GREATER TUBEROSITY FRACTURES
Rotator Cuff Attachment Site | Displacement Threshold 5mm | Posterior Displacement Worst
NEER CLASSIFICATION
Critical Must-Knows
- Three cuff attachments: Supraspinatus (superior), Infraspinatus (middle), Teres minor (inferior)
- 5mm displacement is surgical threshold (3mm for overhead athletes)
- Posterior displacement worst - limits external rotation function
- Axillary view essential - shows posterior displacement (crescent sign)
- Deltoid split must stay within 5cm of acromion to protect axillary nerve
Examiner's Pearls
- "GT fracture with dislocation often reduces after glenohumeral reduction
- "Superior malunion causes impingement, posterior causes rotation loss
- "Screw fixation for good bone, suture anchors for osteoporotic bone
- "External rotation strength testing is key clinical assessment
Clinical Imaging
Greater Tuberosity Fracture Imaging
Critical Greater Tuberosity Exam Points
Displacement Threshold
5mm displacement is the standard surgical threshold. Use 3mm threshold for overhead athletes and laborers requiring full shoulder function. Posterior displacement is more functionally significant.
Rotator Cuff Anatomy
Three tendons attach to GT: Supraspinatus (superior facet), Infraspinatus (middle facet), Teres minor (inferior facet). The subscapularis attaches to lesser tuberosity.
Axillary Nerve Safety
Deltoid split approach must stay within 5cm of acromion. The axillary nerve courses 5-7cm distal to the lateral acromion. Document nerve function before and after any manipulation.
Post-Dislocation Assessment
15-30% of anterior dislocations have associated GT fracture. Often reduces with glenohumeral reduction. Repeat imaging (especially axillary view) after reduction.
At a Glance - Management Decision
| Pattern | Displacement | Patient Factors | Treatment |
|---|---|---|---|
| Minimally displaced | Under 5mm | Any patient | Non-operative (sling, early ROM) |
| Borderline displacement | 3-5mm | Overhead athlete/laborer | Consider surgical fixation |
| Displaced fracture | Over 5mm | Active patient | Surgical fixation (screw/anchor) |
| With anterior dislocation | Variable | Any patient | Reduce first, reassess displacement |
| Posterior displacement | Any | Active patient | Strong surgical indication |
SITSRotator Cuff Attachments to GT
Memory Hook:SITS muscles but only first three attach to Greater Tuberosity - subscapularis sits on lesser!
TUBERGT Fracture Assessment
Memory Hook:The TUBER(osity) tells you what tendons attach and what displacement direction matters most!
FIX GTSurgical Decision Making
Memory Hook:FIX the GT when it meets surgical criteria!
Overview
Greater tuberosity fractures represent a clinically important subset of proximal humerus fractures due to their intimate relationship with rotator cuff function. The greater tuberosity serves as the attachment point for three of the four rotator cuff tendons - supraspinatus, infraspinatus, and teres minor.
Epidemiology
Incidence:
- 15-20% of all proximal humerus fractures
- Bimodal distribution: young males (high energy), elderly females (low energy)
- 15-30% associated with anterior shoulder dislocations
- Higher rate in contact sports and falls
Risk Factors:
- Osteoporosis (elderly)
- Contact sports participation
- Seizure disorders
- Alcohol intoxication
Mechanism of Injury
Direct Mechanism:
- Fall onto lateral shoulder
- Direct blow to shoulder
Indirect Mechanism:
- Forceful abduction with external rotation
- Avulsion by rotator cuff during dislocation
- Hyperabduction injury
Associated Injuries:
- Anterior shoulder dislocation (15-30%)
- Rotator cuff tears
- Hill-Sachs lesion
- Bankart lesion
Anatomy and Pathophysiology
Anatomical Considerations
The greater tuberosity is a critical anatomic landmark that determines rotator cuff function and shoulder biomechanics.
Greater Tuberosity Structure:
- Superior facet: Supraspinatus insertion
- Middle facet: Infraspinatus insertion
- Inferior facet: Teres minor insertion
- Located lateral to the articular surface
- Forms the lateral margin of the bicipital groove
Relationships:
- Lesser tuberosity: Medial, subscapularis insertion
- Bicipital groove: Between tuberosities
- Anatomical neck: Between tuberosities and head
- Surgical neck: Below tuberosities
Blood Supply:
- Anterior humeral circumflex artery (ascending branch)
- Posterior humeral circumflex artery
- Rotator cuff tendon vessels
The greater tuberosity anatomy is crucial for understanding displacement patterns.
Exam Pearl
The "crescent sign" on axillary radiograph shows the displaced greater tuberosity fragment posterior to the humeral head, indicating significant displacement that typically requires surgical intervention.
Classification
Classification
Based on Displacement:
Type I - Minimally Displaced:
- Fragment displaced less than 5mm
- Often associated with undisplaced surgical neck fracture
- Treated non-operatively in most patients
Type II - Displaced:
- Fragment displaced more than 5mm or angulated over 45°
- Significant functional deficit expected if not reduced
- Surgical indication in active patients
Type III - Associated with Dislocation:
- Greater tuberosity fracture with anterior shoulder dislocation
- Fragment often reduces with glenohumeral reduction
- Re-evaluate displacement after reduction
Neer classification remains primary for clinical decision-making.
Classification Summary
| Type | Displacement | Key Features | Treatment |
|---|---|---|---|
| Neer Type I | Under 5mm | Minimal displacement, stable | Non-operative |
| Neer Type II | Over 5mm | Significant displacement | Surgical fixation |
| Neer Type III | Variable | Associated dislocation | Reduce first, reassess |
| Avulsion | Variable | Small cortical fragment | Suture anchor fixation |
| Split | Variable | Larger fragment | Screw or plate fixation |
Clinical Assessment
History and Physical Examination
History
Mechanism:
- Fall onto outstretched hand or shoulder
- Direct blow to lateral shoulder
- Dislocation event (ask about reduction)
- Seizure activity
- Motor vehicle accident
Symptoms:
- Shoulder pain (lateral predominant)
- Inability to lift arm
- Weakness with external rotation
- History of dislocation
Red Flags:
- Numbness over deltoid (axillary nerve)
- Severe weakness (complete cuff avulsion)
- Vascular compromise
Thorough mechanism history helps predict associated injuries.
Physical Examination
Inspection:
- Swelling over lateral shoulder
- Ecchymosis (may extend to arm)
- Arm held in adduction and internal rotation
- Loss of normal shoulder contour
Palpation:
- Point tenderness over greater tuberosity
- Crepitus with gentle rotation
- Assess for associated injuries
Range of Motion:
- Active abduction limited and painful
- External rotation weak and painful
- Passive ROM may be preserved
Key Tests:
- External rotation lag sign (indicates cuff avulsion)
- Hornblower's sign (teres minor function)
- Resisted external rotation strength
External rotation strength testing is critical and must be compared to contralateral side.
Neurovascular Assessment
Axillary Nerve:
- Most commonly injured nerve
- Test deltoid motor function
- Test sensation over "regimental badge" area
- Document before and after any manipulation
Brachial Plexus:
- Complete motor examination
- Sensory examination of upper limb
- May be injured with high-energy mechanism
Vascular:
- Axillary artery at risk with dislocation
- Check distal pulses
- Assess capillary refill
- Consider angiography if concern
Document complete neurovascular examination before any reduction attempts.
ALWAYS document axillary nerve function before and after shoulder reduction. The nerve courses around the surgical neck and is vulnerable during both injury and reduction maneuvers.
Investigations
Imaging Studies
Trauma Series (3 Views Essential):
True AP (Grashey View):
- Perpendicular to scapular plane
- Shows glenohumeral joint space
- Identifies fracture and displacement
Scapular Y View:
- Lateral scapula projection
- Confirms reduction status
- Shows anterior/posterior displacement
Axillary View:
- Shows posterior displacement ("crescent sign")
- Identifies Hill-Sachs lesion
- Confirms glenohumeral reduction
- Most important view for displacement assessment
Velpeau Axillary:
- Alternative if cannot abduct arm
- Patient leans back over cassette
- Useful in emergency setting
The axillary view is most important for assessing GT displacement.
Exam Pearl
The "crescent sign" on axillary radiograph indicates posterior displacement of the greater tuberosity fragment. This finding often indicates need for surgical intervention.
Management Algorithm
Treatment Decision Making
Indications:
- Displacement under 5mm (or under 3mm in athletes)
- Elderly, low-demand patients with larger displacement
- Significant medical comorbidities
- Minimally displaced fracture-dislocation after reduction
Protocol:
Week 0-2:
- Sling immobilization
- Ice, analgesia
- Gentle pendulum exercises
Week 2-6:
- Progressive passive ROM
- Active-assisted exercises
- Avoid active abduction
Week 6-12:
- Active ROM when healed
- Strengthening exercises
- Rotator cuff rehabilitation
After 12 weeks:
- Full activities as tolerated
- Sport-specific training
- Return to work/sport based on function
Non-operative treatment yields excellent results in minimally displaced fractures.
Displacement Thresholds
Standard Patient:
- Under 5mm: Non-operative
- Over 5mm: Surgical fixation
Overhead Athlete/Laborer:
- Under 3mm: Non-operative
- Over 3mm: Consider surgery
Elderly/Low Demand:
- May accept greater displacement
- Consider comorbidities
- Functional goals important
Post-Dislocation Protocol
After Glenohumeral Reduction:
- Repeat imaging (AP, axillary essential)
- Measure persistent displacement
- Fragment often reduces with head
If Fragment Reduces:
- Non-operative treatment
- Early motion important
- Watch for instability
If Fragment Remains Displaced:
- Apply standard criteria
- Surgical fixation likely needed
- Consider associated instability repair
Surgical Technique
Operative Approaches
Indications:
- Isolated greater tuberosity fracture
- Most common approach used
Technique:
- Beach chair or lateral decubitus position
- Incision from anterolateral acromion edge
- Split deltoid in line with fibers
- Stay within 5cm of acromion (axillary nerve)
- Identify fracture fragment and cuff
Advantages:
- Direct access to fragment
- Minimizes soft tissue stripping
- Can extend if needed
Risks:
- Axillary nerve injury (stay proximal)
- Deltoid origin damage
Deltoid-splitting provides excellent access while protecting axillary nerve.
Exam Pearl
The axillary nerve emerges approximately 5-7cm distal to the lateral edge of the acromion. The deltoid-splitting approach must stay within 5cm of the acromion to avoid nerve injury.
Fixation Techniques
Technique:
- Reduce fragment anatomically
- Provisional K-wire fixation
- Cannulated screw over wire
- Washer if poor bone quality
- Typically 2 screws for rotation control
Pearls:
- Aim screws toward medial calcar
- Lag technique if bone allows
- Avoid proud screw head (impingement)
- Bury head below cortical surface
Two screws provide rotational stability and prevent toggle.
Complications
Potential Complications
Incidence: Most common complication of non-operative treatment with displacement
Types:
- Superior malunion: Subacromial impingement
- Posterior malunion: External rotation block
- Combined: Both impingement and rotation loss
Symptoms:
- Pain with overhead activities
- Weakness of external rotation
- Catching and clicking
- Night pain
Management:
- Osteotomy and repositioning
- Arthroscopic subacromial decompression (mild cases)
- May require reverse shoulder arthroplasty in severe cases
Malunion is the primary reason to treat displaced fractures surgically.
Malunion of greater tuberosity fractures with superior displacement causes painful subacromial impingement that may require osteotomy to correct. This reinforces the importance of achieving anatomic reduction in displaced fractures.
Postoperative Care
Rehabilitation Protocol
Goals:
- Protect fixation
- Control pain and swelling
- Maintain passive ROM
Week 0-2:
- Sling immobilization
- Pendulum exercises only
- Ice and analgesia
- Elbow/wrist/hand motion
Week 2-6:
- Passive forward flexion
- Passive external rotation (to neutral)
- No active abduction
- No active external rotation
Precautions:
- No lifting
- Sleep in sling or recliner
- Avoid reaching behind back
Protection phase focuses on healing while maintaining passive mobility.
Outcomes
Expected Results
Minimally Displaced Fractures:
- Union rate over 95%
- Good to excellent outcomes: 85-90%
- Return to pre-injury function: 80-85%
Functional Outcomes:
- Mean Constant score: 85-90
- Mean ASES score: 85-90
- Return to sport: 85%
Time to Recovery:
- Pain resolution: 6-8 weeks
- ROM recovery: 8-12 weeks
- Strength recovery: 12-16 weeks
- Full activity: 3-4 months
Non-operative treatment yields excellent results in appropriately selected patients.
Evidence Base
Key Studies
Platzer et al. - Displaced Greater Tuberosity Fractures
- Retrospective review of 135 patients with GT fractures
- Displacement over 5mm associated with worse outcomes
- Non-operative treatment with over 5mm: 40% unsatisfactory results
Park et al. - Arthroscopic vs Open Fixation
- Compared arthroscopic and open fixation techniques
- Similar functional outcomes between groups
- Arthroscopic group had less blood loss and shorter incision
George et al. - Fracture-Dislocations
- Review of GT fractures associated with anterior dislocations
- 15-30% of anterior dislocations have associated GT fracture
- Most fractures reduce with glenohumeral reduction
Bono et al. - Surgical Treatment Review
- Comprehensive review of surgical techniques
- Screw fixation preferred for large fragments with good bone
- Suture anchor fixation for osteoporotic bone or comminution
Green and Izzi - Classification and Treatment
- Proposed treatment algorithm based on displacement
- Recommended 3mm threshold for high-demand patients
- Emphasized posterior displacement as surgical indication
Viva Scenarios
Practice these scenarios to excel in your viva examination
"A 28-year-old rugby player sustains an anterior shoulder dislocation during a tackle. After closed reduction, X-rays show a greater tuberosity fracture with 8mm of superior displacement. How would you manage this patient?"
"An 82-year-old woman with osteoporosis falls and sustains a greater tuberosity fracture with 7mm of posterior displacement. Her pre-injury Constant score was 70 and she lives independently. What is your approach?"
"At 3 months post-operative following screw fixation of a displaced greater tuberosity fracture, your patient has persistent pain and inability to elevate the arm above 90 degrees. The fracture is united on X-ray. What is your differential and management?"
"Describe the surgical approach and fixation technique you would use for a displaced greater tuberosity fracture in a 45-year-old patient with good bone quality."
MCQ Practice
Self-Assessment Questions
Q1: Surgical Decision Making
Q: A 35-year-old tennis player sustains a greater tuberosity fracture with 4mm of superior displacement. Which factor would most influence your decision toward surgical management?
- A) Patient age
- B) Occupation as an overhead athlete
- C) Superior direction of displacement
- D) Fragment size
- E) Time from injury
A: B - The patient's occupation as an overhead athlete with high functional demands is the key factor. While the standard threshold is 5mm, many surgeons advocate 3mm threshold for overhead athletes requiring full shoulder function.
Q2: Anatomy
Q: Which rotator cuff tendon does NOT attach to the greater tuberosity?
- A) Supraspinatus
- B) Infraspinatus
- C) Teres minor
- D) Subscapularis
- E) All attach to the greater tuberosity
A: D - The subscapularis attaches to the lesser tuberosity, not the greater tuberosity. The three rotator cuff tendons that attach to GT are supraspinatus (superior), infraspinatus (middle), and teres minor (inferior facet).
Q3: Imaging
Q: What is the most important radiographic view for assessing displacement of a greater tuberosity fracture?
- A) True AP (Grashey) view
- B) Scapular Y view
- C) Axillary view
- D) Internal rotation AP view
- E) External rotation AP view
A: C - The axillary view best shows posterior displacement of the GT fragment (the "crescent sign"). Posterior displacement is often the most functionally significant and may be missed on AP views.
Q4: Surgical Approach
Q: When performing a deltoid-splitting approach, how far distal to the acromion must the surgeon stay to avoid axillary nerve injury?
- A) 2cm
- B) 3cm
- C) 5cm
- D) 7cm
- E) 10cm
A: C - The deltoid split must stay within 5cm of the acromion to avoid injury to the axillary nerve, which courses around the surgical neck 5-7cm distal to the lateral acromion.
Q5: Complications
Q: What is the most common complication following treatment of greater tuberosity fractures?
- A) Non-union
- B) Avascular necrosis
- C) Stiffness
- D) Infection
- E) Hardware failure
A: C - Stiffness is the most common complication following both operative and non-operative treatment of GT fractures. This emphasizes the importance of early motion protocols.
Australian Context
Australian Context
Greater tuberosity fractures in Australian practice follow international evidence-based guidelines with specific local considerations for patient populations and healthcare delivery.
The Australian population presents with greater tuberosity fractures in the typical bimodal distribution - young males with high-energy sporting or workplace injuries, and elderly females with low-energy falls often associated with osteoporosis. The significant participation in contact sports such as rugby league, rugby union, and Australian rules football contributes to the younger cohort. Falls prevention programs supported by Australian health departments are important for reducing the elderly fracture burden.
Australian orthopaedic training through the AOA provides comprehensive exposure to shoulder trauma management. The public hospital system allows timely surgical intervention for displaced fractures, while private practice provides additional options for early surgery in appropriate cases. Both settings achieve outcomes comparable to international standards when appropriate indications and techniques are followed.
Rehabilitation services through the public hospital physiotherapy departments and private practitioners support structured post-operative recovery. WorkCover and third-party insurers provide coverage for work-related and motor vehicle accident injuries respectively, facilitating comprehensive rehabilitation programs. Return to work assessments and graduated return to activity programs are well-established within the Australian compensation framework.
Imaging services including plain radiography and CT scanning are widely available throughout metropolitan and regional Australia. MRI access may be more limited in some regional areas, though this is rarely urgently required for acute greater tuberosity fractures. Telehealth and image transfer capabilities support regional management with metropolitan specialist input when needed.
Greater Tuberosity Fractures - Exam Quick Reference
High-Yield Exam Summary
Key Facts
- •Displacement threshold: 5mm standard, 3mm for overhead athletes
- •Three cuff attachments: Supraspinatus (superior), Infraspinatus (middle), Teres minor (inferior)
- •Posterior displacement worst - limits external rotation
- •Superior displacement causes impingement
- •15-30% of anterior dislocations have associated GT fracture
- •Axillary view shows posterior displacement (crescent sign)
- •Deltoid split must stay within 5cm of acromion (axillary nerve)
- •Screw fixation for large fragments with good bone
- •Suture anchors for osteoporotic bone or comminution
Surgical Steps
- •Beach chair position, arm draped free
- •Deltoid-splitting approach from anterolateral acromion
- •Split deltoid in line with fibers, stay within 5cm of acromion
- •Identify fracture and rotator cuff attachment
- •Reduce fragment anatomically
- •Provisional K-wire fixation
- •Place 2 cannulated screws toward medial calcar
- •Bury screw heads below cortical surface
- •Check fixation with fluoroscopy
Common Pitfalls
- •Missing posterior displacement on AP views alone
- •Treating displaced fractures non-operatively in active patients
- •Extending deltoid split beyond 5cm (axillary nerve)
- •Proud hardware causing impingement
- •Prolonged immobilization causing stiffness
- •Missing associated instability in fracture-dislocations
- •Using screw fixation in osteoporotic bone
Examiner Favorites
- •Describe rotator cuff attachments to greater tuberosity
- •What is the surgical threshold for displacement?
- •Why is posterior displacement worse than superior?
- •What approach would you use and why?
- •How do you protect the axillary nerve?
- •How would you fix a GT fracture in osteoporotic bone?
- •Management of GT fracture with anterior dislocation