Advertisement

Minimally Invasive Treatment of Greater Tuberosity Fractures

  • Brian Magovern
  • Xavier Duralde
  • Guido MarraEmail author
Chapter

Abstract

The proximal humerus tends to fracture into four distinct fragments: the humeral shaft, the greater and lesser tuberosities, and the articular surface.1 Neer based his classification system on displacement of these fragments by greater than 1 cm or angulation of more than 45°. In a retrospective review, Neer found that 85% of fractures were considered to be minimally displaced and nonoperative management led to satisfactory results. Displaced two-part greater tuberosity fractures, according to the above criteria, were treated with open reduction and internal fixation.1,2

Several authors, however, have advocated treatment that is more aggressive for fractures of the greater tuberosity. Five millimeters of displacement, particularly in the superior direction, has been suggested as an indication for operative management.35 The major deforming forces on the greater tuberosity are the supraspinatus, infraspinatus, and teres minor, resulting in superior and/or posterior pull of the fragment. Malunion with superior displacement may lead to painful impingement and posterior displacement may result in loss of external rotation, which can be challenging to treat.68

References

  1. 1.
    Neer CS II. Displaced Proximal Humeral Fractures. Part I. Classi­fication and Evaluation. J Bone Joint Surg 1970;52-A:1077–1089Google Scholar
  2. 2.
    Neer CS II. Displaced Proximal Humeral Fractures. Part II. Treatment of Three-Part and Four-Part Displacement. J Bone Joint Surg 1970;52-A:1090–1103Google Scholar
  3. 3.
    McLaughlin HL. Dislocation of the Shoulder with Tuberosity Fracture. Surg Clin North Am 1963;43:1615–1620PubMedGoogle Scholar
  4. 4.
    Levy AS. Greater Tuberosity Fractures of the Humerus. Orthop Trans 1998;22:594Google Scholar
  5. 5.
    Green A, Izzi J. Isolated Fractures of the Greater Tuberosity of the Proximal Humerus. J Shoulder Elbow Surg 2003;12:641–649CrossRefPubMedGoogle Scholar
  6. 6.
    Hawkins RJ, Angelo RL. Displaced Proximal Humeral Fractures. Selecting Treatment, Avoiding Pitfalls. Orthop Clin North Am 1987;18:421–431PubMedGoogle Scholar
  7. 7.
    Flatow EL, Cuomo F, Maday MG, et al. Open Reduction and Internal Fixation of Two-Part Displaced Fractures of the Greater Tuberosity of the Proximal Part of the Humerus. J Bone Joint Surg 1991;73-A:1213–1218Google Scholar
  8. 8.
    Berdjiklian PK, Iannotti JP, Norris TR, et al. Operative Treatment of Malunion of a Fracture of the Proximal Aspect of the Humerus. J Bone Joint Surg 1998;80-A:1484–1497Google Scholar
  9. 9.
    Berger RA. Total Hip Arthroplasty Using the Minimally Invasive Two-Incision Approach. Clin Orthop Relat Res 2003;417:232–241PubMedGoogle Scholar
  10. 10.
    Yeung AT, Tsou PT. Posterolateral Endoscopic Excision for Lumbar Disc Herniation: Surgical Technique, Outcome, and Complications in 307 Consecutive Cases. Spine 2002;27:722–731CrossRefPubMedGoogle Scholar
  11. 11.
    Collinge CA, Sanders RW. Percutaneous Plating in the Lower Extremity. J Am Acad Orthop Surg 2000;8:211–216PubMedGoogle Scholar
  12. 12.
    Schandelmaier P, Partenheimer A, Koenemann B, et al. Distal Femoral Fractures and LISS Stabilization. Injury 2001;32(S3):SC55–SC63PubMedGoogle Scholar
  13. 13.
    Fankhauser F, Gruber G, Schippinger G, et al. Minimal-invasive Treatment of Distal Femoral Fractures with the LISS (Less Invasive Stabilization System): A Prospective Study of 30 Fractures with a Follow up of 20 Months. Acta Orthop Scand 2004;75:56–60CrossRefPubMedGoogle Scholar
  14. 14.
    Anglen J, Choi L. Treatment Options in Pediatric Femoral Shaft Fractures. J Orthop Trauma 2005;19:724–733CrossRefPubMedGoogle Scholar
  15. 15.
    Boldin C, Fankhauser F, Hofer HP, Szyszkowitz R. Three-Year Results of Proximal Tibia Fractures Treated with the LISS. Clin Orthop Relat Res 2006;445:222–229PubMedGoogle Scholar
  16. 16.
    Geissler WB, Petrie SG, Savoie FH. Arthroscopic Fixation of Greater Tuberosity Fractures of the Humerus (Abstract). Arthroscopy 1994;10:344Google Scholar
  17. 17.
    Gartsman GM, Taverna E. Arthroscopic Treatment of Rotator Cuff Tear and Greater Tuberosity Fracture Nonunion. Arthroscopy 1996;12:242–244CrossRefPubMedGoogle Scholar
  18. 18.
    Gartsman GM, Taverna E, Hammerman SM. Arthroscopic Treatment of Acute Traumatic Anterior Glenohumeral Dislocation and Greater Tuberosity Fracture. Arthroscopy 1999;15:648–650CrossRefPubMedGoogle Scholar
  19. 19.
    Bonsell S, Buford DA. Arthroscopic Reduction and Internal Fixation of a Greater Tuberosity Fracture of the Shoulder: A Case Report. J Shoulder Elbow Surg 2003;12:397–400CrossRefPubMedGoogle Scholar
  20. 20.
    Taverna E, Sansone V, Battistella F. Arthroscopic Treatment for Greater Tuberosity Fractures: Rationale and Surgical Technique. Arthroscopy 2004;20:e53–e57CrossRefPubMedGoogle Scholar
  21. 21.
    Carrera EF, Matsumoto MH, Netto NA, Faloppa F. Fixation of Greater Tuberosity Fractures. Arthroscopy 2004;20:e109–e111PubMedGoogle Scholar
  22. 22.
    Chen C, Chao E, Tu Y, et al. Closed Management and Percutaneous Fixation of Unstable Proximal Humerus Fractures. J Trauma 1998;45:1039–1045CrossRefPubMedGoogle Scholar
  23. 23.
    Williams GR, Wong KL. Two-part and Three-part Fractures: Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Pinning. Orthop Clin North Am 2000;31:1–21CrossRefPubMedGoogle Scholar
  24. 24.
    Park MC, Murthi AM, Roth NS, et al. Two-part and Three-part Fractures of the Proximal Humerus Treated with Suture Fixation. J Orthop Trauma 2003;17:319–325CrossRefPubMedGoogle Scholar
  25. 25.
    Ogawa K, Yoshida A, Ikegami H. Isolated Fractures of the Greater Tuberosity of the Humerus: Solutions to Recognizing a Frequently Overlooked Fracture. J Trauma 2003;54:713–717CrossRefPubMedGoogle Scholar
  26. 26.
    Parsons BO, Klepps SJ, Miller S, et al. Reliability and Reproducibility of Radiographs of Greater Tuberosity Displacement. J Bone Joint Surg 2005;87-A:58–65CrossRefGoogle Scholar
  27. 27.
    Sidor ML, Zuckerman JD, Lyon T, et al. The Neer Classification System for Proximal Humeral Fractures. An Assessment of Interobserver Reliability and Intraobserver Reproducibility. J Bone Joint Surg 1993;75-A:1745–1750Google Scholar
  28. 28.
    Siebenrock KA, Gerber C. The Reproducibility of Classification of Fractures of the Proximal End of the Humerus. J Bone Joint Surg 1993;75-A:1751–1755Google Scholar
  29. 29.
    Bernstein J, Adler L, Blank JE, et al. Evaluation of the Neer System of Classification of Proximal Humeral Fractures with Computerized Tomographic Scans and Plain Radiographs. J Bone Joint Surg 1996;78-A:1371–1375Google Scholar
  30. 30.
    Blaine TA, Bigliani LU, Levine WN. Fractures of the Proximal Humerus. In: Rockwood CA, et al (eds.) The Shoulder. Philadelphia: Saunders, 2004, pp. 355–412Google Scholar
  31. 31.
    Sjoden GO, Movin T, Guntner P, et al. Poor Reproducibility of Classification of Proximal Humerus Fractures. Additional CT of Minor Value. Acta Orthop Scand 1997;68:239–242CrossRefPubMedGoogle Scholar
  32. 32.
    Burkhart SS, Lo IKY. Arthroscopic Rotator Cuff Repair. J Am Acad Orthop Surg 2006;14:333–346PubMedGoogle Scholar
  33. 33.
    Kim S, Ha K, Kim S. Bankart Repair in Traumatic Anterior Shoulder Instability: Open Versus Arthroscopic Technique. Arthroscopy 2002;18:755–763CrossRefPubMedGoogle Scholar
  34. 34.
    Nam EK, Snyder SJ. The Diagnosis and Treatment of Superior Labrum, Anterior and Posterior (SLAP) Lesion. Am J Sports Med 2003;31:798–810PubMedGoogle Scholar
  35. 35.
    Lubowitz JH, Elson WS, Guttmann D. Part I: Arthroscopic Management of Tibial Plateau Fractures. Arthroscopy 2004;20:1063–1070CrossRefPubMedGoogle Scholar
  36. 36.
    Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic Reduction Versus Fluoroscopic Reduction in the Management in the Management of Intra-articular Distal Radius Fractures. Arthroscopy 2004;20:225–230CrossRefPubMedGoogle Scholar
  37. 37.
    Schai PA, Hintermann B, Koris MJ. Preoperative Arthroscopic Assessment of Fractures About the Shoulder. Arthroscopy 1999;15:827–835CrossRefPubMedGoogle Scholar
  38. 38.
    Carro LP, Nunez MP, Llata JIE. Arthroscopic-Assisted Reduction and Percutaneous External Fixation of a Displaced Intra-articular Glenoid Fracture. Arthroscopy 1999;15:211–214CrossRefPubMedGoogle Scholar
  39. 39.
    Kim S, Ha K. Arthroscopic Treatment of Symptomatic Shoulders with Minimally Displaced Greater Tuberosity Fracture. Arthroscopy 2000;16:695–700CrossRefPubMedGoogle Scholar
  40. 40.
    Jaberg H, Warner JJP, Jakob RP. Percutaneous Stabilization of Unstable Fractures of the Humerus. J Bone Joint Surg 1992;74-A:508–515Google Scholar
  41. 41.
    Naidu SH, Bixler B, Capo JT, et al. Percutaneous Pinning of Proximal Humerus Fractures: A Biomechanical Study. Orthopaedics 1997;20:1073–1076Google Scholar
  42. 42.
    Gerber C, Schneeberger AG, Vinh T. The Arterial Vascularization of the Humeral Head: An Anatomical Study. J Bone Joint Surg 1990;72-A:1486–1494Google Scholar
  43. 43.
    Gallo RA, Zeiders GJ, Altman GT. Two-Incision Technique for Treatment of Complex Proximal Humerus Fractures. J Orthop Trauma 2005;19:734–740CrossRefPubMedGoogle Scholar
  44. 44.
    Burkhead WZ, Scheinberg RR, Box G. Surgical Anatomy of the Axillary Nerve. J Shoulder Elbow Surg 1992;1:31–36CrossRefGoogle Scholar
  45. 45.
    Hoppenfeld S, de Boer P. The Shoulder, In: Hoppenfeld S, de Boer P (eds.) Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia: Lippincott, 1994, pp. 1–50Google Scholar
  46. 46.
    Gardner MJ, Griffith MH, Dines JS, et al. The Extended Anterolateral Acromial Approach Allows Minimally Invasive Access to the Proximal Humerus. Clin Orthop Relat Res 2005;434:123–129CrossRefPubMedGoogle Scholar
  47. 47.
    Paavolainen P, Bjorkenheim J, Slatis P, Paukku P. Operative Treatment of Severe Proximal Humeral Fractures. Acta Orthop Scand 1983;54:374–379CrossRefPubMedGoogle Scholar
  48. 48.
    Chun J, Groh GI, Rockwood CA. Two-Part Fractures of the Proximal Humerus. J Shoulder Elbow Surg 1994;3:273–287CrossRefGoogle Scholar
  49. 49.
    Hawkins RJ, Kiefer GN. Internal Fixation Techniques for Proximal Humeral Fractures. Clin Orthop Relat Res 1987;223:77–85PubMedGoogle Scholar
  50. 50.
    Earwaker J. Isolated Avulsion Fracture of the Lesser Tuberosity of the Humerus. Skeletal Radiol 1990;19:121–125CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Section of Shoulder and Elbow SurgeryLoyola University Medical CenterMaywoodUSA

Personalised recommendations