Case presentation on greater tuberosity fracture

In this episode we discuss a case presentation regarding a greater tuberosity fracture in a young patient. The X-rays and video presentation can be seen on the YouTube channel.

Transcript

Welcome And Who This Is For

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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves.

Skateboard Fall And Symptom Timeline

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Hello everyone, and welcome back to the podcast. My name is Chuck Dowell. I will be the host for today's episode. Today we are going to do a case presentation on a patient I recently saw in the orthopedic urgent care that I work at. This will be a both audio and video presentation. So if you are following this along on the YouTube channel, you will be able to see the x-rays and the images associated with kind of what I'm talking about during the presentation. So this was a gentleman who came into clinic, 43-year-old gentleman states he was skateboarding about two and a half weeks before I saw him. He had fallen off the skateboard, laying it directly onto the lateral or outside aspect of his shoulder, and was having increased pain within the shoulder. He tried to treat this conservatively, as uh most of us traditionally do with ice elevation, uh, excuse me, ice um limited motion, uh sling immobilization, and um anti-inflammatory medications. After a few weeks, he felt like the symptoms under his uh shoulder pain was not getting better, if not getting worse. He described a blocking sensation within the shoulder. Um, he felt Endor noted some bruising at his elbow and forearm area, and he had significant difficulty with lifting his arm up.

Physical Exam And Motion Limits

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On physical examination, he did have some diffuse edema throughout the shoulder, some bruising into his anticubital fossa area, extending into the elbow area. Diffuse tenderness was noted throughout the lateral shoulder or lateral deltoid area, greater tuberosity area with some extension into the anterior deltoid area. He had noticeable limitations with range of motion. Um, active range of motion was forward flexion at 60 degrees, abduction to 40 degrees, external rotation at 20 degrees, and inter rotation to the belly. Um had significant pain with abduction

X-Ray Findings Greater Tuberosity Fracture

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and forward flexion activities within the lateral shoulder area. So we got x-rays of his shoulder, four views of his shoulder, which again, if you're following along on the YouTube channel, you can see on the screen now. Um so if you see this patient has what we call a greater tuberosity fracture. Um this area at the very top of his shoulder where the rotator cuff, uh, or at least two of the rotator cuff muscles, the superspinatus and infraspinatus attach at, um, it has been fractured off. Uh so again, uh here on this AP view, you could see the best. On the grashy view, um, you could see it maybe even a little bit of an impaction component to it. Uh, on our scapular Y view, um, not much change there. And then on our axillary view, uh, interesting enough, on our axillary view, you can see some subtle changes within this kind of anterior glenoid area, and possibly even on our AP view and this anterior inferior glenoid area. The patient didn't remember during the HPI portion of the shoulder actually dislocating or popping out and are feeling sensations similar to this. But when we discuss these greater tuberosity fractures, um, these fractures often happen secondary to either a direct fall onto the lateral aspect of the shoulder or trying to put that arm out to catch yourself. And this greater tuberosity bumps up against this undersurface of the acromion and can cause the fracture to happen. These fractures can be undisplaced and or displaced fractures, depending upon the nature of the fracture or how specifically they happen. Oftentimes, when they're associated with a dislocation of the shoulder, typically they are displaced fractures. Some people do call these the hidden fractures because oftentimes patients will have undisplaced grated tuberosity fractures, um, as you can potentially see on this MRI here, and they won't know it. So they'll have an injury to their shoulder, they'll be diagnosed as a shoulder sprain or strain. Um, they'll

Hidden Fractures And Post-Injury Stiffness

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have this um subchondrial edema consistent with a fracture within that area, but again, the X-ray will look relatively normal. Uh, oftentimes these are seen with skiing or mountain biking injuries, kind of more high velocity injuries. And these patients, especially these ones that have this hidden type fracture, will come in with um progressive symptoms that are not improving, not following a normal timeline for a shoulder sprain, and oftentimes can be associated with a frozen shoulder afterwards because um they're so stiff they're not moving their shoulder. So when you're questioning these patients and somebody comes in, if they do have a trauma-related lack of motion, I definitely think concern for a frozen shoulder is there, and that's definitely one of the questions you want to ask. And our patient specifically, we didn't necessarily have that he had a direct trauma to the area.

Rotator Cuff Anatomy And Impingement Risk

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Now, when we talk about the greater tuberosity, so um when we're looking at the shoulder, you can see when the shoulder naturally abducts, this uh greater tuberosity area is trying to un you know not impinge on that um on that uh undersurface of the acromion. And so one of the things we worry about, especially if it's a displaced fracture, is when the patient will go to abduct their arm, you'll get impingement on this undersurface of the acromion there. And you can see that on the model we're looking at now. Um again, when we talk about attachments um to the area of the greater tuberosity, um we can see that muscularly, sorry, I let my my information boot up here, um the muscular attachments. Sorry about that, the muscular attachments of that greater tuberosity. So again, if we're looking here, you can see here's the anterior deltoid, so those are the overlying muscles. If we remove a layer from there, you can see under that is our biceps brachii. If we rotate that shoulder around, you could see our infraspinatus and supraspinatus does come in to attach here. And if we rotate this directly laterally, you could see at the top here, um, our infraspinatus comes in and provides external rotation pull of that shoulder, and our supraspinatus comes in and provides abduction pull of the shoulder. If we remove one more layer, um you you'd be able to see that the uh coracochromial ligaments, uh excuse me, the um the coraco humeral ligaments also attach at that greater tuberosity area, as you can see here. So when we talk about direct abduction, so as far as um movement of the shoulder itself, when we look at the supraspinatus, um we can see that the supraspinatus attaches at that lateral aspect uh greater tuberosity and provides this direct abduction pull. Um but you can see here that if there was a displaced fracture with this abiduction pull, that may be um impinging on the undersurface of the um that may be impinging on the undersurface of the acromion itself. If we look at the infraspinatus itself, the infraspinatus provides external rotation to the shoulder. And so you can see on the diagram here, the infraspinatus itself is externally rotating the shoulder. Um and so as we go through the motion, we'll speed this up a little bit here. Um, you can see this pulled external rotation that that gets. So when we're talking about these fractures themselves, our one of our biggest worries is that if we allow this patient to

When Surgery Is Needed And Fixation Options

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have a lot of motion, it will pull at these fracture segments and can actually cause displacement of the fracture itself. Specifically, as far as decision making regarding greater tuberosity fractures, typically surgery is indicated for fractures with more than five millimeters of displacement. And this again is to minimize the risk of subachromial impingement or altered rotator cuff biomechanics, which can happen again with that abduction pull of the superspinatus and external rotation pull of the infraspinatus. Isolated greater tuberosity fractures are fairly uncommon. This is typically about 15% of all proximal humorous fractures. Um, oftentimes these are associated with an anterior shoulder dislocation. Depending on the literature you read, this can be anywhere from 30 to 50 percent. When we talk about greater tuberosity fractures themselves, um we look at the breaking up. So in this patient that you see on the screen now, um, this would be more of a proximal humerus fracture. When we divide that proximal humerus into parts, again, the shaft, the head, the greater tuberosity, looking at the fracture lines. So in this patient, they do have a fracture line through that grater tuberosity, but also have this surgical neck fracture of that proximal humerus. Again, we can have these isolated kind of small grater tuberosity fractures that could cause displacement. It could be this impaction type fracture, or they could be these large fractures which are further concern for displacement. Regarding surgical intervention for these fractures, there are a couple different options. We can do um isolated screws, these can be cannulated to pin the fracture into position. Uh, we can do soft tissue um, you know, fractures. Uh, so we drill a hole inferior to the fracture and pass some suture tape through there andor a button to hold that fracture segment down, or we can even do kind of a full plate uh fixation of this if necessary. Um our patient um we did get an MRI because there again was two and a half weeks out from the initial fracture. Um, and there was some concern about anterior shoulder instability based upon some subtle findings seen on the X-rays.

Immobilisation Rehab Timeline And Follow-Up Imaging

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Uh for treatment-wise, I think the biggest thing for these patients is to initially immobilize them. The concern, if we don't initially immobilize them, would be that potentially the pull of that supraspinatus and infraspinatus will cause displacement of the fractures. So most of the literature would show six weeks of shoulder mobilization with an abduction pillow. That abduction pillow will abduct that arm out, have less stress of that direct pull of that supraspinatus or those rotator cuff muscles on that area. And then typically every two to three weeks, um, getting uh imaging to evaluate and or confirm there's no displacement within the fracture area. Usually at about six weeks, we'll start some light active motion. At 12 weeks, we'll start strengthening to begin. Any patients that have any persistent pain after three months, if you haven't already obtained an MRI, I would obtain an MRI at that time for valuation to ensure that the rotator cuff is intact and there's no significant concerns from that way. Again, as far as operative uh intervention, most would recommend uh more than five millimeters of displacement will cause possible subacromial impingement and change on biomechanical forces. Some authors recommend repairing all greater tuberosity fractures because there is concern about the displacement changing the abduction forces of the shoulder. Um of the studies I reviewed did show that with um five millimeters of displacement, there was a 27% uh change to the deltoid forces regarding abduction of the shoulder. So there can be significant biomechanical concerns, especially in patients uh if there's their dominant arm. So I just thought an interesting case, something we see quite a

Instability Workup MRI Or CT And Key Takeaways

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lot, um, especially in the orthopedic urgent care. Uh keep an eye out for these. Hopefully, this will help as far as if you do see these, what the workup would be. Again, majority of the time, because they're associated with anterior shoulder dislocations, make sure you try to take a good history regarding this and likely getting an MRI on a lot of these, possibly even a CT scan with 3D reconstructions, just to evaluate for the bonyomorphology of the fracture and the underlying concern about issues to the rotator cuff or possible anterior-inferior glenoid associated with the dislocation. Again, when the dislocation happens, it's directly because or the fracture happens because of the direct impact. So we see these hillsac lesions sometimes with these dislocations where that posterior kind of superior shoulder will abut against the anterior-inferior glenoid, but sometimes you can actually fracture the piece of bone off as well during these dislocations. Ideally, reduce the dislocation at first, but with these higher traumatic injuries, may have a higher concern about uh fracture fixation here. Hopefully, you enjoyed this case. Um, we will try to get a few more of these out if possible. If you're enjoying these, please leave any feedback regarding this. Uh, and thank you for joining me.