Proximal humerus fractures show a distinct age-related prevalence, with a sharp increase in numbers starting in the sixth and seventh decades of life because of the development of osteopenia and osteoporosis.1–3 With the relatively recent advent of locking plate technology and advances in surgical technique, a greater proportion of proximal humerus fractures are being treated operatively than in the past.4 In addition, multiple studies have shown an age-related increase in the prevalence of asymptomatic rotator cuff tears, with estimates of a full-thickness tear ranging from 6% to more than 50% in those in the seventh decade of life and older.5–10 Therefore, substantial overlap between the 2 patient populations would be expected. However, despite the amount of literature on the evaluation, management, and outcomes of proximal humerus fractures, surprisingly little has been written on the prevalence of rotator cuff tears in patients with proximal humerus fractures and how they might affect management. This is especially relevant in light of the recent introduction of the reverse shoulder prosthesis as a viable option in acute proximal humerus fractures for patients who are or are likely to be cuff-deficient.11–15
The goal of this study was to determine the prevalence and possible predisposing factors for full-thickness rotator cuff tears encountered during surgery for proximal humerus fractures. In addition, for patients with rotator cuff tears, the authors hoped to describe how this concomitant pathology affected treatment.
Materials and Methods
A retrospective chart review was performed on all patients older than 18 years who underwent surgery with a diagnosis of proximal humerus fracture from January 2007 to June 2012 by a member of the shoulder and elbow service at the authors’ institution. The starting date was chosen to approximately correspond with the increased use of reverse shoulder arthroplasty for fracture. Eight shoulder surgeons operated on 387 fractures in 383 patients during that period. The indications and the type of surgery were at the discretion of the treating surgeon. Only surgical procedures that allowed direct visualization of the rotator cuff were included in the study, eliminating 7 patients who underwent closed reduction and percutaneous pinning and 1 patient who underwent intramedullary nailing. This left all patients who were treated with open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse shoulder arthroplasty and included those whose fractures had been treated primarily arthroscopically. Thirty patients had incomplete records, leaving a total of 349 fractures in 345 patients for review. Follow-up averaged 7.6 months (range, 0–53 months).
Narrative operative reports were then reviewed and correlated with preoperative and postoperative notes. Information obtained for each patient included age at the time of surgery, sex, mechanism of injury, Neer classification, presence or absence of dislocation at the time of injury, procedure performed, complications, and reoperations. Mechanism of injury was divided into low-energy vs high-energy injuries. Low-energy injuries included simple falls from standing. High-energy injuries included falls from height, motor vehicle collisions, and seizures. For fractures with concomitant rotator cuff tears, the tear pattern, preoperative knowledge of rotator cuff status, management of the tear, and change in surgical plan were also documented.
Logistic regression analysis was used to create a model of the probability of rotator cuff tear vs the patient, fracture, and operative factors noted earlier. The model was optimized according to Akaike’s information criterion. Statistical significance was set at P<.05.
Comparison of Proximal Humerus Fractures With and Without Rotator Cuff Tears
A total of 30 rotator cuff tears were found in 349 operative proximal humerus fractures, for a prevalence of 8.6%. The 2 groups were then compared regarding age, sex, mechanism of injury, Neer classification, glenohumeral dislocation, procedure performed, complications, and reoperations (Table 1). On average, the group with a rotator cuff tear was 5.6 years older than the group without a tear (P=.03), and there was a trend toward an increasing prevalence of tears with age (Figure 1 and Table 2). There was a 1:2.1 male-to-female ratio of fractures, with no statistically significant difference between the 2 groups. Most of the injuries (77.4%) were the result of a low-energy mechanism, and this was not significantly different between the groups. The distribution of Neer classification was not significantly different, and no Neer 1-part fractures were reported because only operative fractures were included. Although subgroup analysis of the different subtypes of fractures in the Neer classification did not reach significance, there was a trend toward a higher rate of rotator cuff tears in the 2-part greater tuberosity fractures (Figure 2 and Table 3). A significantly higher rate of dislocations was noted in the group with rotator cuff tears than in the group without these tears (40% vs 12.5%; P=.0004). The type of procedure performed was also significantly different between the 2 groups (P=.0002; Figure 3 and Table 4). Logistic regression was performed, predicting the presence of rotator cuff tears vs the procedure, with ORIF used as the reference because it was the most common procedure. Those who had arthroscopic treatment or reverse total shoulder arthroplasty were more likely to have had an associated rotator cuff tear (P=.005 and .002, respectively; Table 1). No significant association was seen between rotator cuff tear and ORIF and hemiarthroplasty as treatment modalities. Overall complication and reoperation rates were 16.6% and 6.9%, respectively, and were not significantly different between the 2 groups.
Data for Patients With and Without Rotator Cuff Tears
Percentage of rotator cuff tears vs age.
Percentage of Rotator Cuff Tears vs Age
Percentage of rotator cuff tears in each Neer category. Abbreviations: GT, greater tuberosity; SN, surgical neck.
Percentage of Rotator Cuff Tears in Each Neer Category
Percentage of rotator cuff tears vs type of surgery. Abbreviations: ORIF, open reduction and internal fixation; RTSA, reverse total shoulder arthroplasty.
Percentage of Rotator Cuff Tears vs Type of Surgery
Description and Management of Rotator Cuff Tears in Proximal Humerus Fractures
A total of 30 rotator cuff tears were found in the authors’ series of proximal humerus fractures. The description and management of the tears are shown in Table 5. Of these, only 5 were suspected or known preoperatively. One was suspected based on clinical history, 1 was found on a preoperative magnetic resonance imaging (MRI) scan, and 1 patient had a known diagnosis of rotator cuff tear arthropathy. The 2 other patients had previous injury or surgery of the same shoulder that raised suspicion of rotator cuff tear. Of the 30 rotator cuff tears, 14 involved the supraspinatus only; 3 involved the subscapularis only; 1 involved the teres minor only; 5 involved both the supraspinatus and infraspinatus; 1 involved both the supraspinatus and subscapularis; 1 involved the supraspinatus, infraspinatus, and subscapularis; and in 5, the tear pattern could not be accurately identified based on the operative note description. Twenty-two of the rotator cuff tears underwent suture repair at the time of surgery, 7 were treated with reverse shoulder arthroplasty, and 1 went untreated. Only 5 patients had an intraoperative change in plan because of rotator cuff tears, and all of these had reverse shoulder arthroplasty as definitive treatment (Figure 4).
Description and Management of Rotator Cuff Tears Found in Operative Proximal Humerus Fractures
Preoperative anteroposterior radiograph of an 83-year-old woman with a 4-part right proximal humerus fracture (A). Postoperative anteroposterior radiograph obtained 1 month after a reverse total shoulder arthroplasty was performed for a large intraoperative rotator cuff tear (B).
The epidemiology of proximal humerus fractures was established in a number of studies. A strong age-related increase in incidence has been shown, with 1 recent study showing an exponential growth pattern for women 40 to 84 years old.2 This distribution curve places it squarely in the realm of other osteoporotic fractures, including hip fractures.1 Rotator cuff tears have also been shown to have an age-related increase in prevalence in multiple studies, even in asymptomatic individuals.5–10,16 Although diagnostic modalities have differed (ultrasound, MRI, cadaveric dissection) and reported prevalences vary widely, all of the studies have shown increasing rates with age.6,10 Thus, at least theoretically, it should not be unusual to find a concomitant full-thickness rotator cuff tear when performing surgery on a proximal humerus fracture. However, in the authors’ experience, this was not a common finding.
This issue has even greater significance given the more recent literature supporting reverse shoulder arthroplasty for acute proximal humerus fractures.11–15,17 Although most studies of reverse shoulder arthroplasty for primary fractures cite the high rate of tuberosity nonunion or malunion as the compelling reason for its use, the possible advantage of its use in a proximal humerus fracture with rotator cuff tear is not difficult to see. Given the high theoretical risk of encountering a rotator cuff tear during surgery for a proximal humerus fracture, it would not be unreasonable to have a reverse shoulder arthroplasty readily available for every patient of the appropriate age.
The goals of the current study were to identify the rate at which patients undergoing surgery for a proximal humerus fracture were known or found to have a rotator cuff tear and to characterize factors that may be associated with these tears. Other studies have sought to better define the relationship between proximal humerus fractures and rotator cuff tears. However these studies had significant differences in methods, and none included as many patients as the authors’ series. Studies by Fjalestad et al18 and Nanda et al19 examined the rotator cuff by MRI and ultrasound, respectively, but only included patients treated nonoperatively. The authors did not examine patients whose fractures were treated nonoperatively, in part because their question was focused on how and how often a rotator cuff tear changed the management of a proximal humerus fracture. They believed that knowledge of a rotator cuff tear most likely would not significantly alter clinical decision-making in a patient with a proximal humerus fracture that had been considered nonoperative, especially if the patient was asymptomatic before injury. Other studies included a mix of treatment modalities, including conservative management; however, surprisingly, only 1 study explicitly mentioned the use of arthroplasty.20–23
The overall prevalence of full-thickness rotator cuff tears in the authors’ patients was 8.6%, which falls within the large range of 5% to 50% reported in the literature.18,19 It is also on the lower end of the spectrum of reported prevalence of rotator cuff tears in asymptomatic patients, given that the average age of the population was 63.6 years. The authors found that patients with a rotator cuff tear were significantly more likely to be older (68.7 vs 63.1 years; P=.0337) and to have had a fracture-dislocation (P=.0004). Other studies19,21 also found an increased prevalence of rotator cuff tears in proximal humerus fractures with increasing age, although Gallo et al22 did not find that to be the case. However, in their study, Gallo et al22 excluded any patient older than 65 years, thereby removing the age group that would be expected to have a rotator cuff tear. To the authors’ knowledge, no other study has specifically considered dislocation as a factor. Intuitively, however, this finding is consistent with the well-established relationship between shoulder dislocation and rotator cuff tear in those more than 40 years old.24 The next logical question was how many rotator cuff tears found with proximal humerus fractures were acute and traumatic. Bahrs et al21 surmised that 66% of rotator cuff tears in their patients were traumatic, based on simultaneous comparison of the injured and uninjured shoulders. From the authors’ data, it is impossible to accurately determine the rate of acute vs chronic tears, although this could be an area for future study.
In contrast to other studies, no significant relationships could be established between rotator cuff tears and Neer classification.21,22 However, there was a trend toward a higher rate of rotator cuff tears in 2-part fractures involving the greater tuberosity. Dislocation could again be a strong contributing factor to this finding. In another study, Bahrs et al25 showed that 57% of patients with a greater tuberosity fracture had a dislocation as well, hypothesizing that the fracture was essentially a completed Hill-Sachs lesion. In the authors’ population, 16 of 42 patients with an isolated greater tuberosity fracture also had a dislocation, and of the 7 patients with a greater tuberosity fracture and a rotator cuff tear, 5 had a dislocation. This helps to explain the high rate of rotator cuff tears found when a proximal humerus fracture was treated arthroscopically. Although arthroscopic visualization may be more sensitive in identifying tears, all of the fractures treated in this manner were 2-part fractures of the greater tuberosity.
In addition to the higher rate of arthroscopic procedures in proximal humerus fractures with rotator cuff tears, this group also had a higher rate of reverse shoulder arthroplasty and a lower rate of hemiarthroplasty. Of the 30 patients who had a rotator cuff tear,17 an intraoperative decision to perform reverse shoulder arthroplasty was made when the tear was discovered. Only 5 patients in this group were suspected or known to have a pre-existing rotator cuff tear, leading to the conclusion that most tears, although unexpected, were considered repairable without a significant change in the surgical plan. Supporting that conclusion was the finding that at least 18 of the 30 tears found involved only 1 tendon.
The current study has several notable limitations. First, it is retrospective in design and thus is dependent on the narrative operative reports for the details of the procedure and management of rotator cuff tears, when found. In addition, it cannot be assumed that all full-thickness rotator cuff tears would be found during an open procedure. To maximize the accuracy of the diagnosis of a rotator cuff tear, only procedures that directly visualized the rotator cuff were used, excluding closed reduction and percutaneous pinning as well as intramedullary nailing as options. Also, for treatment with ORIF, hemiarthroplasty, and reverse shoulder arthroplasty, surgeons routinely place sutures sequentially around the rotator cuff to augment fixation.
Finally, the current study did not analyze each group with any outcome measures. Ideally, radiographic and functional outcomes would have been compared between the groups. However, the primary goal of this study was to define the prevalence of rotator cuff tears when treating operative proximal humerus fractures.
The current study showed a prevalence rate of 8.6% for rotator cuff tears in surgically managed proximal humerus fractures. Compared with patients without rotator cuff tears, patients with tears were significantly more likely to be older, to have sustained a fracture-dislocation, and to have undergone arthroscopic repair or reverse shoulder arthroplasty for the fractures. Most of the tears were not known or suspected before surgery, yet most could be repaired, with only a small percentage of cases (5 of 349; 1.4%) requiring reverse shoulder arthroplasty for rotator cuff tears.
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- Kim SH, Szabo RM, Marder RA. Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008. Arthritis Care Res. 2012; 64:407–414. doi:10.1002/acr.21563 [CrossRef]
- Singer BR, McLauchlan GJ, Robinson CM, Christie J. Epidemiology of fractures in 15,000 adults: the influence of age and gender. J Bone Joint Surg Br. 1998; 80:243–248. doi:10.1302/0301-620X.80B2.7762 [CrossRef]
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- Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults: the effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995; 77:296–298.
- Moosmayer S, Smith HJ, Tariq R, Larmo A. Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study. J Bone Joint Surg Br. 2009; 91:196–200. doi:10.1302/0301-620X.91B2.21069 [CrossRef]
- Schibany N, Zehetgruber H, Kainberger F, et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. Eur J Radiol. 2004; 51:263–268. doi:10.1016/S0720-048X(03)00159-1 [CrossRef]
- Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995; 77:10–15.
- Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999; 8:296–299. doi:10.1016/S1058-2746(99)90148-9 [CrossRef]
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- Cazeneuve JF, Cristofari DJ. The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly. J Bone Joint Surg Br. 2010; 92:535–539. doi:10.1302/0301-620X.92B4.22450 [CrossRef]
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- Lenarz C, Shishani Y, McCrum C, Nowinski RJ, Edwards TB, Gobezie R. Is reverse shoulder arthroplasty appropriate for the treatment of fractures in the older patient?Clin Orthop Relat Res. 2011; 469:3324–3331. doi:10.1007/s11999-011-2055-z [CrossRef]
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Data for Patients With and Without Rotator Cuff Tears
|Characteristic||Total||Rotator Cuff Tear||No Rotator Cuff Tear||P|
|Fractures, No.||349||30 (8.6%)||319 (91.4%)||N/A|
|Mean age, y||63.6||68.7||63.1||.0337|
| Low energy||270 (77.4%)||25 (83.3%)||245 (76.8%)|
| High energy||59 (16.9%)||4 (13.3%)||55 (17.2%)||.7995|
| Unknown||20 (5.7%)||1 (3.3%)||19 (6.0%)|
| 2-part||162/349 (46.4%)||15/30 (50.0%)||147/319 (46.1%)|
| Surgical neck||112||8||104|
| Greater tuberosity||42||7||35|
| 3-part||98/349 (28.1%)||9/30 (30.0%)||89/319 (27.9%)|
| Surgical neck and greater tuberosity||85||8||77|
| 4-part||89/349 (25.5%)||6/30 (20.0%)||83/319 (26.0%)|
|Dislocation||52/349 (14.9%)||12/30 (40%)||40/319 (12.5%)||.0004|
| Open reduction and internal fixation||250/349 (71.6%)||18/30 (60.0%)||232/319 (72.7%)||N/Aa|
| Arthroscopic fixation||7/349 (2.0%)||3/30 (10.0%)||4/319 (1.3%)||.0047|
| Hemiarthroplasty||66/349 (18.9%)||2/30 (6.7%)||64/319 (20.1%)||.2306|
| Reverse total shoulder arthroplasty||26/349 (7.4%)||7/30 (23.3%)||19/319 (6.0%)||.002|
|Complications||58/349 (16.6%)||5/30 (16.7%)||53/319 (16.6%)||1|
|Reoperations||25/349 (7.2%)||3/30 (10.0%)||22/319 (6.9%)||.4431|
Percentage of Rotator Cuff Tears vs Age
|Age, y||No Tear||Tear||Tear||SE|
Percentage of Rotator Cuff Tears in Each Neer Category
Percentage of Rotator Cuff Tears vs Type of Surgery
|Reverse total shoulder arthroplasty||19||7||26.92%||8.70%|
|Open reduction and internal fixation||232||18||7.20%||1.63%|
Description and Management of Rotator Cuff Tears Found in Operative Proximal Humerus Fracturesa
| Supraspinatus and infraspinatus||5|
| Supraspinatus and subscapularis||1|
| Teres minor||1|
| 3+ tendons||1|
|Preoperative knowledge of rotator cuff tear|
| Suture repair||22|
| Reverse total shoulder arthroplasty||7|
|Intraoperative change in management||5c|