Management of greater tuberosity fracture dislocations of the shoulder

Influence of reestablishing greater tuberosity angle on patient outcomes following greater tuberosity fractures

PURPOSE

This study aimed to assess whether higher values of GTA after osteosynthesis of isolated greater tuberosity fractures were associated with worse functional and symptomatic outcomes.

METHODS

A retrospective analysis was conducted from 2012 to 2024, including all patients with isolated greater tuberosity fractures undergoing osteosynthesis at a single institution. GTA measurements before and after osteosynthesis were recorded, along with the latest QuickDash score and constant shoulder score.

RESULTS

Thirty-four patients were recruited, with 25 undergoing osteosynthesis with cannulated screws and eight with anchors. Twenty-two patients self-administered the QuickDash score and completed the constant shoulder score. The average GTA before surgery was 84.2°, reducing to 62.2° post-surgery. The average constant score was 86.8, and the mean QuickDash score was 7.65. The method of osteosynthesis did not significantly influence GTA or the QuickDash and constant scores. Additionally, post-surgery GTA negatively correlated with the constant score (r = - 0.65, p < 0.01).

CONCLUSIONS

Patients with isolated greater tuberosity fractures undergoing osteosynthesis experience a change in GTA after surgery. However, they achieved satisfactory symptomatic and functional scores post-surgery. The method of osteosynthesis did not significantly influence the GTA or the QuickDash and constant scores. Furthermore, post-surgery GTA negatively correlated with the constant score.

F, Meisterhans M, Borbas P, Wieser K, Grubhofer F. Anterior shoulder dislocation with avulsion fracture of the greater tuberosity results in reliable good outcomes after closed reduction

Background

Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the GT typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment.

Methods

All patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons score and subjective shoulder value, instability assessed with the Western Ontario Shoulder Instability score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements.

Results

A total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n = 4, 14%) or impingement symptoms (n = 3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n = 7) and neuropraxia of the axillary nerve (n = 3) were observed temporarily and resolved during the follow-up period. The American Shoulder and Elbow Surgeons and subjective shoulder value of the conservatively treated patients at the last follow-up was 89.2 ± 19.1 respectively 86 ± 18.2%. No recurrent glenohumeral dislocation was documented. The mean Western Ontario Shoulder Instability score at last follow-up was 8(0-71). The mean GTI decreased from 1.2 ± 0.1 after ASD to 1.1 ± 0.1 at the last follow-up (P = .002). The mean II decreased from 0.6 ± 0.5 after ASD to 0.4 ± 0.3 at the last follow-up (P = .110).

Conclusion

The GT avulsion fragment reduces typically into a close to anatomic position after closed reduction and the GTI even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.