Falls onto the shoulder can damage various parts of the shoulder joint, rotator cuff tendons, ligaments, and bones. A more common bone break after a fall is the greater tuberosity fracture. What is a greater tuberosity humeral fracture, and how do you manage it?
Where is the greater tuberosity located?
The greater tuberosity is at the top outer part of the humeral head. The rotator cuff tendons attach to this tuberosity, moving the shoulder upwards and outwards. This part of the humeral head is often subjected to greater forces during a fall and, thus, is more likely to fracture. We also know that 5-30% of anterior dislocations lead to a greater tuberosity humeral fracture.
Symptoms of greater tuberosity fracture
People with greater tuberosity humeral fractures usually report a recent fall or trauma to the shoulder. Skiing and cycling injuries often cause these injuries due to high-velocity falls.
Your doctor will ask you about the position of your arm during the fall and whether you felt your shoulder pop out of its socket (dislocate). Just over 50% of greater tuberosity fractures are associated with a shoulder joint dislocation. You will also be asked about pins and needles, numbness and weakness in your arm, which may be a sign of co-existing nerve damage.
You should undergo an examination to check for shoulder looseness, tendon function and nerve damage.
Generally, we use X-rays to detect a greater tuberosty humeral fracture. However, particular views are required to ensure we don’t miss subtle breaks. If we are concerned about a displaced fracture, a special CT scan is often used to determine the extent of displacement. MRI scans help detect subtle fractures not seen on X-ray and exclude soft tissue injuries such as a rotator cuff tendon tear or cartilage damage.
Greater tuberosity fracture management
Primarily, we treat these fractures based on whether they are non-displaced or displaced. Although controversial, we believe non-operative treatment is appropriate for non-displaced or minimally displaced fractures (< 5mm). For high-level athletes or sportspeople competing in overhead sports, we consider the cut-off at 3mm of displacement.
We consider surgery early for displaced fractures. Displacement of fractures upwards or behind may block the movements of the shoulder upwards or outwards. Ideally, surgery should be performed within two weeks of the injury before the fracture has time to set. Surgeons can use both open and keyhole approaches with good results. Other indications for immediate surgery include a complete rotator cuff tear or cartilage injury.
Non-operative greater tuberosity fracture rehab protocol
Most cases of greater tuberosity fracture are non or minimally displaced and, therefore, treated without surgery.
Generally, we start with immobilisation in a sling for two weeks. At 2 weeks, we perform a repeat X-ray to ensure the fracture has not moved. Then, shoulder rehab is started in earnest to prevent stiffness. Initially, you should avoid outward (abduction) and external rotation movements for four weeks. Above-shoulder movements should begin six weeks after the fracture has healed.
From 6 weeks, you should see your therapist regularly to obtain the full range of motion and strength in the shoulder. After 12 weeks, you can start sports-specific training tailored to your sport. In some cases, the return of shoulder strength and function can take longer. One study found that the average time to return to activity may take up to 8 months, but this study recruited older patients who are generally slower to recover. Any concern about recovery should necessitate a review with your doctor to ensure correct fracture positioning and exclude other causes of a slow recovery, such as rotator cuff bursitis, total thickness tendon tears, frozen shoulder and joint cartilage damage.
Complications of greater tuberosity humerus fracture
Most of the greater tuberosity humeral fractures heal without problems. However, sometimes, complications develop.
Displaced greater tuberosity fracture
A displaced fracture blocks movement upwards or outwards, leading to shoulder impingement. The consensus is that fracture displacements of 5mm or greater will lead to problems. However, a recent study showed that patients with displaced fractures greater than 5mm had the same outcomes as those with less than 5mm.
Rotator cuff tendon tear
A fall onto the shoulder can also damage the rotator cuff tendons, causing tendon swelling or partial or full-thickness tendon tears. One study found that minimally displaced humeral fractures had a high rate of partial rotator cuff tendon tears.
Persistent pain from rotator cuff tendons can be managed with physiotherapy. Sometimes, we perform an ultrasound-guided cortisone injection for ongoing pain from bursitis. For full-thickness tears, we consider early surgical repair.
Frozen shoulder
Adhesive capsulitis is caused by the stiffening of the shoulder joint capsule, leading to pain and restricted movement. Frozen shoulder is common after a greater tuberosity fracture, particularly in those between 40 and 60 years old. Treatment consists of a frozen shoulder injection followed by mobility exercises.
Other frequently asked questions about greater tuberosity humerus fracture:
How do you sleep with a greater tuberosity fracture?
You may find sleeping propped up on pillows or upright on a chair more comfortable. A cold pack every 2-3 hours will help your pain and swelling in the early stages.
When can I start driving after a greater tuberosity fracture?
Generally, you should start driving when you no longer use a splint—about 2-3 weeks. Pain-free shoulder movements are also critical.
How long does it take for a greater tuberosity fracture to heal?
Generally, we think that these fractures take six weeks to heal. However, it may take a few more months before you return to sport. One study found that the average duration of shoulder pain and reduced function was eight months, although younger patients did better.
Does a greater tuberosity humerus fracture require surgery?
No, in most cases. However, surgery is indicated if the fracture displacement is greater than 5mm (or 3mm in athletes). Other surgical indications include a full-thickness rotator cuff tear or a large cartilage tear. Both open and keyhole surgery have good outcomes.
Final word from sportdoctorlondon about greater tuberosity humerus fracture
Most of these fractures can be treated with short-term rest in a sling followed by active rehab. Recovery can be slow, but most patients recover well in 3-6 months.
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