Indications for Surgery

rarely used to evaluate for a possible greater tuberosity fracture, ultrasound has been reported as a method to diagnose occult nondisplaced greater tuberosity fractures.³⁰

Treatment

fire their posterior cuff muscles while participating in an early passive mobilization program. It would be optimal to determine treatment recommendations on a patient- specific basis as predicated by their cognitive and activity levels in conjunction with the radiographic appearance of the injury.

In summary, the goals of nonoperative management are to maximize motion while preventing further displace- ment. Complications of nonoperative management are typically due to shoulder stiffness and limited motion from subacromial adhesion formation, capsular contracture, or tuberosity displacement. Early appropriate passive motion exercises through a formal directed physical therapy program with a daily home program are critical to avoid these complications.

Surgical Treatment

Surgical Planning

Once operative management is indicated for a greater tuberosity fracture, the treating surgeon must carefully form a preoperative plan to obtain and maintain reduc- tion through an approach that provides the most reliable means of achieving stable fixation. As these injuries may frequently consist of fragments with more com- minution than appreciable on preoperative imaging, we recommend a preoperative plan with a primary and sec- ondary strategy should the initial plan for fixation prove inadequate. The plan begins with selection of patient positioning and the selection of surgical approach and exposure. Several approaches have been described for operative management of greater tuberosity fractures including fragment excision and rotator cuff repair, percutaneous fixation, arthroscopic-assisted fixation, fixation through a mini-open lateral incision or antero- lateral approach, and finally, via the deltopectoral approach. The rationales and limitations of each method will be discussed.

Percutaneous fixation techniques have gained greater popularity with the recent increasing enthusiasm for minimally invasive surgical procedures. These offer the benefits of smaller incisions with a theoretical decrease in disruption of fracture biology and violation of adjacent soft tissues that are critical to fracture healing.³⁷It has been suggested that these techniques decrease postopera- tive pain; others believe that they allow for a more rapid recovery and return to normal function.³⁸Although com- monly used for two- and three-part proximal humeral fractures, percutaneous fixation techniques may be used for large tuberosity fracture fragments with less than 1 centimeter of displacement in physiologically young patients with dense cortical bone who undergo operative management within 7 to 10 days of injury (see Chapter 5).

Limitations of the technique include its inability to directly visualize the fragment and remove interposed periosteal, tendinous, or fascial soft tissue. Excellent fluo- roscopic imaging is mandatory and familiarity with patient positioning and fluoroscope positioning to obtain orthogonal views is beneficial.

Arthroscopically assisted reduction offers similar benefits to percutaneous techniques, but additionally provides significantly enhanced visualization of the fracture, articular surface, and rotator cuff. The tech- niques employed in mini-open or arthroscopically assisted rotator cuff repair are extremely useful and directly applicable to a combined treatment approach for the treatment of greater tuberosity fractures. There- fore, we favor an arthroscopically assisted approach in the treatment of greater tuberosity fractures, but our experience has led us to note that this method requires a greater degree of facility with shoulder arthroscopy on the part of the treating orthopedic surgeon. Limitations include the complex set-up in the operating room to facilitate the arthroscopic exam and allow for intraoper- ative fluoroscopic imaging, which may preclude some surgeons and facilities from employing this technique with ease. The large hematoma associated with a frac- ture may impair visualization and will be influenced by timing of surgery. Despite these potential limitations, the benefits of this approach are numerous, including the opportunity to visualize the rotator cuff directly to rule out a concomitant tear. Certain fracture patterns will allow for visualization of an anatomic reduction through placing the arthroscope in the subdeltoid space.^39,40The arthroscope may be used to facilitate débridement of the fracture-site hematoma and adjacent fibrous scar, mobi- lization of the fracture fragment under direct arthroscopic visualization, and suture passage for a subsequent mini- open approach for internal fixation. Arthroscopy addition- ally allows for the concomitant treatment of associated pathology (the younger patient with an associated Bankart tear following dislocation) as well as an arthro- scopic subacromial decompression as indicated. Finally, for greater tuberosity fractures with small fragments and significant comminution, fragment excision and rotator cuff repair in a single- or double-row construct may be more easily accomplished through an arthro- scopic approach.

The mini-open lateral incision is frequently employed for the treatment of isolated greater tuberosity fractures for several reasons. Most orthopedic surgeons have great comfort in using this approach for rotator cuff repair and patient positioning and operating room set-up are familiar.

In addition, direct visualization of the fracture fragment is possible with the ability to mobilize and manipulate the fragment for placement of stable fixation. Limitations include the inability to dissect greater than 5 centimeters

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below the lateral aspect of the acromion in concern for potential axillary nerve injury, the potential for difficulty in reducing fragments with significant posterior dis- placement, and the need for assistance with retraction of the deltoid. Some surgeons prefer to place this incision more posteriorly along the lateral border of the acromion to facilitate access to fragments with posterior displace- ment and then externally rotate the arm to “deliver” the humerus to the fragment and reduce it anatomically.

A variation of this approach was recently reported in an anatomic study together with the initial results of an accompanying case series of 16 patients treated at our institution.⁴¹ The extended anterolateral acromial approach as described by Gardner et al⁴¹facilitates expo- sure of the proximal humerus with less soft tissue dissec- tion and muscle retraction to gain access to the lateral aspect of the humerus. In this study, 20 cadavers were dissected developing a plane through the anterior deltoid raphe. The authors reported that the anterior branch of the axillary nerve was reliably and predictably found approximately 35 mm distal to the prominence of the greater tuberosity deep to this raphe. They suggested that this approach allows for a minimally invasive approach with excellent exposure of the lateral aspect of the humerus, while minimizing adjacent soft tissue disruption.⁴¹An additional theoretical benefit of employ- ing this approach for greater tuberosity fractures is the anterolateral location still allows for placement of a back- up, secondary posterior incision in cases with more pos- terior displacement identified at surgery than recognized preoperatively.

Advantages of the deltopectoral approach are similar to the direct lateral mini-open approach in that most or- thopedic surgeons feel comfortable with the dissection and exposure. Excellent visualization of the proximal humerus may be obtained and operating room set-up is familiar and straightforward. This approach is particu- larly useful in those patients with a nondisplaced surgi- cal neck component. In that setting the anterolateral or direct lateral (mini-open) approaches will not offer ade- quate visualization in the event the surgical neck com- ponent needs to be addressed. Our preference in this type of fracture pattern is to wait 3 weeks for the surgi- cal neck component of the fracture to heal enough to allow for an arthroscopic-assisted approach to the greater tuberosity fracture as described above. However, with fragments that are posteriorly displaced, it can often be exceedingly difficult to access and mobilize the greater tuberosity fracture fragment without extensive dissection and potential compromise of the blood supply.

Additional concerns include the extent of anterior del- toid retraction and potential for compromise of deltoid integrity, a factor that is critical to any acceptable out- come with surgical intervention about the shoulder.

4 Isolated Tuberosity Fractures

39

Implant selection and secondary strategies will be dis- cussed as they relate to the chosen approach.

Surgical Techniques Arthroscopic-Assisted Techniques

Arthroscopy can be quite helpful in the evaluation of concomitant glenohumeral and subacromial pathology as noted above. Arthroscopic visualization of the sub- acromial and subdeltoid spaces can facilitate hematoma and scar débridement, fragment mobilization, and frac- ture reduction as described above while suture passage under arthroscopic visualization can be more accurate and secure (Fig. 4–4). The direct lateral portal for rotator cuff repair is used to obtain reduction and achieve stable fixation with a cannulated screw in those cases with large fragments and good quality bone. Accessory por- tals allow for placement of tissue graspers or soft tissue elevators to débride soft tissue, facilitate reduction, and assist with subsequent guide-wire passage. Fluoroscopic confirmation of reduction and implant position is per- formed intraoperatively.

Comminuted fragments and/or poor bone quality pre- clude the use of screw fixation. In these cases, arthroscopic techniques employing suture passers to place sutures at the tendon/bone interface assist with mobilization of the fragments and will often allow a more limited open

Figure 4–4 Intraoperative arthroscopic image of polydioxanone (PDS) suture placed through the greater tuberosity fracture fragment.

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Solutions for Complex Upper Extremity Trauma

approach. The fragments can then be fixed to bone using the techniques noted above.

Open Techniques

With the patient under regional or general anesthesia and after the administration of intravenous antibiotics, the patient is placed in the beach-chair position with careful attention to the padding of all bony prominences and maintenance of stable, neutral cervical spine positioning.

A beanbag mattress is utilized and the patient is lateral- ized as a unit to the edge of the operating room table. A direct lateral or anterolateral vertical incision is made for 5 to 8 cm extending from approximately 1 cm superomedial to the lateral aspect of the acromion extending distally.

Full-thickness soft tissue flaps are developed above the deltoid fascia, and #2 braided polyester sutures are placed anteriorly and posteriorly as tagging stitches for later fas- cial repair. The deltoid is sharply incised in-line with its fibers and dissection carried to the level of the subdeltoid bursa, which is excised as necessary for visualization. A #0 Vicryl suture is then placed in a figure-eight fashion ap- proximately 5 cm below the level of the acromion for the lateral approach as a stay suture to limit inferior dissection and the chance of iatrogenic axillary nerve injury. The rotator cuff is palpated, the fracture fragment identified and mobilized, and copious irrigation used to débride and visualize the fracture bed. Although adequate visualization for an anatomic reduction is important, it is equally important to minimize periosteal stripping and limit any unnecessary soft tissue dissection. To assist in obtaining anatomic reduction of the greater tuberosity fracture frag- ment, we will frequently place a #2 braided nonabsorbable polyester suture at the bone–tendon junction. Placing the suture in this location allows for tendon excursion without manipulating the potentially tenuous cortical bone and compromising fixation options.

Assessment of the fragment at this point determines the implant selection. For larger fragments with dense cortical bone or a subjective assessment of good bone stock, 4.5-mm AO/ASIF cannulated screws are well suited. Noncannulated screws may be used as well; however, we believe that place- ment of the cannulated screw guide-wire allows for multi- planar fluoroscopic imaging with minimal manipulation of the fracture fragment. Washers may be used in cases with amenable fragment size to distribute the compressive forces of interfragmentary compression over a greater surface area.

When fragment comminution is present to an extent that screw fixation will not provide reliable compression, suture fixation may be considered. A more distally placed 3.5-mm AO/ASIF cortical screw may be used as⁴¹a post for heavy- suture fixation in a tension-band fashion. We prefer to use

#2 FiberWire suture (Arthrex, Inc./Arthrotek, Inc., Warsaw, IN) for this purpose in figure-eight construct, which provides

additional stability and assists in preventing tuberosity overreduction. Multiple sutures are placed in the bone–

tendon junction and then distally through the humeral cor- tex distal to the fracture site. Alternatively, the parachute technique described by Cornell in 1994 can be used to secure the sutures to the humeral cortex using a post con- sisting of a screw and washer.⁴²The reduction is confirmed with multiplanar fluoroscopy and the wound is copiously irrigated and closed in standard fashion.

Percutaneous Fixation Techniques

The patient is placed in a 30-degree beach-chair position on a beanbag to lateralize the entire body and facilitate in- traoperative fluoroscopic imaging. The table is rotated such that the fluoroscope may be brought in and out from a cephalad position on the ipsilateral side of the operative procedure. Manipulating the rotational arc of the C-arm al- lows the surgeon to visualize anteroposterior and axillary views, and manipulating the tilt allows for converting be- tween a true AP and a standard AP view. After the arm is prepped and draped in the usual sterile fashion, the fluoro- scope is brought in for an AP view and a 1-cm incision is made along the lateral aspect of the acromion. A hemostat or straight Addison clamp is used to divide the deltoid in line with its fibers, and to triangulate the approach to the fragment. Placement of the guide-wire and screw are facili- tated by gentle, small degrees of glenohumeral abduction or adduction to assist in achieving an optimal angle. Occa- sionally, an accessory anterolateral portal may be made for placement of a small freer elevator to assist in obtaining reduction. Knowledge of the anatomical details of the proximal humerus assists the surgeon in determining that a fluoroscopic reduction is indeed anatomic. The path along the guide-wire is then spread and cleared with a he- mostat, and a 4.5- or 6.5-mm cannulated screw inserted with or without a washer as described above. Alternatively, one may use 2.5-mm terminally threaded AO pins placed percutaneously and cut off below the skin, which can be subsequently removed at 3 to 4 weeks pending radi- ographic evidence of healing. The wound is copiously irri- gated and closed in standard fashion.

Complications

Complications of operative management are related to the nature of the injury, the surgical approach, and the techni- cal methods employed to achieve reduction and fixation.

For the purposes of clarification, these may be subdivided into perioperative and postoperative complications. Periop- erative complications include infection, deltoid dehiscence, and axillary nerve injury. Postoperative complications include postoperative contracture, loss of reduction, malu- nion or nonunion, and rarely, avascular necrosis.⁴³

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Perioperative complications may be minimized through a proper selection of the surgical approach, which allows the surgeon to most reliably obtain and maintain reduction through minimal disruption to adjacent tissues. Perioperative antibiotics, meticulous skin handling technique, and thoughtful attention to the location of retractor placement and degree of force used to provide exposure will minimize the risks of infection, deltoid dehiscence, and axillary nerve injury. Anticipating the potential limitations and chal- lenges with selection of the surgical approach will allow for maximal exposure through minimal dissection and retraction. In addition, a careful preoperative plan with a secondary strategy minimizes the duration of surgery and therefore the risk of perioperative complications.

Postoperative complications are minimized through the appropriate application of rehabilitation principals as discussed in detail below. Stable fixation is critical to allow early motion and prevent capsular contracture;

however, active motion must be vigilantly prohibited in the early stages to minimize loss of reduction, malunion, and nonunion. Should capsular contracture develop and the patient fail to appropriately progress to obtain an acceptable range of motion, stiffness may initially be treated with aggressive active-assisted and passive range of motion exercises after union is confirmed. In the un- usual case where these modalities are unsuccessful and the patient has a clinical picture consistent with the post- operative frozen shoulder, we advocate arthroscopic capsular release, which has proven quite successful to relieve pain and restore motion in the literature,⁴⁴as well as subacromial débridement and acromioplasty when indicated. Malunion and nonunion of greater tuberosity fractures may be difficult to treat due to capsular contrac- ture, subacromial scarring and impingement, and alter- ations in normal rotator cuff function. These issues are thoroughly addressed in Chapters 7 and 8.

Postoperative Care and Rehabilitation

Postoperatively the patient is placed in an abduction sling with the arm in neutral (not internal) rotation to mini- mize strain at the fracture site. Elbow, wrist, and digital range-of-motion (ROM) exercises with passive pendu- lums and Codman’s exercises are begun immediately until 10 days when passive, supine external rotation and passive, supine forward elevation are initiated. Early internal rotation and horizontal adduction are avoided to limit tension on the operative fixation. At 6 weeks postoperatively, the sling is gradually discontinued and active-assisted ROM exercises are initiated to achieve full motion with an early emphasis on forward elevation and external rotation progressing to the addition of internal rotation and cross-body adduction. At 10 to 12 weeks, a pro- gram of rotator cuff and periscapular muscle strengthening

is initiated and patients are again instructed to focus on a gradual low-weight high repetition progression. We counsel patients that recovery frequently takes 9 to 12 months for the full resumption of activities of daily living without mild occasional discomfort.

Results

There are few studies in the literature that clearly present the results of operative management of isolated greater tuberosity fractures. In 1924, Santee⁴⁵suggested that even slight displacement of greater tuberosity fractures can result in significant disability. McLaughlin⁶ presented a series of greater tuberosity fractures associated with gleno- humeral dislocation in 1963 and reported that patients with 0.5 to 1.0 cm of displacement had a prolonged recovery and 20% required a reconstructive procedure. However, the con- comitant dislocation may influence the results of this study;

therefore, its pertinence to isolated tuberosity fractures is somewhat limited. Similarly, Young and Wallace³² pre- sented good and acceptable results of nonoperative man- agement for 7 patients with a glenohumeral dislocation and associated tuberosity fracture; however, the results are dif- ficult to interpret particularly because the criteria for shoul- der motion were unclear. In a series of 930 proximal humerus fractures treated surgically, Jakob et al⁷reported only 17 isolated tuberosity fractures and did not report the results of treatment. Paavolainen et al⁴⁶ reported good results for the operative management of six displaced greater tuberosity fractures with screws. In a series of 141 two-part proximal humerus fractures, Chun et al²presented 24 cases of greater tuberosity fracture. Ten of these patients underwent open reduction and internal fixation; 8 patients were treated with screw fixation. At a mean follow-up of 5.1 years, 11 of the 24 patients were evaluated with Neer’s criteria as follows: 1 – excellent, 7 – good, and 3 – fair (inclu- sion criteria for follow-up with regard to operative versus nonoperative management was unclear). The average for- ward elevation in this group at follow-up was 118 degrees and the average external rotation was 35 degrees. Perhaps the best data available in the literature were presented by Flatow et al.¹¹In a series of 16 displaced greater tuberosity fractures treated with heavy nonabsorbable suture through a deltoid-splitting approach, the authors reported the results of 12 patients at an average of 4.5 years follow-up as follows: 6 – excellent and 6 – good. All patients in this series had at least 1 cm of posterior displacement.¹¹

Summary

Isolated greater tuberosity fractures represent a chal- lenging entity for the orthopedic surgeon with regard to optimal diagnosis,⁴⁷ operative indications,11,26,34,35 and Ch04_p34-43.qxd 1/11/08 9:58 PM Page 41