Greater Tuberosity Fractures are a unique type of proximal humerus fractures. Although some people refer to them as shoulder fractures, we prefer to avoid that term as there are many bones around the shoulder. Greater Tuberosity Fractures may occur due to trauma or shoulder dislocation, and represent a boney disruption to the rotator cuff tendons around the shoulder. They can occur in any age group, although they are most commonly due to a fall in older individuals or due to athletic injuries. As the boney piece dislodges, the attached rotator cuff muscles/tendons tend to pull the piece backwards and towards the center of the body.
Patients are often seen first in the Emergency Room, where the diagnosis is made. A sling is applied to help with pain control and to avoid movement around the shoulder. In contrast to many other fractures, it is not possible to ‘cast’ fractures around the shoulder, nor is it necessary in this instance to allow for healing.
Patients are then referred to a fracture clinic where they are seen by an Orthopaedic surgeon. The X-rays obtained and the cause of the injury will help the surgeon determine how severe the injury is. As treatment decisions depend on the size of the fracture and how far it has pulled away from its normal (or ‘anatomic’) location, a CT scan is often obtained.
Fractures with minimal movement from their anatomic location can be treated without surgery. In contrast, if the boney piece is pulled 5mm away or more, surgery is recommended. Pieces that have travelled between 1-4mm require close observation.
If surgery is recommended, the main goal of the procedure is actually to repair the rotator cuff tendons as close to their normal attachment as possible. The boney fracture is secured using strong suture and either a screw or a suture anchor. The combination of the suture and the screw/suture anchor will hold the bone in place to allow for the rotator cuff to heal.
Expected Follow-up and Recovery
Although unique circumstances exist (i.e. 1-4mm of boney movement in the dominant extremity of a worker who performs overhead activity), the following treatment recommendations commonly hold true:
- Stable (0mm of boney movement): Sling for comfort for 4 weeks. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active/assisted fashion, with fully active motion starting at 6 weeks and strengthening starting at 2 months.
- Observe (0-4mm of boney movement): Sling is an absolute requirement for 6 weeks. The goal of the sling is to prevent further displacement of the fracture. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active fashion. Strengthening is avoided until range of motion of the injured shoulder is nearly as good as the uninjured side.
- 5mm or more of boney movement: Surgery is often recommended for fractures with this amount of movement. Following surgery, a sling is an absolute requirement for 6 weeks. The goal of the sling is to allow for healing of both the bone and the rotator cuff tear. During this time finger, wrist and elbow motion may occur, but no motion at the shoulder. Following this, physical therapy can be started in an active fashion. Strengthening is avoided until range of motion of the injured shoulder is nearly as good as the uninjured side, typically at 3 months.
- All slings should be kept clean and dry.
- Swelling is common following an injury or fracture. To decrease swelling consider icing it 15 minutes at a time every 1-2 hours. Ice should be wrapped in a tea-towel to avoid frost-bite.
- Bruising down the arm or across the chest is expected following any fracture around the shoulder
- Occasional numbness that resolves quickly is to be expected. Persistent numbness in the arm is not common and should be mentioned to your physician.
- You may find it more comfortable to sleep in a reclining chair for the first 2-5 weeks following the injury. Ensure the chair is placed close to washrooms and away from any tripping hazards.
General Therapy Instructions
Please note: this alone does not constitute as a formal referral to a physical therapy. As each injury is unique, the below may not apply to everyone.
- While in a sling: Work on active and active assisted range of motion of your fingers/thumb, wrist and elbow to prevent stiffness. As long as your elbow is close to your body, non-weight bearing exercises are safe to perform for the above joints.
- 4-5 weeks following injury: As pain subsides, you can begin to perform light pendular exercises. To do this, you let your arm hang and have gravity rotate your hand around. This allows for some motion through your shoulder without excessive stress on the fracture.
- 5-6 weeks following injury: Once your fracture is healed you will begin to wean the sling and start physical therapy. The goal is to regain 80% of your shoulder motion by 12 weeks post injury.
- 12 weeks post injury: Add in strengthening of the shoulder, with sport or job specific exercises as needed.
- At all times: Let pain be your guide. Excessive discomfort or therapist concern should prompt you to contact your Orthopaedic Surgeon or Family Physician.
Shoulder fractures can cause significant stiffness and weakness around the shoulder. Depending on the severity, your treating physician will comment on your expected recovery. In general, we aim to return people to 80% of their previous function and back to work before the 12-week mark. Office workers are often able to return to work 2-4 weeks following injury, and may use a keyboard and mouse in a sling with their elbow at their sides.
- Wrist/Finger Stiffness: May require formal physical therapy over 6 months to resolve. Chance of finger/wrist stiffness can be greatly decreased by keeping both joints moving.
- Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
- Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.
Summary of Common Treatment/Rehabilitation Pathway