Isolated fractures of the greater tuberosity of the proximal humerus

Figures & data

Figure 1. The left shoulder of a 64-year-old patient (no. 3, Table 3), who suffered an anterior glenohumeral dislocation of the left shoulder with an avulsed greater tuberosity.

Figure 2. Patient no. 9 (Table 3) before and after open reduction and internal fixation with cannulated screws of a moderately displaced fracture of the greater tuberosity (white arrows). An MRI scan illustrates the fracture line (white arrows).

Figure 3. Patient no. 6 (Table 3) before and after open reduction and internal fixation of greater tuberosity fragments with major displacement (white arrows). The multiple fragments were fixed with a screw and a tension wire.

Figure 4. Patient no. 18 (Table 3) before and after open reduction and plate fixation of a moderately displaced fracture of the greater tuberosity (white arrows).

Table 1. Overview of clinical evaluation considering fragment displacement

Scores	Degree of fragment displacement ^a			p-value
	None/minor (n = 17)	Moderate (n = 8)	Major (n = 5)
DASH score ^b
75–100 (poor)	–	–	–
50–74 (moderate)	1	–	1
25–49 (good)	3	1	–
< 25 (excellent)	13	7	4
Mean (SD)	13 (17)	10 (12)	14 (24)	0.9
95% CI	4 to 22	0 to 20	–16 to 44
Constant score
86–100 (excellent)	3	1	–
71–85 (good)	7	5	3
56–70 (moderate)	3	2	1
< 55 (poor)	4	–	1
Mean (SD)	71 (18)	72 (16)	69 (17)	1.0
95% CI	62 to 80	59 to 85	48 to 90

^a None/minor indicates displacement of ≤ 5 mm, moderate indicates displacement of 6–10 mm, and major indicates displacement of > 10 mm.

^b DASH: Disabilities of the Arm, Shoulder and Hand scale.

Table 2. Active ROM at the time of follow-up examination

	Degree of fragment displacement and ROM ^a			p-value
	None/minor	Moderate	Major
	(n = 17)	(n = 8)	(n = 5)
Forward flexion	155 (105–170)	149 (100–170)	142 (130–155)	0.6
Abduction	147 (90–170)	142 (95–175)	146 (130–160)	0.9
External rotation	54 (30–70)	49 (30–70)	40 (20–60)	0.2
Internal rotation	72 (50–90)	69 (40–90)	68 (50–80)	0.8

^a The range of motion (ROM) of the affected arm is presented as the mean value in degrees with the range in parentheses.

Table 3. Synopsis of clinical and radiographic evaluation of patients with isolated greater tuberosity fractures of the humerus

Clinical evaluation							Radiographic evaluation
A	B	C	D	E	F	G	H	I	J	K	L	M	N
No/minor displacement (≤ 5 mm)
3	F	64	3 screws+ suture	impingement	4.2	50	anterior	+, CT	2	4	0	2	2
4	F	33	–	impingement	8.3	79	–	+	1	0	0	0	0
5	M	26	–	–	2.5	88	anterior	+	1	4	0	0	0
7	F	58	–	–	10	64	–	+	2	0	–5	0	0
10	M	54	–	–	4.2	81	–	+	1	0	0	0	0
11	F	71	–	–	36	70	anterior	+	1	0	0	0	2
12	F	38	–	–	0	82	–	+	2	0	0	0	0
13	M	57	–	–	7.5	83	–	+	1	0	0	0	0
14	M	40	–	–	0	89	–	+, CT	3	–4	4	0	0
15	F	74	–	–	32	42	–	+, MRI	1	0	5	0	0
16	M	65	–	impingement	58	38	anterior	+	3	5	0	2	0
20	M	53	2 screws	–	0	92	–	+	1	4	0	0	0
22	F	80	–	–	8.3	80	–	+	1	0	5	1	0
23	F	65	–	–	0	80	anterior	+	3	0	0	0	0
24	F	36	2 screws	impingement	34.2	44	–	+	1	0	0	0	0
28	F	37	–	impingement	6.7	57	–	+, CT	2	4	0	0	0
29	F	58	–	non-union	11.7	81	–	+, MRI	1	0	0	0	0
Moderate displacement (6–10 mm)
1	F	83	–	–	23	51	anterior	+	3	6	5	0	2
2	F	85	–	–	7.5	78	–	+	2	0	–10	0	3
8	M	48	3 screws	–	1.7	83	–	+, CT	3	0	6	0	0
9	F	53	3 screws+suture	impingement	33	44	anterior	+, MRI	2	0	6	0	0
17	F	53	–	–	3.3	80	–	+, CT	1	0	6	0	0
18	M	31	plate	–	2.5	89	anterior	+	3	9	5	1	0
21	M	76	–	–	5	77	–	+	1	6	8	0	2
26	F	68	3 screws	–	5.8	74	anterior	+	2	0	7	0	0
Major displacement (> 10 mm)
6	F	80	1 screw + TW	–	1.7	77	–	+	> 3	10	–20	2	2
19	M	55	plate+suture	–	0	78	–	+, CT	1	0	–17	2
25	F	68	2 screws	–	13	64	–	+	2	11	7	0	2
27	F	60	3 screws+suture	impingement	57	41	–	+	1	7	12	0	2
30	M	63	2 screws	–	0	85	–	+	1	30	6	2	3

A Pat no

B Sex

C Age

D ORIF

E Discomfort shoulder impingement syndrome was clinically determined with the Neer sign

F DASH score

G Constant score

H Shoulder dislocation

I Imaging

+: radiography

CT: computed tomography

MRI: magnetic resonance imaging

J No. of fragments

Fragment displacement (anterior and cranial displacement are given as positive values, posterior and caudal as negative values)

K Vertical

L Horizontal

M Heterotopic ossification

0 = none

1 = moderate

2 = severe

N Osteoarthritis – Kellgren-Lawrence classification

0 = normal

1 = questionable

2 = incipient or mild

3 = moderate

4 = severe

Figure 5. Radiographs of the right shoulder illustrating severe periarticular calcification (white arrows) of a patient (no. 30, Table 3) who was treated operatively with ORIF with screws for a major displaced fracture of the greater tuberosity. After radiographic healing, the metal was removed.