Greater and lesser tuberosity fractures are well known fractures of upper end of humerus. Out of these two greater tuberosity is commoner than lesser one.

These fractures are quite often missed in the emergency.  This may occur due to following reasons

• Small piece of fractured bone may be overlooked. But it is important to understand that fractured bone may be attached to rotator cuff.
• Small fragments may be missed to be calcific deposits.
• Pieces may be superimposed on the humeral head and may be difficult to appreciate.
• When an anterior glenohumeral dislocation is present in association with a greater tuberosity fracture, attention may be focused on the dislocation, and the tuberosity fracture may be missed.

The greater tuberosity is displaced superiorly by the supraspinatus or posteromedially by the infraspinatus and teres minor. In lesser tuberosity fractures on the other hand, displacement tends to be medial because of the pull of the subscapularis.

Associated Dislocation

7% to 15% of glenohumeral dislocations have an associated greater tuberosity fracture. A gentle attempt to reduce the dislocation might be given but much force should not be applied so as not to cause further fracture in the humerus. Rarely surgery for open reduction of the dislocation may be required. Once the glenohumeral dislocation has been reduced, the greater tuberosity usually reduces into its bed

If it remains displaced after reduction of dislocation, open reduction and internal fixation be considered.
Lesser tuberosity fractures tend to occur in conjunction with posterior glenohumeral dislocations but are less common. The line of treatment is similar as discussed previously. The dislocation is addressed first and further evaluation is done to assess the fracture for suitable treatment.

Treatment
Nonoperative treatment is rarely used for displaced greater tuberosity fractures, unless age or infirmity argues against surgical management.The treatment protocol ids similar to that of undisplaced fractures

Traditionally displaced fractures of the lesser tuberosity were treated non-operatively but now there is data to suggest that patients are benefited by internal fixation of the fragment.

When to operate?

• More than 10 mm of posterior retraction
• 5 mm of superior displacement

In both these cases the patient might be considered for surgical repair. However he treatment should be individualized depending on patient’s activity level and demands.

Rehabilitation
Patients with greater tuberosity fractures

• Passive elevation, external rotation with help of a stick, and pendulum exercises are immediately begun.
• Active motion is  not allowed  until radiographs show early bone healing.
• Stretches and light active to resistive exercises are begun at 6 weeks.
• Strengthening and stretching are begun at 3 months.

Patients with lesser tuberosity fractures

• Forward flexion to about 90 degrees in full internal rotation is immediately begun .
• Gentle passive external rotation is also performed but the limb should not go beyond neutral position.
• External rotation to 45 degrees and full elevation are allowed depending upon the bone healing as demonstrated on radiographs after 6 weeks
• Full stretching and strengthening exercises are initiated after 3 months or as guided by fracture healing.

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