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Fracture of greater tuberosity of humerus — Clinical Guidelines

Overview

Fractures of the greater tuberosity of the humerus, often part of more complex proximal humerus fractures, significantly impact shoulder function and quality of life, particularly in elderly patients. These injuries frequently result from falls and can lead to substantial disability due to pain, limited mobility, and impaired daily activities. The management of these fractures is crucial as they are projected to increase by 32% by 2030, necessitating effective treatment strategies to restore function and reduce complications. Understanding optimal treatment approaches, including the choice between cemented and uncemented reverse shoulder arthroplasty (RSA), is vital for clinicians to improve patient outcomes in day-to-day practice 1.

Pathophysiology

The pathophysiology of greater tuberosity fractures typically involves high-energy trauma leading to disruption of the bony architecture and soft tissue attachments, particularly the rotator cuff tendons. In more complex scenarios, such as multi-part fractures, additional disruption of the anatomical structures around the shoulder joint can occur, including the humeral head, lesser tuberosities, and glenoid fossa. These disruptions can lead to mechanical instability, impaired healing, and subsequent functional deficits. The greater tuberosity, crucial for the attachment of the supraspinatus and infraspinatus tendons, plays a pivotal role in shoulder stability and motion. When fractured, it can result in compromised rotator cuff function, leading to pain, weakness, and reduced range of motion 1 2 3.

Epidemiology

Proximal humerus fractures, including those involving the greater tuberosity, predominantly affect older adults, with incidence rates significantly increasing in individuals over 65 years of age. These fractures account for approximately 5% of all fractures and are the third most common fracture type in this demographic. Geographic variations exist, with higher incidences reported in regions with aging populations and potentially higher rates of osteoporosis. Epidemiologic trends indicate a growing prevalence, with a notable shift towards surgical interventions, particularly RSA, over traditional hemiarthroplasty 1 3 4.

Clinical Presentation

Patients with greater tuberosity fractures typically present with acute shoulder pain, swelling, and limited range of motion. Common symptoms include difficulty in abduction and external rotation, reflecting the involvement of the rotator cuff attachments. Red-flag features include significant deformity, neurovascular compromise, and inability to reduce a dislocation, which necessitate urgent evaluation and intervention. Atypical presentations may involve subtle symptoms in elderly patients who might underreport pain or functional limitations 1 3.

Diagnosis

The diagnostic approach for greater tuberosity fractures involves a combination of clinical assessment and imaging studies. Specific Criteria and Tests:

Clinical Examination: Assess for tenderness over the greater tuberosity, pain with specific movements (e.g., abduction, external rotation), and signs of rotator cuff dysfunction.

Imaging:

- X-rays: Initial imaging to identify fracture lines, displacement, and involvement of other parts of the proximal humerus. - CT/MRI: For detailed assessment of fracture patterns, soft tissue injuries, and to guide surgical planning in complex fractures.

Differential Diagnosis:

- Rotator Cuff Tears: Distinguished by MRI findings showing full-thickness tendon tears rather than bony disruptions. - Shoulder Dislocation: Identified by abnormal positioning of the humeral head on X-rays and absence of fracture lines. - Osteoarthritis: Characterized by joint space narrowing and osteophyte formation on X-rays, without acute fracture signs 1 3 4.

Management

Non-Surgical Management

Initial Immobilization: Use of a sling for pain relief and to reduce movement.

Physical Therapy: Gradual mobilization and strengthening exercises once pain subsides, focusing on rotator cuff and shoulder girdle muscles.

Pain Management: Analgesics (e.g., NSAIDs) to manage pain and inflammation.

Surgical Management

#### Reverse Shoulder Arthroplasty (RSA)

Indications: Complex fractures, significant bone loss, poor bone quality, and functional demands requiring restoration of shoulder function.

- Cemented vs. Uncemented Fixation: - Cemented RSA: Stronger initial fixation, particularly beneficial in the first 2 years 1. - Uncemented RSA: Reduced operative time, lower complication rates (infection, neurological injury, thromboembolism), and potential for better bone preservation 1 6 7. - Stem Design: Consider shorter stems to minimize stress shielding and preserve bone stock 2. - Tuberosity Fixation: Use of modular systems with bone grafts to enhance healing and functional outcomes 11.

#### Hemiarthroplasty

Indications: Less complex fractures where anatomic healing of tuberosities is feasible.

- Prosthetic Choice: Anatomic hemiarthroplasty to maintain native rotator cuff function if tuberosities are intact and amenable to healing 3.

Postoperative Care

Rehabilitation: Early mobilization and progressive strengthening exercises tailored to the surgical approach and fracture complexity.

Monitoring: Regular follow-up to assess functional recovery, pain levels, and signs of complications such as infection or loosening of the prosthesis.

Complications

Acute Complications:

- Infection: Higher risk with surgical interventions, particularly in cemented RSA 4. - Neurovascular Injury: Risk during surgical exposure and fixation. - Thromboembolic Events: Increased risk postoperatively, especially in immobile elderly patients.

Long-Term Complications:

- Stress Shielding and Bone Loss: More common with longer stems in uncemented RSA 2. - Tuberosity Nonunion: Can impair functional outcomes, particularly in anatomic reconstructions 6. - Prosthetic Loosening: Higher incidence in cemented stems over time 1.

Prognosis & Follow-up

Expected Course: Favorable outcomes with appropriate surgical intervention, particularly RSA, leading to significant pain relief and functional improvement.

Prognostic Indicators: Patient age, fracture complexity, bone quality, and adherence to postoperative rehabilitation.

Follow-up Intervals: Initial follow-up at 6-8 weeks, then every 3-6 months for the first year, tapering to annually thereafter. Monitoring includes clinical assessment, imaging (X-rays, MRI), and functional outcome scores (e.g., Constant-Murley Score).

Special Populations

Elderly Patients

Considerations: Increased risk of complications, slower recovery, and need for tailored rehabilitation plans.

Management: Emphasis on minimizing surgical trauma, using uncemented fixation to reduce complications, and close monitoring of postoperative recovery.

Osteopenic Bone

Approach: Prefer RSA over hemiarthroplasty to avoid reliance on tuberosity healing, which may be compromised in osteopenic bone 14.

Key Recommendations

Consider RSA for Complex Fractures: In elderly patients with complex proximal humerus fractures, RSA is recommended to restore function and reduce reliance on anatomic healing (Evidence: Strong 1 3 14).

Evaluate Bone Quality: Assess bone quality preoperatively to guide the choice between cemented and uncemented fixation (Evidence: Moderate 1 6).

Use Shorter Stems in Uncemented RSA: To minimize stress shielding and preserve bone stock (Evidence: Moderate 2).

Tuberosity Fixation Techniques: Employ modular systems with bone grafts to enhance healing and functional outcomes in RSA (Evidence: Moderate 11).

Early Mobilization and Rehabilitation: Initiate early postoperative mobilization and tailored rehabilitation programs to optimize recovery (Evidence: Moderate 3 14).

Regular Follow-Up: Schedule frequent follow-up visits to monitor for complications and functional progress (Evidence: Moderate 1 3).

Monitor for Infection and Loosening: Closely monitor for signs of infection and prosthetic loosening, especially in cemented RSA (Evidence: Moderate 4 1).

Tailor Management to Patient Age and Comorbidities: Adjust surgical and rehabilitation strategies based on patient-specific factors (Evidence: Expert opinion 1 3).

Consider Hemiarthroplasty for Less Complex Fractures: For simpler fractures where anatomic healing is feasible, hemiarthroplasty can be a viable option (Evidence: Moderate 3).

Evaluate Functional Outcomes: Use validated outcome measures to assess and guide treatment efficacy (Evidence: Moderate 9 10).

References

1 Orhan Ö, Kaya İ, Bingöl İ, Sarikaya B, Ayvali MO, Ata N et al.. Cemented Versus Uncemented Reverse Shoulder Arthroplasty Treatment of Proximal Humerus Fractures: National Shoulder Arthroplasty Data from Türkiye. Clinics in orthopedic surgery 2024. link 2 Kramer M, Olach M, Zdravkovic V, Manser M, Raiss P, Jost B et al.. The effects of length and width of the stem on proximal humerus stress shielding in uncemented primary reverse total shoulder arthroplasty. Archives of orthopaedic and trauma surgery 2024. link 3 Khazzam M, Ahn J, Sager B, Gates S, Sorich M, Boes N. 30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews 2023. link 4 Köppe J, Stolberg-Stolberg J, Rischen R, Faldum A, Raschke MJ, Katthagen JC. In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures. Clinical orthopaedics and related research 2021. link 5 O'Rourke D, Fan X, Gupta A, Cutbush K, Martelli S. An explorative time-elapsed μCT-based cadaveric study on humeral stem stability in reverse shoulder arthroplasty. Journal of the mechanical behavior of biomedical materials 2026. link 6 Lazaro JS, Nanavati R, Pignataro J, Austin LS, DeBernardis D. Age influences lesser tuberosity osteotomy nonunion following anatomic total shoulder arthroplasty. Journal of shoulder and elbow surgery 2026. link 7 Lacroix C, Spangenberg GW, Faber KJ, Langohr GDG. Does improved resection plane coverage during shoulder arthroplasty influence proximal humeral bone stress? A comparison of circular vs. elliptical humeral heads. Journal of shoulder and elbow surgery 2025. link 8 Catma MF, Adıgüzel İF, Yildiz SY. Radiographic Changes and Clinical Outcomes Associated with Two Different Press-Fit Humeral Stems in Primary Reverse Shoulder Arthroplasty. Nigerian journal of clinical practice 2024. link 9 Nieboer MJ, Hao KA, Tams C, King JJ, Wright TW, Simovitch RW et al.. Quantifying success after reverse total shoulder arthroplasty: the minimal clinically important percentage of maximal possible improvement. Journal of shoulder and elbow surgery 2023. link 10 Schoch BS, King JJ, Fan W, Flurin PH, Wright TW, Zuckerman JD et al.. Characteristics of anatomic and reverse total shoulder arthroplasty patients who achieve ceiling scores with 3 common patient-reported outcome measures. Journal of shoulder and elbow surgery 2022. link 11 Fortané T, Beaudouin E, Lateur G, Giraudo P, Kerschbaumer G, Boudhissa M et al.. Tuberosity healing in reverse shoulder arthroplasty in traumatology: Use of an offset modular system with bone graft. Orthopaedics & traumatology, surgery & research : OTSR 2020. link 12 Frank RM, Cotter EJ, Strauss EJ, Jazrawi LM, Romeo AA. Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity. The Journal of the American Academy of Orthopaedic Surgeons 2018. link 13 Solomon JA, Joseph SM, Shishani Y, Victoroff BN, Wilber JH, Gobezie R et al.. Cost Analysis of Hemiarthroplasty Versus Reverse Shoulder Arthroplasty for Fractures. Orthopedics 2016. link 14 Lopiz Y, García-Coiradas J, Serrano-Mateo L, García-Fernández C, Marco F. Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: results, health-related quality of life and complication rates. International orthopaedics 2016. link 15 Lädermann A, Denard PJ, Boileau P, Farron A, Deransart P, Terrier A et al.. Effect of humeral stem design on humeral position and range of motion in reverse shoulder arthroplasty. International orthopaedics 2015. link 16 Schmidt CC, Jarrett CD, Brown BT, DeGravelle M, Sawardeker P, Weir DM et al.. Effect of lesser tuberosity osteotomy size and repair construct during total shoulder arthroplasty. Journal of shoulder and elbow surgery 2014. link 17 Gideroğlu K, Toksoy S, Akan M, Yildirim S, Sümbüloğlu E, Aköz T. In-vitro comparison of the lengthening and biomechanical properties of three tendon lengthening techniques. Eklem hastaliklari ve cerrahisi = Joint diseases & related surgery 2009. link 18 Huffman GR, Itamura JM, McGarry MH, Duong L, Gililland J, Tibone JE et al.. Neer Award 2006: Biomechanical assessment of inferior tuberosity placement during hemiarthroplasty for four-part proximal humeral fractures. Journal of shoulder and elbow surgery 2008. link 19 Russo R, Visconti V, Lombardi LV, Ciccarelli M, Giudice G. The block-bridge system: a new concept and surgical technique to reconstruct articular surfaces and tuberosities in complex proximal humeral fractures. Journal of shoulder and elbow surgery 2008. link

Fracture of greater tuberosity of humerus