A New “Trapdoor technique” for Fixation of Displaced Greater Tuberosity Fractures of the Shoulder

Abstract

Isolated greater tuberosity fractures of the proximal humerus are frequently displaced posteriorly and superiorly by the pull of the rotator cuff. This displacement can lead to a decline in function if left untreated. Traditionally these fractures have been treated surgically using screw fixation. On occasions this metalwork can remain prominent and potentially cause impingement. We present a new surgical Btrapdoort echnique for fixation of isolated greater tuberosity fractures which can avoid these problems and be utilised either open or arthroscopically. Following reduction of the isolated greater tuberosity fragment, two double loaded metal screw in anchors are placed through stab incisions in the rotator cuff at the bone-tendon interface and secured into the humeral head. A suture from each of the anchors is tied together to secure the tuberosity fragment proximally and a suture-less anchor is inserted distal to the fracture site forming an inverted triangle. The remaining sutures are placed through the suture-less anchor and tensioned independently. As the sutures are tied and snugged tight, the distal aspect of the fracture reduces, thus closing the Btrapdoor.^This is a newly described versatile technique that can be used regardless of the size and comminution of the tuberosity fragment and can be performed either open or arthroscopically. It avoids the problems of metalwork prominence and irritation and the use of the suture-less anchor allows independent tensioning of the sutures to ensure adequate fracture reduction.

A new low-profile anatomic locking plate for fixation of comminuted, displaced greater tuberosity fractures of the proximal humerus

“…Generally, superior migration of the GT may result in subacromial impingement and weakness in abduction, whereas posterior migration may result in a loss of external rotation. 15 Bono et al, 2 in their biomechanical study, showed that the glenohumeral abduction force of the deltoid was significantly increased by 16% and 27% by superior displacements of the GT of 0.5 cm and 1 cm, respectively. Therefore, the current literature recommends operative treatment of GT fractures with >5 mm of displacement.…”

Inferior displacement of greater tuberosity fracture suggests an occult humeral neck fracture: a retrospective single-centre study

“…If conservative treatment fails, it is of utmost importance to correct the valgus of the humeral neck and then reduce the GT fracture by surgery. Internal fixation can be performed using screws, a proximal humerus locking plate, or a proximal humerus locking intramedullary nail [27][28][29].…”

Hook Plate Fixation for Isolated Greater Tuberosity Fractures of the Humerus

“…20) Using the same suture-tensioning method, we performed a concomitant 3.5-mm LCP hook plate fixation for isolated GT fractures and an augmentation tension suture fixation of the rotator cuff, using cortical screws and two differently sized washers. For severely comminuted fractures, we applied the trapdoor technique using suture anchor developed by McLaughlin-Symon et al 11) by replacing the sutureless anchor with a 3.5-mm LCP hook plate.…”

“…4) Various fixation methods for GT fractures exist, including the transosseous suture fixation, the cannulated screw fixation, the plate fixation, the cerclage wire fixation, and the arthroscopic suture anchor fixation. 3,[5][6][7][8][9][10][11] For patients with olecranon fractures or those who have undergone olecranon osteotomies, 3.5-mm locking compression plate (LCP) hook plate (Synthes, West Chester, PA, USA) is commonly used for fixation. For GT fixation, this plate has lower profile than the proximal humeral plates and, therefore, lower the chances of postoperative subacromial impingements.…”