication appropriate for the severity of the pain. General anaesthesia may be necessary. There is no consensus regarding the optimal reduction technique, although the need for gentle manoeuvres that do not cause pain is universally recognised. Immobilisation currently involves keeping the elbow by the side with the arm internally rotated for 3-6weeks depending on patient age. Vessel and nerve injuries are rare but can cause major functional impairments. Follow-up evaluations are in order to check the recovery of normal function, which may be more difficult to achieve in patients with concomitant lesions; and to detect recurrent shoulder instability and rotator cuff lesions. At the acute phase, surgery is indicated only in patients with complications or after failure of the reduction manoeuvres. Shoulder immobilisation with the arm externally rotated and surgical treatment of the first episode are controversial strategies that are discussed herein.

Misses and errors in upper extremity trauma radiographs

OBJECTIVE

The article reviews a select group of traumatic upper extremity injuries that can be easily misinterpreted on radiographs.

CONCLUSION

The awareness of these specific injuries and an understanding of their underlying pathophysiology and the role that radiographs can play in their evaluation will give the reader the best opportunity to make the important imaging findings and guide appropriate treatment.

Accurate Measurement of Greater Tuberosity Displacement Without Computed Tomography: Validation of a Method on Plain Radiography to Guide Surgical Treatment

INTRODUCTION

Residual displacement of greater tuberosity (GT) fractures has been shown to negatively affect shoulder function. However, accurate measurement of GT displacement remains a problem with errors up to 13 mm on plain radiography (XR). A new GT ratio for measuring fracture displacement on XR is described, validated, and correlated with computed tomography (CT) and surgical decision making.

METHODS

A retrospective review of shoulder radiographs was performed from 2007 to 2010 to identify all cases of isolated GT fractures with both XR and CT. The GT ratio was performed on all XR and correlated with superior GT displacement measured on CT. The GT ratio was then tested for accuracy of surgical decision using 5-mm superior displacement on CT as the cutoff. Finally, the inter- and intraobserver reliabilities of the GT ratio were calculated and compared with the Neer and Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classifications.

RESULTS

Forty cases of acute GT fractures with XR and CT were identified. The GT ratio correlated very well with superior displacement on CT (Pearson correlation = 0.852, P < 0.01) and accurately classified GT fractures as "surgical" (n = 9, 23%) or "nonsurgical" (n = 31, 77%). GT ratios ≤0.00 were nonsurgical, ≥0.50 were surgical, and 0.00-0.50 warranted further imaging (P < 0.01). The GT ratio performed as well as or better than the AO and Neer classifications for inter- and intraobserver reliabilities.

CONCLUSIONS

The GT ratio described in this study correlates very well with CT for superior GT fracture displacement. It involves significantly less radiation and accurately classifies GT fractures as nonsurgical (ratio < 0.00), surgical (ratio > 0.50), or as benefiting from further imaging (0.00-0.50). It performs as well or better than the Neer or AO classification.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A new morphological classification for greater tuberosity fractures of the proximal humerus: validation and clinical implications

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique.

Minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment

BACKGROUND

Minimally displaced (<3 mm) and non-displaced fractures of the proximal humerus are a common source of disability; nevertheless, there is no agreement on the recommended rehabilitation program in these patients. The purpose of this study was to evaluate the outcome of this group of patients and describe the rehabilitation protocol we have used for the treatment of this injury.

METHODS

We retrospectively analyzed the records of patients diagnosed with minimally displaced (<3 mm) fractures of the greater tuberosity who were admitted to our institute between June 2007 and May 2008. Patients were treated with a three-phase protocol. In the first phase, patients were immobilized in a sling for 3 weeks. In the second phase, pendular and active assisted exercises were begun 3 to 6 weeks after the injury. In the third phase, active exercises were commenced starting 6 weeks after injury.

RESULTS

Sixty-nine patients matched our inclusion and exclusion criteria. At an average follow-up of 31 months (range, 26-41 months), the average Constant score improved from 40 points (range, 33-58 points) to 95 points (range, 75-100 points). Average satisfaction score improved from 4.2 of 10 (range, 2-6) to 9.5 of 10 (range, 7-10). The reported average duration of pain and decreased range of motion from the time of injury was 8.1 months (range, 1-24 months).

CONCLUSIONS

When the diagnosis of a minimally displaced fracture of the proximal humerus is made, the patient can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol. Nevertheless, clinicians and patients should be aware that full recovery from the injury may take an average of 8 months.

Suture anchor versus screw fixation for greater tuberosity fractures of the humerus--a biomechanical study

Suture anchors and screws are commonly used for fixation of humeral greater tuberosity (GT) fractures in either arthroscopic or open surgeries, but no biomechanical studies have been performed to compare the strength of fixation constructs using these two implants. This cadaveric study aimed to compare the biomechanical strength of three different fixation constructs in the management of GT fractures: Double-Row Suture Anchor Fixation (DR); Suture-Bridge Technique using suture anchors and knotless suture anchors (SB); and Two-Screw Fixation (TS). The experimental procedure was designed to assess fracture displacement after cyclic loading, failure load, and failure mode of the fixation construct. Significant differences were found among the SB (321 N), DR (263 N), and TS (187 N) groups (SB > DR > TS, p < 0.05) in the mean force of cyclic loading to create 3 mm displacement. Regarding the mean force of cyclic loading to create 5 mm displacement and ultimate failure load, no significant difference was found between the DR (370 N, 480 N) and SB (399 N, 493 N) groups, but both groups achieved superior results compared with the TS group (249 N, 340 N) (p < 0.05). The results suggested that the suture anchor constructs would be stronger than the fixation construct using screws for the humeral GT fracture.

Isolated fractures of the greater tuberosity of the proximal humerus: a long-term retrospective study of 30 patients

BACKGROUND AND PURPOSE

The diagnosis and treatment of isolated greater tuberosity fractures of the proximal humerus is not clear-cut. We retrospectively assessed the clinical and radiographic outcome of isolated greater tuberosity fractures.

PATIENTS AND METHODS

30 patients (mean age 58 (26-85) years, 19 women) with 30 closed isolated greater tuberosity fractures were reassessed after an average follow-up time of 3 years with DASH score and Constant score. Radiographic outcome was assessed on standard plain radiographs.

RESULTS

14 of 17 patients with undisplaced or slightly displaced fractures (≤ 5 mm) were treated nonoperatively and had good clinical outcome (mean DASH score of 13, mean Constant score of 71). 8 patients with moderately displaced fractures (6-10 mm) were either treated nonoperatively (n = 4) or operatively (n = 4), with good functional results (mean DASH score of 10, mean Constant score of 72). 5 patients with major displaced fractures (> 10 mm) were all operated with good clinical results (mean DASH score of 14, mean Constant score of 69). The most common discomfort at the follow-up was an impingement syndrome of the shoulder, which occurred in both nonoperatively treated patients (n = 3) and operatively treated patients (n = 4). Only 1 nonoperatively treated patient developed a non-union. By radiography, all other fractures healed.

INTERPRETATION

We found that minor to moderately displaced greater tuberosity fractures may be treated successfully without surgery.

Shoulder stiffness

Shoulder stiffness is commonly encountered in clinical practice but varies greatly in severity and etiology. Loss of shoulder range of motion can be a patient's primary complaint or may be a secondary finding. Possible causes of stiffness include guarding due to pain or secondary gain issues (nonanatomic), true mechanical blockage due to acute or chronic trauma, adhesive capsulitis, rotator cuff disease, or surgery on or near the shoulder. This review includes a more detailed discussion of these causes as well as the appropriate history and physical and diagnostic testing recommended for each. Finally, treatment strategies for each group of patients will be presented.