Fractures of the greater tuberosity of the humerus Arthroscopic treatment strategies

Isolated greater tuberosity (GT) fractures of the humerus represent a rare fracture morphology. In most cases, the cause is traumatic anterior shoulder dislocation associated with abrupt passive abduction and external rotation of the arm. This leads to avulsion of the tendon-bone interface and represents the most common mechanism of injury. The decision for surgical treatment is based on the degree and the direction of dislocation and whether it is a monofragmentary or multifragmentary fracture. Due to the anatomical proximity to adjacent structures, only minor dislocations of 3-5 mm are tolerated as a result of bony impingement or rotator cuff affection, depending on the background sport. In addition to the initial assessment of fracture morphology, follow-up control is essential as secondary dislocation can be detected in 50-60% of cases. For stabilization or refixation of dislocated GT fractures, different surgical techniques are available depending on the fracture type. Closed reduction with screw osteosynthesis, open reduction with screw or plate osteosynthesis, and arthroscopic procedures are differentiated. A classification based on fracture morphology differentiates three basic morphological types: the avulsion fracture (avulsion type), the impacted fracture (depression type), and the split fracture (split type). Further imaging in the sense of computed tomography (CT) and magnetic resonance imaging (MRI) is often helpful in assessing the fracture morphology. Avulsion fractures in particular lend themselves to a purely arthroscopic approach. With increasing improvements in suture anchor systems, arthroscopic techniques have been described in recent years that enable stable refixation in the sense of a double-row technique. Various case series confirm the functionality of the arthroscopic approach with good clinical and radiological results. In the case of distal fragment protrusion > 3 cm in the sense of split fractures, correct arthroscopic positioning of the lateral suture anchor row is not adequately possible and therefore limits the arthroscopic procedure.