Ayahiro D. Takashima, BA
Medical Student
Emory University School of Medicine
Atlanta, Georgia, United States
Rosa M. Pasculli, MD, MBA, RMSK
Assistant Professor of Orthopaedics and Physical Medicine and Rehabilitation
Emory Orthopaedics, Division of Sports Medicine
Atlanta, Georgia, United States
A 16-year-old football player presented to clinic with two weeks of anterior right shoulder pain that started after he fell on an outstretched arm. He experienced numbness, tingling, and weakness following the game. He reported sharp pain, radiating to the upper arm, worse with overhead movements and weightbearing, alleviated with rest, and denied instability.
On exam, there was no ecchymosis, +tenderness to palpation at the proximal humerus, with intact but painful active range of motion (ROM) and strength in all planes. Axillary nerve sensation was intact.
X-ray showed a subtle lucency within the proximal humeral head-neck junction concerning for fracture. The physis appeared normal. A CT scan confirmed nondisplaced avulsion fracture of the greater tuberosity (GT).
The patient started home exercises and underwent 5 PT sessions with improvement in pain, ROM, and functional testing. He successfully returned to sport ~10 weeks post injury.
Proximal humerus fractures in children are rare and represent ~0.45% of all pediatric fractures. There is limited data on isolated GT fractures in this population. They can be challenging to identify on radiographs when nondisplaced, with up to 59% missed on initial evaluation. In younger patients, these fractures are associated with trauma; however, isolated avulsion GT fractures are rare compared to other shoulder injuries in adolescent athletes.
While nondisplaced or minimally displaced GT fractures are usually treated nonoperatively, the degree of displacement that indicates surgical treatment is debated. The most common indication for surgical management is >5mm of displacement, but some suggest >3mm in certain overhead and younger patient populations.
The case underscores the importance of accurate diagnosis of isolated GT avulsion fractures, as this is a rare injury in the adolescent athlete population. Physiatrists should consider referral to an orthopedic surgeon for fractures with >3mm displacement.
