1 Treatment principles topenlarge
The greater tuberosity fragment tends to be displaced superiorly and posteriorly due to the pull of the rotator cuff (supraspinatus and infraspinatus tendon). If the greater tuberosity heals with displacement (5 mm or more), it may impinge upon the coracoacromial arch, limiting motion, and producing pain. In this position, it provides a shorter lever arm for the supra- and infraspinatus tendons, and thus weakens them.
Note that the greater tuberosity fragment tends to redisplace, causing delayed bone healing. The biceps tendon may be incarcerated in the fracture.
2 Reduction and temporary fixation of the greater tuberosity topenlarge
Reduction of the greater tuberosity
One can try to reduce the greater tuberosity closed, though this is unlikely to succeed. A manipulative reduction with a threaded pin through a stab incision under image intensification often works. If not, open reduction is required.
Closed reduction maneuver
In a slender patient, with the arm slightly abducted, it may be possible to press the greater tuberosity fragment into position with your thumb.
Under image intensifier control, make a small stab incision over the lateral aspect of the greater tuberosity fragment. Spread the deltoid muscle gently and insert a small elevator, ball-spiked pusher, or hook. To reduce the greater tuberosity, apply the instrument to its upper border and …
… push it into its bed.
Temporary fixation of the greater tuberosity
The K-wire(s) is inserted while the reduction is maintained with the instrument.
Confirmation of reduction
Reduction and proper placement of the K-wire should be confirmed under image intensifier control.
3 Fixation of the greater tuberosity topenlarge
It is the surgeons preference whether to use 3.5 mm cannulated lag screws (as illustrated) or small fragment screws.
Note: Washers might be advisable with osteoporosis or fragmentations. Generally, they are not preferable as they make the screw heads more prominent and may result in shoulder impingement.
If the greater tuberosity fragment is large, two screws may be used for better fixation.
Note: make sure to avoid the axillary nerve by placing the second screw rather proximal.
Once osteosynthesis is completed remove all K-wires.
Check fixation by image intensification.