Open Reduction and Internal Fixation of Two-Part Displaced Fractures of the Greater Tuberosity of the Proximal Part of the Humerus*

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two to eight years) after open reduction and internal

fixation of a two-part displaced fracture of the greater

tuberosity of the proximal part of the humerus. The

indication for operative reduction was one centimeter or

more of displacement of the fracture as seen on the

di-agnostic radiographs. The anterosuperior

deltoid-split-ting approach, combined with rotation of the humerus,

allowed adequate exposure of the retracted tuberosity.

Internal fixation of the greater tuberosity with heavy,

non-absorbable sutures and careful repair of the rotator

cuff permitted early passive motion. All fractures healed

without postoperative displacement. Six patients had an

excellent result and six had a good result; active elevation

averaged 170 degrees. There was one partial, transient

palsy of the axillary nerve.

Although 15 to 40 per cent of fractures of the proximal


of the humerus have some involvement of the greater

tubenosity’82242, two-part displaced fractures of the greater

tubenosity have been uncommon in reported series. Of all

operatively treated fractures of the proximal part of the

humerus that were reviewed at the AO documentation

cen-ten, fewer than 2 per cent were isolated, displaced fractures

of the greater tuberosity’9. However, this fracture may be

undendiagnosed and thus may be more common than the

literature suggests. Radiographic findings can be subtle

be-cause of the often small size of the fragment as well as

superimposition of the fragment oven the humeral head on

standard radiognaphs’ . Furthermore, small fragments may

be confused with deposits of calcium253’.

Two-part displaced fractures of the greater tuberosity

may result in limitation of motion and disability if they are

* No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject ofthis article.

No funds were received in support of this study.

t 161 Fort Washington Avenue, New York. N.Y. 10032.

:1:Suite IJ, 88-25 153rd Street, Jamaica, New York I 1432.

§University of Pittsburgh Center for Sports Medicine. Craig Street

at Baum Boulevard, Pittsburgh. Pennsylvania 15213.

#{182}JGreenwich Orthopaedic Associates, Greenwich Office Park

Build-ing 6, Greenwich, Connecticut 06831.

The purpose of this retrospective study was to

deter-mine the long-term results of open reduction and internal

fixation of two-part displaced fractures of the greater

tu-berosity that had been treated through a standard operative


Materials and Methods

Sixteen patients who had a two-part displaced fracture

of the greater tuberosity were treated with open reduction

and internal fixation at the Columbia-Presbyterian Medical

Center between 1982 and 1990. Patients having a fracture

that was more than six weeks old at the time of the operation

and those who had had a previous attempt at internal fixation

were excluded from the study. The fractures were classified

according to the criteria of Neer2, and all of the patients

were treated under the supervision of one of three of us

(L. U. B., S. J. Mc!., or E. L. F.). The indication for the

operation was at least one centimeter of displacement of the

tuberosity in any plane in an active, healthy patient.

Radiographs in three planes (anteropostenior and lateral

radiographs of the scapula, and an axillary radiograph) were

used to assess displacement of the tuberosity (Figs. 1-A,

1-B, and 1-C). Superior displacement was assessed, on the

anteropostenior radiograph, as the displacement of the

frag-ment in the axis of the humerus proximal to the articular

surface. The displacement was measured at the insertion of

the rotator cuff, just lateral to the articular surface. The

axillary radiograph was inspected for posterior retraction

and overlap of the fragment of the tuberosity with the

an-ticular surface. Posterior retraction was measured as the

amount of overlap, or, if well shown on the radiograph, as

the distance from the anterior edge of the fragment to the

anterior edge ofthe defect. In patients who could not tolerate

abduction of the arm for a standard axillary radiograph, a

Velpeau axillary radiograph8 was obtained. Computed

tom-ographic scans were made for three patients for whom an

adequate axillary or Velpeau axillary radiograph could not

be obtained. Axial cuts were most helpful, allowing


..‘. . A 1-B

Fig. 1-A: Anteropostenor radiograph made with the shoulder in internal rotation, showing superior displacement of a displaced fracture of the greater


Fig. 1-B: Lateral scapular radiograph showing posterior retraction of the fragment.

All sixteen patients had more than one centimeter of

posterior retraction of the tubenosity as seen on the axillary

radiographs or computed tomographic scans. Twelve

frac-tunes were also displaced more than one centimeter on the

antenoposterior radiograph, but four fractures had less than

one centimeter (average, four millimeters and range, two

to six millimeters) of superior displacement on this


Twelve patients were evaluated by interview, physical

examination, and radiognaphs at two to eight years, with an average follow-up of 4.5 years. Of the four patients who

were excluded from the study, three had had the operation

within the last two years, and one had been lost to


There were seven men and five women. The ages

ranged from thirty-four to seventy-two years, with an

av-erage of fifty-three years. The injury was the result of a fall

onto the arm in nine patients, a motor-vehicle accident in

two patients, and a gunshot in one patient. Two patients

had sustained a concomitant anterior glenohumenal

dislo-cation, with the fracture of the greater tuberosity remaining

displaced after glenohumeral reduction in our hospital.

At the follow-up evaluation, the patients were asked

about pain and functional status. On examination, active

elevation and external rotation were recorded, as was

pas-sive internal rotation. Manual testing of elevation and of

external rotation power was performed. Antenoposterior

ra-diographs of the scapula were assessed to determine union

Axillary radiograph showing posterior displacement with overlap of the

fragment onto the articular surface.

and height of the tuberosity with respect to the articular

surface. Axillary radiographs were examined for any

resid-ual overlap of the tuberosity on the articular surface, and

supraspinatus outlet nadiographs733 were examined for

evi-dence of encroachment on the space occupied by the

rotator-cuff tendon from below by a prominent tuberosity.

The result at follow-up was rated as excellent if the

patient had no pain, had full use of the extremity, and had


into its bed with multiple heavy, non-absorbable sutures,

which incorporate the strong rotator-cuff tendon (Fig. 3).

If the fragment is large, it is reduced in size by trimming

some of its cancellous bone. The greater tuberosity has three

facets for the insertions of the supraspinatus, infraspinatus,

and teres minon2’#{176}. Depending on the extent of the fracture

ofthe tuberosity, sutures are placed to pull the supraspinatus

facet down and the teres minor facet forward. The tear in

the rotator cuff, which occurs in the interval between the

tendons of the supraspinatus and subscapularis muscles, is

meticulously repaired. This may be done before placement

All of the fractures healed. Serial radiographs showed

no loss of reduction and no heterotopic bone in any patient.

Anteroposterion radiographs showed that all tuberosities had

healed below the level of the articular surface. This was

confirmed by the outlet radiographs, which showed the

pre-served space under the coracoacromial arch. Axillary

ra-diographs did not reveal any instances of persistent overlap

of the articular surface from posterior retraction of the


No patient had more than mild pain. Six patients had

no pain, while six patients had varying degrees of mild pain

FIG. 2 FIG. 3

Figs. 2 and 3: Schematic drawings depicting the operative technique.

Fig. 2: A four to five-centimeter incision is made in the direction of the skin creases anterosuperiorly. The deltoid is split (but not detached) from

the anterolateral corner of the acromion about four centimeters distally. A stay suture is placed to prevent propagation of the split, which might injure

the axillary nerve. (Reproduced, with permission, from Bigliani, L. U.: Fractures ofthe Proximal Humerus. In The Shoulder, edited by C. A. Rockwood,

Jr. , and F. A. Matsen, III. Vol. 1, p. 307. Philadelphia, W. B. Saunders, 1990.)

Fig. 3: The fragment is sutured back into its bed with multiple heavy, non-absorbable sutures through drill-holes in the bone. The concomitant

longitudinal tear of the rotator cuff is repaired. (Reproduced, with permission, from Bigliani, L. U. : Fractures of the Proximal Humerus. in The


FIG. 4-A FIG. 4-B

Figs. 4-A and 4-B: Computed tomographic scans of the shoulder of a patient who had an anterior two-part fracture-dislocation.

Fig. 4-A: After closed reduction of the glenohumeral joint, the fracture of the greater tuberosity remained displaced and the humeral head was

subluxated anteriorly.

Fig. 4-B: After open reduction and internal fixation of the tuberosity, there was reduction of the glenohumeral subluxation once the rotator cuff was

reattached to the proximal part of the humerus.

with use of the shoulder. None of the patients were limited

in their activities. None had clinical findings indicating

sub-acromial impingement.

Active elevation of the shoulder at follow-up ranged

from 150 to 180 degrees (average, 170 degrees) and external

rotation, from 40 to 80 degrees (average, 63 degrees). The

amount of internal rotation was not recorded for two

pa-tients. In the other ten patients, internal rotation ranged from

the ability to reach the seventh thoracic level with the hand

posteriorly to the ability to reach the second lumbar level

(average, ninth thoracic level). None of the patients had

loss of strength in the shoulder.

The result was rated excellent in six patients and good

in six. There were no satisfactory on unsatisfactory results.

One patient had a partial, transient palsy of the axillary

nerve. A stay suture had not been used at the end of the

deltoid split, and the split may have lengthened with

op-erative retraction, placing tension on the nerve. There was

full recovery of axillary motor function nine months after

the operation. At the two-year follow-up examination, the

patient had 150 degrees of active elevation, and the result

was rated good.

There were no infections or complications of

wound-healing. No reoperations were needed.


It has been speculated that fractures of the greater

tu-benosity result from the weak trabecular pattern of bone in

the proximal part of the humerus in old, osteoponotic

patients’6. Others have noted that the hiatus (rotator

inter-val) between the supraspinatus and subscapularis tendons,

spanned by the coracocapsular (coracohumeral) ligament,

prevents the subscapularis tendon and lesser tuberosity from


included in the fracture2. The exact mechanism of

fracture is unknown, but it may involve shearing against

the glenoid at the extremes of rotation or at dislocation,

although avulsion by the pull of the rotator cuff alone has

been hypothesized’3. Interposition of the long head of the

biceps tendon has been mentioned as a factor preventing

reduction of the fragment of the tuberosity’7, but this was

not seen in any of our patients.

Phemister recommended that rotational anteroposterior

radiographs be made to visualize fractures of the greaten

tuberosity hidden by superimposition of the humeral head39.

Morris et al., in a study of eighteen fractures of the proximal

part of the humerus, found that plain radiognaphs clearly

showed superior displacement of the greater tuberosity but

were misleading for the assessment of posterior retraction28.

Computed tomographic scans were better in such patients28.

Our findings were similar, in that anteroposterior and outlet

radiographs were reliable for the assessment of superior

displacement but often failed to demonstrate precisely the

amount of posterior retraction and overlap of the fragment

with the articular surface. However, we found that a

good-quality axillary radiograph (standard or Velpeau) was

gen-erally sufficient for such an assessment.

Computed tomographic scans may be indicated in

pa-tients who have equivocal findings. We believe that sole

reliance on standard anteroposterior radiographs may lead

to underestimation of the amount of posterior displacement

of the fragment and that the reported incidence of two-part

displaced fractures of the greater tuberosity may be falsely

low. Four of our patients had evidence of less than one

centimeter of superior displacement of the fragment on

an-teroposterior radiographs but more than one centimeter of

posterior displacement on axillary radiographs.

Fractures ofthe greater tuberosity frequently occur with

anterior glenohumeral dislocation’#{176}27. With reduction of

the glenohumenal dislocation, the tubenosity may or may


tear in the rotator cuff at the rotator interval between the

supraspinatus and subscapularis tendons4-5-32.

Several authors have commented on mechanical

block-age of abduction of the shoulder by a superiorly displaced

tuberosity3-’#{176}-’2-35. A posteriorly displaced tuberosity may

also impinge against the posterior glenoid and block external

rotation32. Such loss of external rotation may be more

pro-nounced with elevation of the shoulder#{176}.

Early anecdotal reports on the non-operative treatment

of fractures of the greater tubenosity gave few data on the

amount of displacement’5-45-48. McLaughlin found that

frac-tunes of the greaten tuberosity that healed with more than

one centimeter of displacement resulted in permanent

dis-ability, while those with one-halfcentimeter of displacement

or less did well24. He reported that patients who had between

one-half and one centimeter of displacement of the fragment

often had a prolonged convalescence, with some having

permanent pain and disability and with 20 per cent needing

a reconstructive procedure24.

Olivier et al. reported only 69 per cent satisfactory

results in a series of seventy-nine fractures (displaced and

non-displaced) of the greater tuberosity that were treated

been performed25, but there are few follow-up data on this

technique. Keen2#{176}seems to have performed the first open

reduction and internal fixation of an acute fracture of the

greater tuberosity, in 1907, but he credited Bardenhauer

with having developed the concept in 1886 and Muller with

having done the first repair of an old fracture in 1898.

Internal fixation has been achieved with pins23- and

screws29-38, but transosseous sutures have been generally

preferred for comminuted fractures of the greater

tuber-osity’9-36. Some investigators have used sutures

exclusive-ly2’31. Published follow-up data about these techniques are

limited. A study of 930 operatively treated fractures of the

proximal part of the humerus included seventeen isolated,

displaced fractures of the greater tuberosity, but no

follow-up results were given’9. Another study of six displaced

frac-tunes of the greater tuberosity that were stabilized with

screws showed good results38. We have found that


bone stock is necessary for fixation with screws, but it is

frequently lacking in these comminuted fractures. We

be-lieve that incorporation of the insertion of the tendon into

the suture fixation of the tuberosity is an important step in

the technique626.


1. AHOVUO, J.;PAAVOLAINEN, P.;and BJORKENHEIM, J.-M. : Fractures of the Proximal Humerus Involving the Intertubercular Groove. Acta Radiol.,

30: 373-374, 1989.

2. BAKER, D. M. , and LEACH, R. E.: Fracture Dislocation of the Shoulder - Report of Three Unusual Cases with Rotator Cuff Avulsion. J. Trauma, 5: 659-664, 1965.

3. BANDI, W.: Zur Operativen Therapie der Humeruskopf- und-Halsfrakturen. Hefte Unfallheilk. , 126: 38-45, 1975.

4. BIGLIANI, L. U.: Fractures of the Proximal Humerus. In The Shoulder, edited by C. A. Rockwood, Jr., and F. A. Matsen, III. Vol. 1, pp.

278-334. Philadelphia, W. B. Saunders, 1990.

5. BIGLIANI, L. U.: Treatment of Two- and Three-Part Fractures of the Proximal Humerus. In Instructional Course Lectures, The American Academy

of Orthopaedic Surgeons. Vol. 38, pp. 231-244. Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1989.

6. BIGLIANI, L. U.: Shoulder Trauma. In Orthopaedic Knowledge Update 2: Home Study Syallabus, pp. 195-206. Edited by R. H. Fitzgerald, Jr.

Park Ridge, Illinois, The American Academy of Orthopaedic Surgeons, 1987.

7. BIGLIANI, L. U.; MORRISON, D. S.;and APRIL, E. W.: The Morphology of the Acromion and Its Relationship to Rotator Cuff Tears. Orthop.

Trans. , 10: 228, 1986.

8. BLOOM, M. H., and OBATA, W. G.: Diagnosis ofPosterior Dislocation ofthe Shoulder with Use ofVelpeau Axillary and Angle-up Roentgenographic

Views. J. Bone and Joint Surg. ,49-A: 943-949, July 1967.

9. BOHLER, J.: Les fractures rdcentes de l’#{233}paule. Acta Orthop. Belgica, 30: 235-242, 1964.

10. CODMAN, E. A.: The Shoulder. Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston, privately

printed, 1934.

1 1. DEHNE, ERNST: Fractures at the Upper End of the Humerus. A Classification Based on the Etiology of the Trauma. Surg. Clin. North America,

25: 28-47, 1945.

12. DEPALMA, A. F., and CAUTILLI, R. A.: Fractures of the Upper End of the Humerus. Clin. Orthop. , 20: 73-93, 1961. 13. GIBBONS, A. P.: Fracture of the Tuberosity of the Humerus by Muscular Violence. British Med. J., 7: 1674. 1909.

14. GRATZ, C. M.: Anterior Subglenoid Dislocation with Fracture of the Greater Tuberosity of the Humerus. Surg. Clin. North America, 10:

549-551, 1930.

15. GREELEY, P. W., and MAGNUSON, P. B.: Dislocation of the Shoulder. Accompanied by Fracture of the Greater Tuberosity and Complicated by


16. HALL, M. C., and ROSSER, MARGARET: The Structure of the Upper End of the Humerus with Reference to Osteoporotic Changes in Senescence

Leading to Fractures. Canadian Med. Assn. J., 88: 290-294, 1963.

17. HENDERSON, R. S.: Fracture-Dislocation of the Shoulder with Interposition of Long Head of Biceps. Report of a Case. J. Bone and Joint Surg., 34-B(2): 240-241, 1952.

18. HORAK, JAN, and NILSSON, B. E.: Epidemiology of Fracture of the Upper End of the Humerus. Clin. Orthop. , 1 12: 250-253, 1975.

19. JAKOB, R. P.;KRISTIANSEN, T.;MAYO, K. ; GANZ, R. ; and MUu.ER, M. E. : Classification and Aspects of Treatment of Fractures of the Proximal

Humerus. in Surgery of the Shoulder, pp. 330-343. Edited by J. E. Bateman and R. P. Welsh. St. Louis, C. V. Mosby, 1984.

20. KEEN, W. W.: I. Fracture of the Greater Tuberosity of the Humerus, with Dislocation of the Humerus into the Axilla. Immediate Reduction of

Dislocation. On Seventh Day Nailing of Fragment of Tuberosity in Place. Ann. Surg. , 45: 938-944, 1907.

21. KEENE, J. S.;HUIZENGA, R. E.;ENGBER, W. D.; and RoGERs, S. C. : Proximal Humeral Fractures. A Correlation of Residual Deformity with Long-Term Function. Orthopedics, 6: 173-178, 1983.

22. LIND, T.; KR#{216}NEit,K.; and JENSEN, J.: The Epidemiology of Fractures of the Proximal Humerus. Arch. Orthop. and Traumat. Surg. , 108: 285-287, 1989.

23. LOVETT, R. W.: The Diagnosis and Treatment of Some Common Injuries of the Shoulder Joint. Surg. ,Gynec. and Obstet. , 34: 437-444, 1922. 24. MCLAUGHLIN, H. L.: Dislocation of the Shoulder with Tuberosity Fracture. Surg. Clin. North America, 43: 1615-1620, 1963.

25. MCWHORTER, G. L.: Fracture of the Greater Tuberosity of the Humerus with Displacement. Report of Two Operated Cases with Author’s Technic of Shoulder Incision. Surg. Clin. North America, 5: 1005-1017, 1925.

26. MADAY, M. G.; FLATOW, E. L.; CUOMO, FRANCES; MILLER, S. R.; MCILVEEN, S. J.; and BIGLIANI, L. U.: Open Reduction and Internal Fixation of 2- and 3- Part Proximal Humerus Fractures. Orthop. Trans., 15: 29, 1991.

27. MEYERDING, H. W.: Fracture-Dislocation of the Shoulder. Minnesota Med. , 20: 717-726, 1937.

28. MoIuuS, M. E. ; KILCOYNE, R. F.; SHUMAN, W. ; and MATSEN, FREDERICK, III: Humeral Tuberosity Fractures: Evaluation by CT Scan and

Management of Malunion. Orthop. Trans. , 11: 242, 1987.

29. MULLER, M. E. ; ALLoOwER, M. ; and WILLENEGGER, H.: Manual of Internal Fixation. Technique Recommended by the AO-Group. New York,

Springer, 1970.

30. NEER, C. S., II: Shoulder Reconstruction, pp. 377-380. Philadelphia, W. B. Saunders, 1990.

31. NEER, C. S., II: Fractures about the Shoulder. in Fractures in Adults, edited by C. A. Rockwood and D. P. Green. Ed. 2, pp. 675-721. Philadelphia,

J. B. Lippincott, 1984.

32. NEER, C. S., II: Displaced Proximal Humeral Fractures. Part I. Classification and Evaluation. J. Bone and Joint Surg. , 52-A: 1077-1089, Sept.


33. NEER, C. S., II, and POPPEN, N. K.: Supraspinatus Outlet. Orthop. Trans. , 11: 234, 1987.

34. NEER, C. S., II; MCCANN, P. D.; MACFARLANE, E. A.; and PADILLA, NILSA: Earlier Passive Motion Following Shoulder Arthroplasty and Rotator

Cuff Repair. A Prospective Study. Orthop. Trans. , 11: 23 1, 1987.

35. NEVIASER, J. S.: Complicated Fractures and Dislocations about the Shoulder Joint. J. Bone and Joint Surg. , 44-A: 984-998, July 1962. 36. OLIVIER, H.; DUFOUR, 0.; and DUPARC, J.: Les fractures du trochiter. Rev. chir. orthop., 62 (Supplement): 113-118, 1976.

37. OLIVIER, H.;DUPARC, J.;and ROMAIN, F.: Fractures of the Greater Tuberosity of the Humerus. Orthop. Trans. , 10: 223, 1986.

38. PAAVOLAINEN, PEKKA; BJORKENHEIM, J.-M. ; SLATIS, PAR; and PAUKKU, PERTTI: Operative Treatment of Severe Proximal Humeral Fractures. Acta Orthop. Scandinavica, 54: 374-379, 1983.

39. PHEMISTER, D. B.: Fractures of the Greater Tuberosity of the Humerus. With an Operative Procedure for Fixation. Ann. Surg. , 56: 440-449,


40. POST, MELVIN: Fractures of the Upper Humerus. Orthop. Clin. North America, 11: 239-252, 1980.

41 . ROBERTS, S. M.: Fractures of the Upper End of the Humerus. An End-Result Study Which Shows the Advantage of Early Active Motion. J. Am. Med. Assn. , 98: 367-373, 1932.

42. ROSE, S. H.; MELTON, L. J.; MORREY, B. F.; ILSTRUP, D. M.; and Rioos, B. L.: Epidemiologic Features of Humeral Fractures. Clin. Orthop.,

168: 24-30, 1982.

43. SANTEE, H. E.: Fractures about the Upper End of the Humerus. Ann. Surg., 80: 103-114, 1924.

44. SCHLAEPFER, KAxL: Uncomplicated Dislocations of the Shoulder: Their Rational Treatment and Late Results. Am. J. Med. Sci. , 167: 244-255, 1924.

45. SEVER, J. W.: Fracture of the Head of the Humerus. Treatment and Results. New England J. Med. , 216: 1100-1107, 1937. 46. STEVENS, J. H.: Fractures of the Upper End of the Humerus. Ann. Surg. , 69: 147-160, 1919.

47. STEVENS, J. H.: The Action of the Short Rotators on the Normal Abduction of the Arm, with a Consideration of Their Action in Some Cases of

Subacromial Bursitis and Allied Conditions. Am. J. Med. Sci. , 138: 870-884, 1909.

48. TAYLOR, H. L.: Isolated Fracture of the Greater Tuberosity of the Humerus. Ann. Surg. ,47: 10-12, 1908.




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