Introduction

The lesser tuberosity fracture may result in weakness if it is not fixed. The primary task of the plate is to stabilize a metaphyseal fracture that requires disimpaction to correct significant angulation.

Deltopectoral approaches are best suited for lesser tuberosity reduction and fixation and plate application. Occasionally, an anterolateral approach provides sufficient access.


Sutures in the subscapularis tendon insertion aid both reduction and fixation of the lesser tuberosity. Once reduced, lesser ... enlarge

Suture fixation of the lesser tuberosity

Sutures in the subscapularis tendon insertion aid both reduction and fixation of the lesser tuberosity. Once reduced, lesser tuberosity sutures are tied to a similar suture in the infraspinatus tendon for provisional fixation. Ultimately, these sutures contribute significantly to primary stability of the lesser tuberosity.


Proper reduction of the lesser tuberosity is often demanding. enlarge

Lesser tuberosity reduction

Proper reduction of the lesser tuberosity is difficult. Its position is hard to visualize with intraoperative image intensification.
Medial displacement of the lesser tuberosity (A) produces an intraarticular anterior step which can compromise internal rotation.
Lateral displacement of the lesser tuberosity (B) obstructs the bicipital groove and may compromise the bicipital tendon. If possible, correct reconstruction of the bicipital groove is desirable to allow sliding of the tendon. An alternative would be tenodesis of the long head of the biceps.


Sutures placed through the insertions of each rotator cuff tendon increase stability and should also be used. enlarge

Tension band sutures in addition to plate and screws

Sutures placed through the insertions of each rotator cuff tendon increase stability, and should be used as well as the plate and screws, particularly for more comminuted and/or osteoporotic fractures. With osteoporotic bone, the tendon insertion is often stronger than the bone itself, so that sutures placed through the insertional fibers of the tendon may hold better than screws or sutures placed through bone.
These additional sutures are typically the last step of fixation.


Standard plates provide an alternative option, for example the modified cloverleaf plate. enlarge

Angular stable versus standard plates

This procedure describes proximal humeral fracture fixation with an angular stable plate (A). Sometimes, these implants are not available. Standard plates provide an alternative option, for example the modified cloverleaf plate (B). Presently, the specific indications, advantages, and disadvantages of angular stable and standard plates are being clarified. There is some evidence that angular stable plate provide better outcomes. In addition to type and technique of fixation, the quality of reduction, the soft-tissue handling, and the characteristics of the injury and patient significantly influence the results. There is no evidence that the use of angular stable plates will overcome these other factors.