Injury, Int. J.

Care Injured (2008) 39, 284298

www.elsevier.com/locate/injury

REVIEW

Isolated tuberosity fractures of the proximal

humerus: Current concepts,
Konrad I. Gruson *, David E. Ruchelsman, Nirmal C. Tejwani

NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, New York, NY, United States

Accepted 24 September 2007

KEYWORDS Summary Despite the relatively common occurrence of fractures of the proximal
Greater tuberosity humerus amongst the elderly, the subgroup of isolated greater and lesser tuberosity
fracture; fractures have remained less well understood. While the majority of two-part
Lesser tuberosity fractures result from a standing-height fall onto an outstretched hand, isolated
fracture; tuberosity fractures are also commonly associated with glenohumeral dislocations
Proximal humerus or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity
fracture fractures are considered uncommon, isolated lesser tuberosity fractures are generally
considered exceedingly rare. Non-operative treatment including a specific rehabili-
tation protocol has been advocated for the majority of non-displaced and minimally
displaced fractures, with generally good outcomes expected. The treatment for
displaced fractures, however, has included both arthroscopically assisted fixation
and open or percutaneous reduction and internal fixation (ORIF). The choice of
fixation and approach depends not only on fracture type and characteristics, but
also on a multitude of patient-related factors. With an expected increase in the level
of physical activity across all age groups and overall longer lifespans, the incidence of
isolated tuberosity fractures of the proximal humerus is expected to rise. Orthopaedic
surgeons treating shoulder trauma should be aware of treatment options, as well as
expected outcomes.
# 2007 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Regional anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Study conducted at the NYU Hospital for Joint Diseases, New York, NY.

None of the authors have a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including
(but not limited to) employment, consultancies, stock ownership, honoraria and paid expert testimony.
* Corresponding author at: NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 330 East 70th Street, Suite #5D, New
York, NY 10021, United States.
E-mail address: kig_md@yahoo.com (K.I. Gruson).

00201383/$ see front matter # 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2007.09.022
Isolated tuberosity fractures of the proximal humerus 285

Muscular deforming forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Vascular anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Clinical evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288
Associated injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Tuberosity fracture management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Fixation techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Greater tuberosity fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Lesser tuberosity fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Post-operative rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
Complications of operative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Introduction 2% of all proximal humeral fractures. In contrast,

the incidence of isolated greater tuberosity frac-
The relatively benign radiographic appearance of tures has been estimated to be 20% of all proximal
isolated tuberosity fractures of the proximal humerus humeral fractures. Furthermore, isolated greater
belies the poor functional outcome that can result tuberosity fractures comprise about 5% of all opera-
from inappropriately treated injuries. While patient tively treated proximal humeral fractures. Chun
functional outcomes following non-operative man- et al. reported that 26 of 141 cases of their two-
agement of two-part surgical neck fractures have part fractures were displaced greater tuberosity
generally been good,34,11 the outcomes of conserva- fractures.9 These fractures may be more challenging
tively treated, displaced fractures of the greater and to identify on initial plain radiographs because of
lesser tuberosity have been disappointing. Despite osseous overlap when the glenohumeral joint is
the disagreement in the literature regarding the internally rotated. Additionally, small comminuted
magnitude of displacement of the greater tuberosity fragments may simply be overlooked or misinter-
that warrants surgical intervention, most authors preted as calcific deposition within the rotator cuff
agree that even 5 mm of posterosuperior displace- or intra-articular loose bodies. Recently, Ogawa
ment can lead to clinically significant impingement. et al. found that 59% of isolated greater tuberosity
Tuberosity fractures may occur either as a component fractures were missed on initial evaluation, with
of a comminuted proximal humerus fracture or in rotator cuff tendonitis and tear comprising the
isolation. Isolated fractures of the greater tuberosity majority of the misdiagnoses.39 The true incidence
are associated with a glenohumeral dislocation in of greater tuberosity fractures may, therefore, be
approximately 1030% of cases. Because isolated higher.
lesser tuberosity fractures are uncommon, there The typical patient who sustains a proximal hum-
exists far less literature on the management and eral fracture is an elderly, osteoporotic female
outcomes of this injury, with the mainstay of our following a low-energy trauma (i.e. fall from stand-
current knowledge based on case series and isolated ing height). Conversely, as reported by Ogawa et al.,
reports. A systematic protocol for identifying these the majority of lesser tuberosity fractures occur in
sometimes difficult to recognise fractures and decid- male patients between the second and fifth decades
ing which require operative intervention to optimise of life followed by adolescents with an open prox-
functional outcome will be essential for all ortho- imal humeral physis, and are often diagnosed late in
paedic surgeons and physicians dealing with upper the patient presenting with complaints of chronic
extremity trauma. shoulder pain.38,31 The demographics of patients
who sustain isolated greater tuberosity fractures
have been more extensively reviewed. Kim et al.
Epidemiology reported a series of 610 proximal humeral fractures
subclassified into isolated greater tuberosity frac-
Fractures of the proximal humerus comprise tures (group I: 115 cases) and all other proximal
approximately 5% of all fractures and almost half humeral fractures (group II: 495 cases).26 The two
of all humeral fractures.28 Isolated lesser tuberosity groups differed significantly with respect to mean
fractures are exceedingly rare. With fewer than 100 age (group I: 42.8 years versus group II: 54.2 years),
cases described in the literature, isolated lesser gender (group I: predominantly male; group II: pre-
tuberosity fractures only account for approximately dominantly female) and presence of comorbidities.
286 K.I. Gruson et al.

Chun et al. also demonstrated fewer medical comor- limits its use in the clinical setting. A reproducible
bidities in patients with isolated greater tuberosity and reliable standardised classification that guides
fractures as compared to those with surgical neck treatment and relates prognosis is needed in order
fractures.9 In an epidemiological review of 507 to compare outcome studies.
minimally displaced proximal humeral fractures
treated non-operatively, Gaebler et al. found that
patients with AO Type A fractures, including a sig- Regional anatomy
nificant number of greater tuberosity fractures,
were significantly younger than all other frac- Muscular deforming forces
tures.14 Furthermore, only age and ability to inde-
pendently shop were predictors of 1-year functional The humeral tuberosities serve as attachment points
outcome. Collectively, these findings emphasise for the rotator cuff musculature (Fig. 1). The most
that patients with isolated lesser and greater tuber- proximal portion of the articular surface sits 6 to
osity fractures are younger and healthier than their 8 mm above the tuberosities, preventing impinge-
counterparts with other proximal humeral fracture ment of the tuberosities against the acromial under-
patterns. Based on these results,9,26,14 isolated surface. The subscapularis inserts onto the lesser
tuberosity fractures are clinically distinct, and tuberosity, and the supraspinatus, infraspinatus
may benefit from more aggressive management and teres minor insert sequentially onto the greater
when displacement is present. tuberosity. The tendon for the long head of the biceps
runs through the inter-tubercular groove and is
restrained by both the transverse humeral ligament
Classification as well as fibres from the superior-most portion of the
subscapularis tendon. Given the nature of these
The most commonly cited classification for fractures insertions, the direction of part displacement may
of the proximal humerus has been that of Neer,37 be anticipated following fracture. Specifically, a dis-
itself a modification of Codmans original descrip- placed greater tuberosity fracture is pulled proxi-
tion of four well-defined fracture partsthe greater
and lesser tuberosities, the humeral head and the
shaft. Displacement greater than 1 cm or angulation
of greater than 458 is required for classification as a
part. Therefore, displaced, isolated tuberosity frac-
tures, as well as displaced fractures of the surgical
or anatomic neck are considered two-part proximal
humerus fractures. Two-part valgus impacted prox-
imal humerus fractures represent a distinct entity.10
The significance of these parts lies in the deforming
forces (see below) that act on them once they are
fractured. Although several series52,51 have demon-
strated only fair/moderate inter- and intra-obser-
ver reliability using the Neer classification, it
remains the most commonly used system. These
findings are significant when they alter treatment.
We recommend additional radiographs (internal and
external rotation views) or CT scan when the classi-
fication is equivocal.
The AO/ASIF classification system attempts to
categorise proximal humeral fractures into three
major groups based on articular involvement and
the number of major fracture lines, and emphasises
the vascular supply to the articular segment. AO
Type A fractures are unifocal, involving the greater
tuberosity or neck. The displaced tuberosity frac- Figure 1 Muscular deforming forces on the proximal
ture, for example, would be an 11A1.2. However, humerus. Direction of arrows demonstrates direction of
the multiple subdivisions included within this sys- deforming force by each muscular insertion. (A) Supras-
tem, coupled with the fact that it has not been pinatus; (B) infraspinatus and teres minor; (C) subscapu-
shown to be predictive of long-term outcomes, laris; (D) pectoralis major; (E) deltoid.
Isolated tuberosity fractures of the proximal humerus 287

Figure 2 (a) External rotation anteroposterior radiograph and (b) axillary view demonstrate anterior glenohumeral
dislocation with a displaced greater tuberosity fracture and associated bony Bankart lesion. Following closed reduction,
(c) external rotation view demonstrates a reduced glenohumeral articulation and reduction of the greater tuberosity.

mally and posteriorly. Lesser tuberosity fractures,
commonly associated with posterior glenohumeral
dislocations, will be displaced medially. In the major-
ity of cases involving an anterior glenohumeral dis-
location, the greater tuberosity fragment will reduce
to the head following closed reduction33,15 (Fig. 2).
This has been reported for posterior dislocations and
the lesser tuberosity as well.20
Vascular anatomy
The vascular supply of the proximal humerus is
important to understand as it helps guide treatment
by providing a framework through which to assess
post-fracture and/or post-ORIF vascularity of the
humeral head and the potential for osteonecrosis
(ON) following displaced fractures (Fig. 3). Ana-
tomic studies35,18 have demonstrated that the arc-
uate artery arises as a terminal branch from the
anterolateral division of the anterior circumflex and
is the major intraosseous supply to the head. Brooks
et al. demonstrated that epiphyseal perfusion may
persist via abundant intraosseous anastamoses
despite elimination of the anterior circumflex
artery.7 The posterior circumflex artery supplies
only a small posteroinferior portion of the humeral
288
Figure 3 Vascular supply to the proximal humerus. (A)
Axillary artery; (B) anterior humeral circumflex artery; (C)
posterior humeral circumflex artery; (D) arcuate artery;
(E) small vessels via rotator cuff insertions.
epiphysis.18 The tuberosities receive small perfora-
tors from the anterior and posterior circumflex
arteries. Additionally, multiple extraosseous ana-
stamoses exist between the circumflex arteries
and the surrounding thoracoacromial, supra- and
subscapular arteries. This well developed vascular
network explains the low incidence of ON of the
humeral head following isolated tuberosity frac-
tures. Hertel et al. found that involvement of the
anatomic neck is a good predictor of humeral head
ischaemia, whereas tuberosity displacement of
>1 cm and associated glenohumeral dislocation
are poor/moderate predictors following intracapsu-
lar fracture of the proximal humerus.21
Clinical evaluation
As discussed previously, isolated tuberosity frac-
tures occur in younger, more physically fit patients.
Several mechanisms have been proposed. During a
fall onto an outstretched upper extremity, tuberos-
ity avulsion and fracture propagation may occur
secondary to an eccentric load applied to the
respective tuberosity by the attached rotator cuff.
38,19
In a recent review of 103 patients with isolated
greater tuberosity fractures by Bahrs et al., over
one-half of these injuries occurred in the setting of
K.I. Gruson et al.
traumatic anterior glenohumeral dislocation.2 The
majority had either no fracture displacement, or
inferior displacement of the tuberosity, making
impingement of the tuberosity against the acromion
a more likely mechanism. Alternatively, the greater
tuberosity may impact against the anteroinferior
glenoid, resulting in either Hill Sachs/Bankart
lesions and/or a greater tuberosity fracture frag-
ment of varying size secondary to shear during
anterior glenohumeral dislocation/subluxation.
For lesser tuberosity fractures, the humeral head
would be posteriorly dislocated.
These patients present with the injured extre-
mity held close to the axial skeleton. Inspection
reveals swelling around the upper shoulder and
ecchymosis may extend into the axilla and distally
along the upper arm. Non-specific tenderness over
the proximal humerus is elicited. In the acute set-
ting, it is difficult to clinically distinguish tuberosity
fracture from cuff pathology; imaging is paramount
in making this important distinction. In both scenar-
ios, patients will not tolerate cuff strength testing
against resistance. A thorough neurovascular exam
in conjunction with a secondary survey for addi-
tional osteoporotic fractures should be performed.
Concomitant glenohumeral dislocations should be
reduced in a timely fashion utilising conscious seda-
tion or glenohumeral injection.
Imaging
A standard radiographic trauma series of the
shoulder must be obtained for accurate diagnosis
of fracture lines, displacement, comminution and
presence of associated glenohumeral dislocation.
The requisite films include an AP in neutral rotation,
a scapular Y view, and an axillary view. The axillary
radiograph provides information as to the displace-
ment of the tuberosity fragment. If pain precludes
obtaining an axillary view, the Velpeau view can be
substituted. Film quality should be scrutinised, as
overexposure may lead to failure to identify a small
or minimally displaced fracture fragment. Ogawa et
al.39 reported that the majority of missed greater
tuberosity fractures were indeed one-part fractures
involving only the supraspinatus facet. The amount
of displacement can be difficult to determine on
standard radiographs. Using a cadaver model with
greater tuberosity osteotomy followed by poster-
osuperior displacement, Parsons et al. demon-
strated that the most accurate displacement
measurements were determined from the AP view
in external rotation and the AP view with 158 caudal
tilt.42 The interobserver reliability in deciding
whether a fracture was operative based on an indi-
Isolated tuberosity fractures of the proximal humerus
vidual image was found to be moderate. However,
when given a complete series of four images for a
particular displacement, more consistent with clin-
ical situations, the appropriate treatment was
recommended for 75% of the cases with 5 mm dis-
placement and all cases of 10- and 15 mm displace-
ment. We recommend that that a shoulder trauma
series include an AP in external rotation to most
accurately define greater tuberosity displacement.
CT scans with coronal and sagittal plane recon-
structions are being obtained in the emergency
room setting with increasing frequency as an
adjunct to plain films to help identify fracture
characteristics (i.e. displacement, occult fracture
lines, intra-articular extension) that may impact
surgical approach, technique and implant selection
(Fig. 4). CT scans are also useful for obese patients,
or those who cannot comply with the radiographic
technician. While a recent study found that the
addition of CT images improved interobserver relia-
Figure 4 CT reconstructions for fracture delineation. (a) Axial and (b) sagittal oblique reconstructions demonstrating
posterosuperior displacement of a large greater tuberosity fracture fragment. (c) A three-dimensional reconstruction of
the above two-part fracture.
289
bility in assessing the number of fracture fragments,
displacement of the lesser tuberosity, and articular
involvement,36 others have found poor reproduci-
bility of fracture classification with the addition of a
CT scan.53 A complete radiographic shoulder series
of good quality should preclude getting a CT scan in
most instances.
Ultrasonography and magnetic resonance ima-
ging (MRI) performed for suspected traumatic rota-
tor cuff tear have been shown to be useful in
detecting occult tuberosity fractures when initial
plain films have been negative. The true prevalence
of occult tuberosity fractures is unknown. However,
Zanetti et al. reported MRI evidence of radiographi-
cally occult fractures of the greater tuberosity in
nine (38%) of 24 consecutive patients with clinically
suspected traumatic tears of the rotator cuff (seven
of which occurred in patients <40 years old).63
Other smaller studies have demonstrated the use-
fulness of MRI in detecting radiographically occult
290 K.I. Gruson et al.

tuberosity fractures.32,46 Furthermore, Mason et al.
found that nondisplaced greater tuberosity frac-
tures diagnosed by MRI were not associated with
cuff pathology requiring operative intervention.32
Ultrasound evaluation of the rotator cuff may reveal
occult tuberosity fracture as evidenced by cortical
disruption.44 Ultrasound has become the diagnostic
modality of choice in many European and select
North American centres when initial radiographs
are unremarkable. As a noninvasive and inexpensive
test, its use is likely to become more widespread as
more experience is gained with its application to
shoulder pathology. Both modalities may prevent
the use of unnecessary diagnostic shoulder arthro-
scopy for patients with occult fractures.
Associated injuries
The majority of associated injuries are found in
conjunction with tuberosity fracture-dislocations
and involve the adjacent neurovascular structures.
Nerve injury occurs in about one-third of greater
tuberosity fracture-dislocations, with recovery in
the majority of the cases after several months
indicating that most are neuropraxias or low grade
axonotmesis secondary to stretch or external pres-
sure during the initial trauma.15 Axillary nerve invol-
vement is most commonly described with anterior
shoulder dislocations and fracture-dislocations sec-
ondary to its location. However, generalised bra-
chial plexopathies including cord and peripheral
nerve injuries have also been reported.15,62 Electro-
myographic (EMG) evaluation of the brachial plexus
suggest that neurological sequelae, even following
non-displaced proximal humeral fractures, are
underestimated.58,59 The presence of deltoid atony
represented by inferior glenohumeral subluxation
after fracture is a commonly overlooked sequela and
may be the cause of poor functional recovery even
after fracture healing (Fig. 5). An EMG should be
obtained if palsy persists at 3 months, as most of

Figure 5 Post-reduction muscular atony. (a) Persistent inferior glenohumeral subluxation following closed reduction.
(b) External rotation anteroposterior and (c) axillary radiographs demonstrate a reduced glenohumeral joint and
resolution of deltoid atony following suture anchor fixation which was selected given the tuberosity comminution.
Isolated tuberosity fractures of the proximal humerus
these injuries should recover to a major degree by
that time.59
Vascular injuries following proximal humeral frac-
tures, dislocations and fracture-dislocations are
uncommon, but may include pseudoaneurysm, frank
vessel rupture,54,64 and venous thrombosis.61 The
majority of these involve a segment of the axillary
artery. The presence of an expanding haematoma,
absence of proximal pulses and development of upper
extremity neuropathy are investigated urgently with
angiogram to determine if vascular intervention is
required.
While some authors feel that isolated tuberosity
fracture precludes significant additional soft tissue
injury, others have reported concomitant rotator
cuff tears.25 Fractures associated with glenohum-
eral dislocation may result in capsulolabral and/or
chondral injuries.17,4 These concomitant soft tissue
injuries not apparent on standard radiography may
be the etiology of persistent patient complaints
following fracture union.60
Tuberosity fracture management
The exact operative threshold with respect to
tuberosity displacement in order to maximise
patient functional outcome remains controversial.
Non-displaced or minimally displaced (<5 mm)
fractures of the greater tuberosity are generally
treated without surgery.40 These fractures are
usually stable and early glenohumeral mobilisation
is initiated following a short period of immobilisa-
tion. Platzer et al. reviewed 135 patients with
isolated greater tuberosity fractures with less than
5 mm of displacement who were uniformly treated
non-operatively with immobilisation followed by a
formal therapy program.45 At a mean 3.7 years
follow-up, 97% good-to-excellent results were
obtained and displacement below 5 mm had no
effect on outcome. A trend towards worse out-
comes in patients with greater than 3 mm of dis-
placement was observed, but this was not
statistically significant. In a series of 104 patients
with 1-part greater tuberosity fractures, Koval
et al. also found no correlation between amount
of greater tuberosity displacement and outcome at
a mean 41 months post-injury.27 While 77% good-to-
excellent results were found, 90% of patients
reported mild or no pain, and functional recovery
averaged 94%. The presence of medical comorbid-
ities and older age has been correlated with inferior
functional outcome at 1 year.14 Associated injuries,
rehabilitation, and the pre-existing function of the
shoulder may also affect outcome following con-
servative management.
291
Significant posterosuperior displacement can
lead to malunion and impingement. The displace-
ment of the rotator cuff insertion also alters the
force couple between the cuff and deltoid during
glenohumeral joint abduction. Although Neer
recommended conservative management for tuber-
osity fractures with less than 1 cm of displace-
ment,37 Bono et al. demonstrated mechanical
abutment of a malunited tuberosity with the under-
surface of the acromion with 1 cm of superior dis-
placement in a dynamic biomechanical cadaver
model of tuberosity malunions.5 Furthermore, all
posterior and superior displacement combinations
of the greater tuberosity resulted in increased del-
toid abduction forces.5
For lesser tuberosity fractures, the accepted
indications for surgery have included fragment dis-
placement of 5 mm or 458 of angulation, mechanical
block to internal rotation, continued pain, and
weakness of terminal internal rotation. Concern
over late displacement and possible involvement
of the bicipital groove has led some surgeons to
fix even minimally displaced lesser tuberosity frac-
tures.38 Ogawa et al. presented one of the largest
recent series and recommended ORIF for all acute
fractures regardless of fragment size and displace-
ment in order to achieve an excellent long-term
outcome.38 Other authors have recommended non-
operative treatment with non-displaced fractures
and reported clinical success.57,55 Non-operative
management followed by delayed therapy may be
reserved for chronic cases. The lack of specific
treatment guidelines may be responsible for the
variable functional outcomes reported following
these injuries.
Indications for operative intervention should con-
tinue to be based on multiple factors. Fracture
characteristics displacement, location, comminu-
tion should be analysed on radiographs and any
available advanced imaging modalities. Patient
characteristics age, comorbidities, extremity-
dominance, pre-injury shoulder and individual level
of function, local bone quality must be contem-
plated. Finally, surgeon experience with these inju-
ries plays a role in the treatment algorithm.
Fixation techniques
Greater tuberosity fractures
The approaches to the tuberosity include both open
and arthroscopic techniques. Open techniques may
be performed through the standard deltopectoral
approach or through a deltoid splitting approach.
More recently, arthroscopically assisted techniques
292
have been described to allow for more complete
evaluation of the rotator cuff and to minimise soft
tissue dissection.8,56,6,16,48 Given the abnormal anat-
omy in fracture cases, these procedures demand
experienced arthroscopists. Patient positioning and
instrumentation are the same as those used for
arthroscopic cuff repairs with additional implants
depending on associated soft tissue injury. Addition-
ally, fluoroscopic imaging is recommended to assess
fracture reduction. Arthroscopy allows for visualisa-
tion of both the glenohumeral and subacromial
spaces. Taverna et al. described a technique for
arthroscopic reduction and percutaneous fixation
of the greater tuberosity fragment.8 The posterior
portal should be adjusted more superiorly and lat-
erally to facilitate better visualisation of the tuber-
Figure 6 Postoperative (a) anteroposterior, (b) scapular-Y and (c) axillary radiographs following cuff-type repair with
suture anchors.
K.I. Gruson et al.
osity fragment. The fibrous tissue on the fragment
and in the bed of the tuberosity should be debrided to
allow for more anatomical reduction. Provisional
fixation should be performed using Kirschner wires,
over which a cannulated screw with washer can be
advanced. Comminuted fractures may be treated
similar to rotator cuff repairs.4 Arthroscopy has been
advocated as an alternative to open procedures
which may result in reduced morbidity, although a
steep learning curve is expected.8,56,6,16,48 Larger
series will be required before the success of the
arthroscopic approach can be fully evaluated.
The deltopectoral approach or the deltoid split-
ting13 approach through a bra-strap skin incision
along Langers lines can be used to approach the
fragment. Surgeon experience and the size of the
Isolated tuberosity fractures of the proximal humerus 293

Figure 7 Tuberosity screw fixation. Injury (a) anteroposterior and (b) axillary radiographs demonstrate a large,
displaced greater tuberosity fracture sustained from penetrating trauma. The soft tissue defect in the deltoid is
appreciated. The patient underwent emergency debridement of the open fracture. The tuberosity fragment was
mobilised with ethibond suture and provisionally reduced with K-wires. Final fixation construct (c and d) included a
4.0 mm cannulated screw and washer supplemented with a fibrewire tension-band through drill holes.

fracture fragment dictate the approach. Large frag-
ments may be difficult to visualise through a mus-
cular split as distal exposure is limited by the
axillary nerve. The patient is placed in the beach
chair position and the free arm on a sterile padded
Mayo stand. Prior to prepping and draping the extre-
mity, one must ensure that the fluoroscopy can be
positioned appropriately. General or regional anaes-
thesia may be used at the preference of the surgeon.
The procedure depends on the size and commi-
nution of the tuberosity fragment. With multiple
small fragments, internal fixation may prove diffi-
cult and primary rotator cuff-type repair through
drill holes with heavy nonabsorbable sutures or
suture anchors is preferred (Fig. 6). With a large
tuberosity piece, fixation may be achieved using a
screw with a washer to minimise comminution while
tightening the screw (Fig. 7). Percutaneous reduc-
tion represents an alternative to formal open
approaches to minimise surgical site morbidity
and improve cosmesis; this should be performed
for larger tuberosity fragments and by surgeons
experienced in this technique.
Alternatively, a heavy suture may also be used in
a figure-of-eight pattern, placing the fragment back
into the fracture bed and minimising potential hard-
ware-related problems13,41 (Fig. 8). A recent cada-
veric study showed no difference between various
commonly used suture materials for fixation of the
tuberosity.24 The results of these operations are
dependent on achieving anatomic reduction, secure
fixation to allow for early passive mobilisation, and
patient compliance with postoperative regimens.
Park et al. demonstrated 89% excellent-to-satisfac-
tory results in a series of 2- and 3-part proximal
humeral fractures which included 13 greater tuber-
294
Figure 8 Tuberosity suture fixation. (a) Illustration of
proper suture placement for fixation of a greater tuber-
osity fracture. The greater tuberosity (b) has been
reduced into the fracture bed.
osity fractures treated with suture fixation.41 Simi-
larly, Flatow et al. evaluated their series of 12
isolated greater tuberosity fractures treated with
suture and reported six excellent and six good
results at 5 years follow-up.13 We do not recommend
routine excision of small tuberosity fragments and
direct repair of the rotator cuff directly to the bone
bed, as bone-to-bone healing is more reliable than
tendon-to-bone healing.
Lesser tuberosity fractures
Operative management of isolated lesser tuberosity
fractures presents unique issues. The integrity of
the proximal humeral physis in the skeletally imma-
ture patient must be respected during fracture
fixation. Fixation techniques using heavy suture
and suture anchors may minimise physeal trauma.31
In the adult patient, cannulated screws with or
without washers,38,57,43 heavy suture, and cerclage
wire38,20 have been used (Fig. 9). Often, the sub-
scapularis and bone fragment unit will need to be
mobilised and fibrous tissue removed. The approach
for fixation must consider the involvement of the
medial wall of the inter-tubercular groove and,
thus, the integrity of the tendon of the long head
of the biceps. Open approaches to the lesser tuber-
K.I. Gruson et al.
osity are limited to the deltopectoral approach and
this has comprised the majority of the experience in
the literature. A unique arthroscopic approach using
suture anchors has recently been described, with
the patient achieving pain-free motion and a return
to overhead sports.49 Because of the intimate rela-
tionship between the superior fibres of the subsca-
pularis and the tendon of the long head of the
biceps, arthroscopic fixation of the tuberosity frag-
ment should be performed only when the biceps
tendon is not subluxed. Regardless of fixation type,
most reports document excellent results following
operative repair of an isolated lesser tuberosity
fracture, with return to full function by 36
months.31,43,49,30,12,47,50,29 Satisfactory outcomes
have also been reported with operative treatment
of chronic cases.38,43
Post-operative rehabilitation
Rehabilitation regimens are individualised and
adapted to accommodate associated injuries,
bone/soft tissue quality, strength of fixation and
anticipated patient compliance. Post-operative
tuberosity fractures follow a protocol similar to
the post-rotator cuff repair patient. This is particu-
larly relevant to those patients with severely com-
minuted tuberosity fractures in which the bone
fragments were either removed or incorporated into
the suture repair. Immediate pendulum exercises
are followed by a course of passive range of motion;
forward flexion, internal and external rotation may
be initiated in the supine position. Passive motion is
advanced as tolerated. For greater tuberosity frac-
tures, cross-arm adduction and internal rotation
beyond the chest wall early on should be avoided
as this may stress the repair. Similarly, early exter-
nal rotation should be limited for lesser tuberosity
repairs to neutral rotation. The patient should main-
tain their shoulder in a sling when not performing
therapy.
By 68 weeks, active and active-assisted range
of motion and stretching exercises are initiated.
Isometric strengthening begins by 3 months. For
most patients, particularly younger ones, normal
activity is initiated at that time. For stable frac-
tures treated non-operatively, shoulder motion
should be delayed for approximately 10 days fol-
lowing injury. If pain has been significantly reduced,
the patient may begin a protocol similar to that
above. Reinforcement of ADLs is essential for a
successful outcome. Duration of physiotherapy14
and initiation prior to 2 weeks post-injury27 have
been positively correlated with long-term func-
tional outcomes.
Isolated tuberosity fractures of the proximal humerus 295

Figure 9 Fixation of displaced lesser tuberosity fracture. (a) External rotation and (b) axillary views demonstrate a
two-part lesser tuberosity fracture and a significant reverse Hill-Sachs lesion sustained during a posterior dislocation
associated with a seizure. (c and d) CT images demonstrate the fracture displacement. The lesser tuberosity remained
medially displaced despite glenohumeral reduction. Postoperative (e) anteroposterior and (f) axillary views following
lesser tuberosity mobilisation and screw fixation.
296
Complications of operative treatment
Complications following operative fixation of tuber-
osity fractures include those of other extra-articular
metaphyseal fractures, namely infection, malunion,
nonunion, AVN, adhesive capsulitis and iatrogenic
neurovascular injury. These can be minimised with
careful surgical technique, early diagnosis and
intervention. No large series of tuberosity fractures
have specifically examined these complications.
Glenohumeral or subacromial space infection fol-
lowing open or arthroscopic approaches are treated
with prompt irrigation and debridement, in addition
to intravenous antibiotics. Poor outcomes have been
reported following subacromial infections following
subacromial corticosteroid injections.22 Osteone-
crosis of the humeral head is a rare complication
following an isolated tuberosity fracture, and the
vascular insult probably occurs during the initial
trauma or is iatrogenic. Prevention of postoperative
shoulder stiffness requires formal physio therapy
with early and progressive passive range of motion
and stretching. If adhesions develop, the patient
should undergo early manipulation with or without
lysis of adhesions (open or arthroscopic). Iatrogenic
nerve injury commonly involves the axillary nerve
and results from excessive retraction during the
deltopectoral approach.
Impingement and loss of rotator cuff function
from nonunion or malunion may result from poor
surgical technique or loss of fixation. Accurate
intra-operative assessment of bone quality and
selection of appropriate fixation help to prevent
these complications. Arthroscopic management of
tuberosity malposition is evolving. Gartsman et al.
described simultaneous arthroscopic rotator cuff
repair with fixation of a greater tuberosity non-
union.16 Malunion of the lesser tuberosity has also
been managed with arthroscopic debridement to
improve shoulder internal rotation.23 Tuberosity
malunions may require corrective osteotomy or
acromioplasty. In a series of 39 patients with prox-
imal humeral malunion, Beredjiklian et al. reported
satisfactory results in 9 of 10 patients with Type I
malunion (malunited tuberosity but a congruent
joint surface) following tuberosity osteotomy or
acromioplasty. Unsatisfactory outcome may be
anticipated when the osseous deformity is not
addressed.3 Arthroplasty represents a technically
challenging alternative to osteotomy. Antuna et al.
found reliable improvements in shoulder elevation
and external rotation, pain relief, and patient satis-
faction following arthroplasty for 2- and 3-part
greater tuberosity malunions. These authors advo-
cated intentional malpositioning of the prosthetic
stem in order to avoid tuberosity osteotomy and
K.I. Gruson et al.
have found no detrimental effect on functional
outcome.1
Summary
Recent outcome studies have reported on the func-
tional deficits of patients with missed or inappro-
priately treated isolated tuberosity fractures. This
stresses the importance of timely diagnosis, which is
initiated with thorough history taking, elucidation
of the mechanism of injury, and physical examina-
tion which must include a secondary musculoskele-
tal survey. Greater tuberosity fractures and
displacement are best identified on the AP view
of the shoulder with external rotation. In the setting
of significant trauma and negative radiographs,
especially in the younger patient, it is prudent to
obtain further imaging of the shoulder to rule out
either a traumatic tear of the rotator cuff or an
occult tuberosity fracture. The exact operative
threshold with respect to tuberosity displacement
in order to maximise patient functional outcome
remains controversial. Good-to-excellent results
are anticipated following nonoperative treatment
of non-displaced/minimally displaced (<5 mm) iso-
lated greater tuberosity fractures. Fractures dis-
placed >1 cm should be operatively stabilised and
the biomechanical and clinical impact from this
magnitude of displacement is well-documented.
Operative indications for fractures displaced
between 5 mm and 1 cm should not solely be based
upon radiographic displacement. Multiple factors
for these fractures in this grey zone of displace-
ment should be considered, including fracture char-
acteristics (displacement, location, comminution),
patient characteristics (age, comorbidities, extre-
mity-dominance, pre-injury level of function, local
bone quality), and surgeon experience. Studies have
demonstrated the difficulty in reliably quantifying
tuberosity displacement in this range, and perhaps
fixing these fractures in the younger, more active
population may be warranted.
Far less experience exists with isolated lesser
tuberosity fractures. Clinical series remain small
or are limited to case reports. Operative treatment
is recommended with significant displacement,
blockage to motion, significant clinical weakness,
or continued pain. Although the surgery for chronic
cases is more difficult because of problems with
rotator cuff mobilisation and bony stabilisation,
good outcomes have been reported. A successful
functional outcome following isolated tuberosity
fractures depends to a great degree on proper
indications, good surgical technique, appropriate
post-operative therapy and patient compliance.
Isolated tuberosity fractures of the proximal humerus
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