Radiographic Measurements
Union/malunion was assessed by 2 orthopedic surgeons during their fellowship year in shoulder and elbow surgery. These surgeons were blinded to patients’ clinical outcomes. Each surgeon reviewed each patient’s radiographs twice to determine whether the reduction was anatomical. Anatomical reduction was achieved if the greater-tuberosity-to-head height was between 4 and 10 mm. Malunion was defined as loss of more than 3 mm of anatomical fracture reduction (from the original reduction) on any radiologic view at most recent follow-up. Loss of reduction was considered minimal if the fracture fragment was displaced less than 3 mm.
Statistical Analysis
A descriptive analysis of patient variables and outcomes was used for this small cohort of patients. Statistical significance was set at α = 0.05.
Results
Eleven patients (7 women, 4 men) underwent plate osteosynthesis for an isolated greater tuberosity fracture (Figure 2). Mean age at surgery was 60 years (range, 37-71 years). All patients were right-hand–dominant; 7 of the 11 sustained the injury on the dominant side. For all 11 patients, final postoperative ROM and complications were recorded. No patient required additional surgery. Before injury, all patients felt their shoulder was 100% normal. Nine of the 11 patients were available for assessment of functional outcome and ROM at a mean (SD) of 27 (8) months (range, 16-44 months). At final follow-up, mean (SD) forward elevation was 147° (28°; range, 100°-180°), and mean (SD) external rotation was 25° (15°; range, 10°-60°). Mean (SD) SANE score was 72 (17; range, 50-90), and mean (SD) PSS was 79 (16; range 43-90). On a 1-to-10 scale, patients’ mean (SD) overall satisfaction was 8.6 (1.9; range, 4-10). Of the 9 patients who worked before injury, 8 returned to preoperative duty. Six patients reported stiffness (consistent with ROM). All patients said they would have the surgery again (Table).
All patients experienced radiographic union. Three of the 11 had minimal (<3 mm) loss of reduction. Mean (SD) time to union was 10.7 (4.2) weeks (range, 6.1-21.6 weeks). There were no wound complications and no need for any hardware removal.
Discussion
Isolated greater tuberosity fractures are less common than other types of proximal humerus fractures but often require surgical intervention for less displacement when compared with those fractures.2,14 Multiple techniques (eg, suture fixation, percutaneous pinning, arthroscopic techniques) have been used, but none has established itself as the gold standard for treatment of these difficult injuries.2,5,9,11,13-16 The results of the present study show that plate osteosynthesis can reliably be used to achieve anatomical reduction and good functional outcomes in isolated greater tuberosity fractures. Even with the added stability of the plate and suture construct, a small number of fractures still displaced. In addition, despite having achieved anatomical union, many patients in this study experienced stiffness and functional loss, which speaks to the challenges associated with management of these fractures.
Self-reported outcomes were less favorable for patients in our study (despite achieving mean forward elevation of 147°) than for patients who underwent greater tuberosity repair in other studies.2,5,10 In a study of 12 patients who underwent ORIF of a 2-part displaced fracture of the greater tuberosity of the proximal part of the humerus, Flatow and colleagues5 found half the patients had an excellent outcome, and the other half had a good outcome with active elevation averaging 170°. In another study, conducted over 11 years, 165 patients with a proximal humeral fracture were treated with transosseous suture fixation. Union occurred in all patients except the 2 patients with 3-part fractures, and 155 patients had excellent or very good fracture reduction.10 Therefore, final ROM for these patients may not be a good indicator of actual final function, and previous reports likely underestimated the functional loss experienced by these patients.
The incidence of isolated greater tuberosity fractures likely will increase as the population ages and becomes more active.2,14,16 Patients with isolated greater tuberosity fractures are more likely to be male, to be younger, and to have fewer medical problems than patients with other types of proximal humerus fractures.14 In addition, patient expectations regarding life after displaced greater tuberosity fractures are unique compared with expectations of patients who have other proximal humerus fractures; displaced greater tuberosity fractures usually occur in more active patients, who may expect to return to work and may place higher demands on themselves after treatment,2,14,16,24 possibly leading to lower subjective clinical outcomes.
Various operative treatment techniques for isolated greater tuberosity fractures have been described. Flatow and colleagues5 reported excellent return of forward elevation after ORIF with heavy suture, and half the patients reported excellent outcomes. Other techniques have had mixed results. Bhatia and colleagues11 reported on long-term outcomes of internal fixation using a double row of suture anchors in isolated, displaced greater tuberosity fractures in 21 patients. Outcomes were rated excellent in 8 patients, good in 10, satisfactory in 2, and unsatisfactory in 1. Braunstein and colleagues12 examined the biomechanical strength of various fixation constructs and found that tension band wiring or cancellous screws were superior to suture fixation. More recently, Ji and colleagues13 described encouraging outcomes of arthroscopic fixation of isolated displaced proximal humerus fractures in 16 patients. Mean postoperative American Shoulder and Elbow Surgeons (ASES) score was 88, and mean improvement in University of California, Los Angeles (UCLA) score was 31 points. In addition, mean forward elevation was 148.7° at most recent follow-up.