Operative treatment is indicated if greater tuberosity is displaced by 5 mm or displaced by 3 mm in the case of athletes due to the risk of rotator cuff dysfunction. This unique fracture pattern can be allocated under Codman’s classification system. According to his classification, there are 14 different fracture types possible. In 1934, Codman divided PH into four separate fragments – head, greater tuberosity, lesser tuberosity, and shaft. Ĭombined tuberosity fracture with intact humeral shaft is not mentioned in Neer, AO Muller, and Jakob classification, few of the commonly followed classification systems for PHFs. Another reason for their rarity is that they predominantly occur in the young age group, elderly people with osteoporosis usually had three- or four-part PH fracture (PHF) or associated rotator cuff tendon tear. Greater tuberosity fracture occurs with a fall on the outstretched hand with the elbow in full extension or flexion or after a direct blow to the lateral aspect of the shoulder. Approximately 5–30% of anterior shoulder dislocations are complicated by greater tuberosity fractures. Lesser tuberosity fractures which are commonly associated with posterior glenohumeral dislocation usually occur due to contraction of subscapularis muscle when the arm is forced into abduction and external rotation. Reconstruction of both the tuberosities and stability of the construct was confirmed under fluoroscopy.Ī combined fracture of greater and lesser tuberosity is an extremely uncommon injury due to different injury mechanisms for both. PH locking plate was applied and the Ethibond sutures were passed through islets of the plates ( Fig. The reduction of greater tuberosity was held temporarily with Kirschner wires. Greater tuberosity was reduced anatomically with the help of Ethibond no.5 passed through the supraspinatus bone tendon junction. 5 was passed through the subscapularis tendon and lesser tuberosity was secured. The lesser tuberosity was displaced medially due to subscapularis attachment. The greater tuberosity was displaced superiorly and posteriorly due to the pull by supraspinatus. ![]() The patient underwent surgery under general anesthesia through deltopectoral approach after obtaining written informed consent. ![]() Open reduction and rigid internal fixation and anatomical reconstruction of tuberosities were the pre-operative plan.ģ-D reconstruction images showing anterior (a) and posterior (b) aspect of the right glenohumeral joint with comminuted greater tuberosity fracture and displaced lesser tuberosity with intact glenohumeral joint. It also confirmed that there was no impacted fracture between the humeral head and shaft. CT scan with three-dimensional reconstruction (3-D) was done for further understanding of fracture configuration which confirmed fracture of greater tuberosity which was displaced 10 mm superiorly and 5 mm posteriorly, furthermore, to our surprise, lesser tuberosity fracture displaced 6 mm medially was also noticed ( Fig. CT scan with sagittal and axial cuts demonstrated comminuted greater tuberosity fracture and displaced lesser tuberosity fracture with head shaft in continuity ( Fig. ![]() Initial impression on plain radiograph anteroposterior (AP) view of the right shoulder showed displaced greater tuberosity fracture with no other obvious bony injury ( Fig. There was no associated neurovascular deficit. On clinical examination, she had tenderness over the anterolateral aspect of the right shoulder and abduction, internal rotation and external rotation movements were restricted. She had a history of fall from stairs 1.5 months back and sustained direct blow to the right shoulder for which she was managed conservatively at local hospital. A 32-year-old right hand dominant female, housemaid by occupation, presented to our outpatient department with pain in the right shoulder and restricted range of motion for 1.5 months.
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