Proximal humerus fractures are the second most common fracture in the upper extremity, accounting for 4% to 5% of all fractures.1-4 The majority of these injuries can be treated without an operation. For fractures that require surgery, there are multiple options, including closed reduction, percutaneous pinning, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty.3-9
Isolated greater tuberosity fractures (AO [Arbeitsgemeinschaft für Osteosynthesefragen] 11.A1) make up a small subset of proximal humerus fractures. In general, patients who sustain an isolated greater tuberosity fracture are younger and more active than those who sustain other proximal humerus fractures.2,10 As a result, in the treatment of greater tuberosity fractures, there is increased emphasis on return to high activity and function. Nondisplaced or minimally displaced fractures typically are treated nonoperatively with good success.11,12 Patients with fractures displaced more than 5 mm, and highly active patients with fractures displaced more than 3 mm, usually are recommended for surgical treatment.2,11-14 The many options for treating these difficult fractures include suture fixation, percutaneous techniques, screw fixation, and, more recently, arthroscopic suture techniques.2,5,13,15,16 The goal of any of these operative interventions is to restore normal function and minimize pain around the injured shoulder. Although most of the operative techniques for greater tuberosity fractures have predictable results, none has been established as the gold standard for the treatment of displaced greater tuberosity fractures.2,5,13,15-18 Use of plate osteosynthesis for displaced proximal humerus fractures not isolated to the greater tuberosity is becoming more widespread in the orthopedic community.1,4,19,20 However, the orthopedic literature includes very few reports of using this technique for isolated displaced greater tuberosity fractures.18 This surgical approach potentially provides increased stability, improved maintenance of reduction, and earlier range of motion (ROM) in the postoperative period. These outcomes in turn may allow for improved pain control and earlier return to normal activities than is the case with other operative interventions for these difficult injuries.
We conducted a study to determine the radiographic and clinical outcomes of plate osteosynthesis for displaced greater tuberosity fractures. We hypothesized that excellent clinical and radiographic outcomes could be achieved using this surgical technique.
Patients and Methods
After obtaining institutional review board approval for this study, we retrospectively identified 11 consecutive patients with an isolated displaced greater tuberosity fracture (AO 11.A1) treated with plate osteosynthesis by Dr. Getz between December 2009 and May 2011 (Figures 1A, 1B). We collected data on age at time of surgery, sex, length of follow-up, worker’s compensation status, and complications. At a minimum of 21 months (mean, 27 months; SD, 8 months; range, 16-44 months), we assessed ROM and administered validated outcome scores, including the Single Assessment Numeric Evaluation (SANE)21,22 and the Penn Shoulder Score (PSS).23
Surgical Technique
The deltopectoral approach was used in all 11 patients. A standard incision was made over the deltopectoral interval starting at the coracoid and extending about 6 cm toward the deltoid insertion. After the internervous plane was entered between the deltoid and pectoralis major, the clavipectoral fascia was divided. The greater tuberosity fracture was identified with the leading edge of the fracture 1 cm posterior to the bicipital groove in all cases. Organized hematoma was removed from the fracture site to allow reduction. Three 1-mm braided polyester tapes were placed into the rotator cuff at the insertion onto the greater tuberosity fragment. The sutures thus captured the fragment and were used to obtain reduction and fixation. The fragment was provisionally pinned by placing a 2.0-mm Kirschner wire high on the fragment as to not block plate application. Fluoroscopic imaging was used to determine the appropriate position of the fracture reduction. A standard periarticular proximal humerus 3.5-mm locking compression plate (Zimmer) was used in all patients. The plate was contoured to achieve more compression in several cases in which plastic deformation or comminution was present. The sutures that were attached to the greater tuberosity were then brought through the plate. The plate was then slid down onto the humerus and pinned under fluoroscopic guidance. Three bicortical screws were used to affix the plate to the humeral shaft to compress the fracture into the fracture bed. Two to 4 locking screws were placed into the humeral head to improve the rotational stability of the construct. Last, the sutures through the plate were tied for added fixation.
Rehabilitation
In the immediate postoperative period, all patients were placed in a standard shoulder sling. The sling was worn for 6 weeks. At 2 weeks, patients started formal, standardized physical therapy, including passive ROM for elevation and external rotation. At 6 weeks, they began internal rotation stretching and active-assisted motion. Cuff strengthening began gently, as motion and pain allowed, after 8 weeks. Formal physical therapy continued until full or maximal improvement in motion and strength had been achieved.