Fracture of the Humeral Greater Tuberosity

The humeral greater tuberosity fracture represents one of the most frequent orthopedic injuries affecting the shoulder joint, involving a bone portion of fundamental importance for upper limb biomechanics. The greater tuberosity, also known as the greater tubercle of the humerus, is the bony prominence located in the lateral and superior part of the humeral head. This structure serves as a crucial anchor point for three of the four muscles that make up the rotator cuff: the supraspinatus, infraspinatus, and teres minor. An injury at this level compromises not only skeletal integrity but also profoundly alters muscular balance and joint stability, requiring an extremely accurate therapeutic and rehabilitative approach.

Table of Contents

• Anatomy and Biomechanics: The Role of the Humeral Greater Tuberosity
• Causes and Risk Factors
• Symptoms and Clinical Signs
• Diagnosis: How to Recognize the Fracture
• Medical and Surgical Treatment
• The Physiotherapy Rehabilitation Pathway
• Recommended Therapeutic Exercises
• Prevention and Long-Term Advice
• Frequently Asked Questions (FAQ) About Humeral Greater Tuberosity Fracture
• Conclusion
• Frequently Asked Questions
• Resources
• Sources and Scientific References

Anatomy and Biomechanics: The Role of the Humeral Greater Tuberosity

To fully understand the consequences of this injury, it is essential to analyze the anatomy of the region. The glenohumeral joint (the shoulder) is the most mobile joint in the human body, but this extraordinary mobility occurs at the expense of intrinsic stability. Stability is primarily guaranteed by soft tissues, particularly the rotator cuff.

The humeral greater tuberosity functions as a lever arm for the tendons that insert on it. When the supraspinatus muscle contracts, it pulls the greater tuberosity upward and medially, initiating arm abduction. Simultaneously, the infraspinatus and teres minor act as external rotators and stabilizers, depressing the humeral head to prevent it from impinging against the acromion (subacromial impingement).

When a fracture occurs at this site, the continuous traction exerted by these powerful muscles can cause displacement of the bone fragment. If the fragment shifts superiorly or posteriorly, shoulder biomechanics are severely altered, leading to severe functional limitations, chronic pain, and premature joint wear.

Causes and Risk Factors

The humeral greater tuberosity is a bony prominence on the upper arm bone where rotator cuff tendons attach, and its fracture disrupts shoulder mechanics, causing pain and functional limitation. The causes leading to this type of trauma can be divided into two main categories, closely related to the patient’s age and bone quality.

High-Energy Trauma

In young and active patients, the injury typically results from high-energy trauma. These include:

• Sports injuries: Falls during contact sports (rugby, football, martial arts) or high-speed sports (cycling, skiing, snowboarding).
• Motor vehicle accidents: Particularly motorcycle or bicycle accidents, where direct impact to the shoulder is frequent.
• Glenohumeral dislocations: Very often, the greater tuberosity fracture is associated with an anterior shoulder dislocation. During dislocation, the greater tuberosity can impact against the glenoid rim, fracturing, or can suffer an avulsion fracture due to violent traction of the rotator cuff tendons.

Low-Energy Trauma and Predisposing Factors

In elderly patients, especially postmenopausal women, bone quality plays a determining role. In the presence of osteoporosis or osteopenia, bone mineral density is reduced, making the greater tuberosity extremely vulnerable. In these cases, fracture can occur from very low-energy trauma, such as:

• Accidental domestic falls: A simple fall with direct impact to the shoulder.
• Fall on outstretched hand (FOOSH): The impact energy is transmitted from the wrist, along the forearm and arm, discharging onto the shoulder joint and causing bone fracture.

Symptoms and Clinical Signs

The clinical presentation is generally acute and unequivocal. The main symptoms include:

• Acute and sharp pain: Pain is immediate, localized in the lateral and anterior shoulder region. It tends to worsen significantly with any attempt at movement, especially during abduction (lateral arm elevation) and external rotation.
• Functional impairment: The patient is unable to actively lift their arm. They often present to the emergency room supporting the injured limb with the healthy hand, keeping it close to the body to minimize pain.
• Swelling (Edema) and Ecchymosis: In the hours and days following trauma, significant swelling develops. A hematoma (ecchymosis) may appear on the shoulder and, due to gravity, descend along the arm to the elbow or even the chest.
• Night pain: Nighttime rest is severely compromised. Finding a comfortable position is difficult and pain intensifies if one inadvertently turns onto the injured side.
• Bone crepitus: In some cases, during palpation or slight passive movements, it is possible to feel a sensation of crackling or crepitus, due to friction between bone fragments.

Diagnosis: How to Recognize the Fracture

A timely and accurate diagnosis is fundamental for establishing the correct therapeutic pathway. The diagnostic process always begins with a clinical examination, followed by specific instrumental investigations.

Clinical Examination

The specialist doctor or emergency room personnel will assess the history (trauma dynamics) and proceed with visual inspection and palpation. The neurovascular integrity of the upper limb will be evaluated to exclude injuries to the axillary nerve or blood vessels, possible complications in case of associated dislocation.

Instrumental Investigations

• Radiography (X-ray): This is the first-line examination. Standard projections (anteroposterior, true lateral, and axillary) are performed to visualize the fracture, assess the degree of fragment displacement, and verify the possible presence of dislocations.
• Computed Tomography (CT): If the X-ray shows a complex fracture or if greater joint involvement is suspected, CT provides detailed three-dimensional images. It is indispensable for preoperative planning in case surgical intervention is necessary.
• Magnetic Resonance Imaging (MRI): It is not a routine examination in the acute phase for bone, but becomes crucial if associated soft tissue injuries are suspected, such as massive rotator cuff tears, glenoid labrum lesions, or capsular damage.

Medical and Surgical Treatment

Treatment choice depends on a critical factor: the degree of bone fragment displacement. International orthopedic guidelines establish precise parameters.

Conservative Treatment

If the fracture is non-displaced or minimally displaced (generally displacement less than 3-5 millimeters in active patients, and up to 5-10 millimeters in elderly patients with low functional demands is tolerated), conservative treatment is chosen.
This approach includes:

• Immobilization: Use of an arm sling (often in neutral position or slight abduction) for a period varying from 3 to 4 weeks. The goal is to keep bone fragments close together to allow callus formation.
• Pharmacological therapy: Administration of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation in the acute phase.

Surgical Treatment

If the greater tuberosity fragment is significantly displaced, retracted superiorly or posteriorly, surgical intervention becomes necessary. A fragment healed in the wrong position would cause severe subacromial impingement and chronic strength deficit.
Surgical techniques include:

• Open reduction and internal fixation (ORIF): Fragment fixation through titanium screws, dedicated plates, or wire and cerclage systems (tension band wiring).
• Arthroscopy: In selected cases, reduction and fixation (often with suture anchors) can be performed with minimally invasive arthroscopic technique, which also allows inspection and repair of any associated tendon lesions.

The Physiotherapy Rehabilitation Pathway

Rehabilitation is the true cornerstone of functional recovery. Regardless of whether treatment was conservative or surgical, the physiotherapy pathway must be rigorous, progressive, and personalized. The shoulder is a joint that tends to stiffen very quickly; therefore, the physical therapist’s goal is to find the delicate balance between protecting the healing bone tissue and preventing joint stiffness (adhesive capsulitis).

The rehabilitation protocol is generally divided into four distinct phases.

Phase 1: Protection and Pain Control (Weeks 0-4)

During the first weeks, the greater tuberosity is forming the primary bone callus. Protection is maximal.

• Brace management: The patient wears the brace day and night, removing it only for personal hygiene and prescribed exercises.
• Physical therapies: Equipment such as magnetotherapy (to stimulate osteogenesis), cryotherapy (ice), and laser therapy can be used for pain and edema control.
• Distal mobilization: It is essential to keep uninvolved joints active. Active exercises are performed for the fingers, wrist, and elbow, plus cervical spine movements to avoid compensatory muscle contractions.
• Pendulum exercises: If authorized by the orthopedist, gentle Codman pendulum exercises are started, which allow joint decompression without activating shoulder musculature.

Phase 2: Passive and Active Assisted Mobility Recovery (Weeks 4-8)

Once control radiographs confirm the beginning of bone consolidation, brace weaning proceeds.

• Passive mobilization (PROM): The physical therapist gently moves the patient’s arm in all directions (flexion, abduction, internal and external rotation) respecting the pain threshold. The goal is to stretch the joint capsule that retracted during immobilization.
• Active assisted mobilization (AAROM): The patient begins moving their arm with help from the healthy limb. Exercises with a wand (or stick), pulley use, and wall sliding are introduced.
• Hydrokinesiotherapy: If available, rehabilitation in heated water is excellent in this phase, as buoyancy cancels limb weight, facilitating movement and reducing pain.

Phase 3: Active Mobility Recovery and Beginning Strengthening (Weeks 8-12)

In this phase, bone is generally consolidated and able to withstand muscular traction forces.

• Active mobilization (AROM): The patient moves their arm against gravity without assistance, aiming to recover complete range of motion.
• Isometric strengthening: Muscle contractions against fixed resistance without joint movement are started, to reactivate rotator cuff and deltoid musculature.
• Scapulothoracic stabilization: Intensive work on muscles that control the scapula (trapezius, rhomboids, serratus anterior). A stable scapula is the fundamental foundation for a healthy shoulder.

Phase 4: Advanced Strengthening and Return to Function (Months 3-6)

The final phase aims to return the patient to daily, work, or sports activities.

• Progressive resistance exercises: Use of elastic bands (Theraband) of different tensions, free weights, and isotonic machines.
• Proprioception and neuromotor control: Exercises on unstable surfaces, use of medicine balls, and rhythmic perturbations to improve reflexes and dynamic joint stability.
• Specific gestures: Simulation of movements required by the patient’s work or specific sport (e.g., throwing simulation, tennis serve, or load lifting).

Recommended Therapeutic Exercises

Below are described some key rehabilitation exercises. Remember that execution must always be supervised and authorized by a professional.

Codman Pendulum Exercises

• Purpose: Joint decompression and early micro-mobility.
• Execution: Standing, lean on a table with the healthy hand, bending the trunk forward. Let the injured arm hang toward the floor, completely relaxed. Using movement of the pelvis and trunk, swing the arm forward and backward, left and right, and in small circles. The arm should behave like an inert pendulum.

Active Assisted Flexion Exercise with Wand

• Purpose: Recovery of anterior elevation.
• Execution: Supine (lying face up), grasp a light wand with both hands. Use the strength of the healthy arm to push the wand upward and backward, bringing the injured arm into flexion above the head. Hold the maximum stretch position (without acute pain) for 5-10 seconds and slowly return to starting position.

External Rotator Strengthening with Elastic Band

• Purpose: Strengthening of infraspinatus and teres minor.
• Execution: Standing, injured arm elbow bent at 90 degrees and against the side (it is recommended to place a small rolled towel between the elbow and side). Grasp an elastic band fixed to a handle or door at waist height. Keeping the elbow still, rotate the forearm outward, stretching the elastic. Slowly return to starting position controlling the movement.

Prevention and Long-Term Advice

Preventing a fracture is not always possible, especially in case of severe accidental trauma, but it is possible to act on modifiable risk factors.

• Bone health: It is essential to monitor bone density, especially after age 50. Adequate intake of Calcium and Vitamin D, combined with regular weight-bearing physical activity, helps maintain strong bones and prevent osteoporosis.
• Fall prevention: In elderly individuals, it is useful to adapt the home environment (remove slippery rugs, install grab bars in bathrooms, improve lighting) and perform balance exercises to reduce fall risk.
• Athletic preparation: For athletes, adequate warm-up, maintaining good flexibility, and specific strengthening of shoulder stabilizing muscles reduce the risk of dislocations and indirect trauma.

Frequently Asked Questions (FAQ) About Humeral Greater Tuberosity Fracture

Conclusion

The humeral greater tuberosity injury is a traumatic event requiring immediate medical attention and a meticulous care pathway. The synergy between correct orthopedic diagnosis and a well-structured physiotherapy rehabilitation program is key to restoring the shoulder’s natural functionality, strength, and freedom from pain. Patient consistency in performing exercises and respecting biological healing times is determining for therapeutic success.

For any doubts, specific evaluation, or to undertake an adequate rehabilitation pathway, it is always recommended to consult your doctor or physical therapist.

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Frequently Asked Questions

What are the complete recovery times for this fracture?

Complete recovery times for a humeral greater tuberosity fracture can vary significantly depending on fracture severity, treatment approach (conservative or surgical), and individual patient factors. A structured rehabilitation program, guided by a physical therapist, typically extends over several months, with full functional recovery often achieved between 3 to 6 months or longer.

How should I sleep during the first weeks of immobilization?

During the initial weeks of immobilization following a humeral greater tuberosity fracture, sleeping in a semi-recumbent position, such as in a recliner or propped up with pillows, is often recommended to enhance comfort and maintain proper alignment. Using pillows to support the affected arm and prevent unwanted movement can also be beneficial.

When can I return to driving?

Returning to driving after a humeral greater tuberosity fracture is contingent upon adequate pain control, restoration of sufficient range of motion, and strength in the affected arm, particularly for steering and emergency maneuvers. This decision should be made in consultation with a healthcare provider, ensuring the individual can safely operate a vehicle without compromising their recovery or public safety.

Is there a risk of developing “frozen shoulder” after this fracture?

Yes, there is a recognized risk of developing adhesive capsulitis, commonly known as “frozen shoulder,” following a humeral greater tuberosity fracture, especially due to prolonged immobilization. Early, controlled mobilization exercises, as prescribed and supervised by a physical therapist, are crucial in minimizing this complication and promoting optimal joint health.

Sources and Scientific References

1. Neer CS. Displaced proximal humeral fractures: part I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.
2. Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012;(12):CD000434. DOI: 10.1002/14651858.CD000434.pub3
3. Hodgson S. Proximal humerus fracture rehabilitation. Clin Orthop Relat Res. 2006;442:131-138. DOI: 10.1097/01.blo.0000194677.02506.45
4. Monica J et al. (2016). Acute Shoulder Injuries in Adults. Am Fam Physician. 94:119-27. PubMed
5. Budharaju A et al. (2024). Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder Elbow. 16:449-458. DOI | PubMed
6. Hodgson S (2006). Proximal humerus fracture rehabilitation. Clin Orthop Relat Res. 442:131-8. PubMed
7. Camden P et al. (1992). Fracture bracing the humerus. Injury. 23:245-8. DOI | PubMed