Distal radius T-shaped locking plate with suture anchors for humeral greater tuberosity fracture with rotator cuff injury: A case report

Abstract

Greater tuberosity (GT) fractures with rotator cuff injuries are challenging due to risks of nonunion and functional loss. We report a case treated with a distal radius locking plate combined with suture anchors. A female patient presented with shoulder pain and immobility 4 weeks after trauma, diagnosed with humeral head dislocation and rotator cuff tear. She underwent minimally invasive fixation using this combined technique, which provides stable fracture reduction while repairing the rotator cuff. At the 18-month follow-up, shoulder function was fully restored with no complications. This combined technique achieved favorable outcomes, suggesting that it may represent a safe and effective option for selected patients with similar complex injuries.

Introduction

Greater tuberosity (GT) fractures of the humerus are common injuries in shoulder trauma, accounting for approximately 20% of all proximal humerus fractures. ¹ These fractures typically result from the impact of the GT against the anterior surface of the glenoid fossa or from the traction force exerted by the rotator cuff muscles. GT fractures are often accompanied by rotator cuff injuries, and if inadequately treated or diagnosed late, they may progress to chronic fractures, leading to persistent pain, shoulder dysfunction, and reduced quality of life. ² As the bony attachment site for the rotator cuff muscles, the GT is essential to shoulder joint biomechanics. Anatomically, the GT serves as the common insertion point for the supraspinatus, infraspinatus, and teres minor muscles, whose coordinated contractions enable complex shoulder movements such as abduction and external rotation. ³ A fracture of the GT not only disrupts the bony structure but also often leads to tears or avulsions of the rotator cuff tendons attached to it. ⁴

The primary challenge in treatment is addressing both the bone fracture and the associated soft tissue injury simultaneously. Traditional treatment approaches have clear limitations: While locking plates provide fracture stability, they are ineffective in treating rotator cuff injuries. ⁵ On the other hand, anchors alone are insufficient to provide the fixation strength necessary for larger or displaced fracture fragments. ⁶ Additionally, this fracture complicate treatment further due to the formation of local scar tissue and osteoporosis-related changes. ⁷

Various treatment options are available for humeral GT fractures combined with rotator cuff injuries in clinical practice. Traditional open reduction and internal fixation (ORIF) with plates has notable drawbacks, including poor plate-to-bone surface conformity and the need for repeated reshaping during surgery, which extends the duration of the procedure. ⁸ More importantly, conventional plate designs do not address the needs of rotator cuff repair, lacking effective suture anchorage structures after fixation, which complicates or even prevents rotator cuff repair. ⁹ Suture anchors fixation techniques have shown excellent results in repairing acute rotator cuff injuries, and newer anchor designs incorporate sutures that can simultaneously fix fracture fragments and repair the rotator cuff. However, for larger fragments, anchor fixation alone may not provide sufficient mechanical strength, increasing the risk of fixation failure. ¹⁰ In recent years, the introduction of locking hook plates has provided greater stability for the shoulder joint, yielding favorable clinical and radiographic outcomes. However, these plates can irritate the rotator cuff, and postoperative stiffness is a common issue. ¹¹ The advent of minimally invasive techniques offers new perspectives on this problem. Multiple locking plates simplify surgical procedures, minimize trauma, and provide reliable fixation in treating displaced humeral GT fractures. While maintaining strength, these plates reduce soft tissue irritation. Nonetheless, postoperative complications such as adhesive capsulitis and shoulder impingement syndrome may still occur. ¹²

Recent research into the microstructure of the GT of the humerus has revealed that osteoporosis and reduced bone quality significantly affect the success of internal fixation. Micro-computed tomography (CT) analysis has shown that trabecular density and three-dimensional structural parameters of the proximal humerus are directly correlated with screw retention force. Patients with poor bone microstructure face a 3- to 5-fold increased risk of screw pullout during surgery. ¹³ This highlights the importance of assessing bone quality in the treatment of chronic fractures and selecting fixation strategies tailored for patients with osteoporosis.

This case report describes the use of a combination of a distal radius T-shaped locking plate and suture anchors in a single patient with a subacute GT fracture of the humerus complicated by osteoporosis. After 18 months of follow-up, the patient showed excellent clinical outcomes with no residual shoulder joint dysfunction or deformity.

Case report

A female patient in the fifth decade of life presented to the hospital 4 weeks after sustaining a fall that resulted in right shoulder pain, swelling, and restricted range of motion. Physical examination revealed localized tenderness and pressure pain in the right shoulder, along with significant limitations in active flexion and extension. The patient was unable to perform abduction or external rotation of the shoulder. Pulses in the right brachial and radial arteries were intact, and there were no signs of sensory numbness or brachial plexus nerve damage in the right upper limb.

Imaging findings confirmed the diagnosis: Computed tomography (CT) revealed an avulsion fracture of the right GT of the humerus, with cortical bone discontinuity and displacement of the fracture fragments, belongs to Mutch type I, as shown in Figure 1(a). Magnetic resonance imaging (MRI) of the right shoulder joint further demonstrated the avulsion fracture of the GT, along with surrounding bone marrow edema. Additionally, the MRI showed supraspinatus tendon injury, edema in the supraspinatus, infraspinatus, and subscapularis muscles, and fluid accumulation around the shoulder joint, as depicted in Figure 1(b), (c), and (d). The final diagnosis was subacute avulsion fracture of the GT of the humerus with a rotator cuff tear. The Constant-Murley Shoulder Scoring Scale (CMS) and University of California-Los Angeles (UCLA) of the function in right shoulder joint was 52 and 25, respectively, before surgery, which was conducted by 2 independent doctors in a blind manner. Although preoperative dual-energy X-ray absorptiometry was not performed, several indirect indicators suggested underlying osteoporosis. First, the patient was a female in her fifth decade of life, an age group at increased risk of postmenopausal osteoporosis. Second, CT revealed thinning of the humeral head cancellous bone and reduced trabecular density at the fracture site.

Figure 1.

(a) CT of GT fracture of the humerus (b, c, d) MRI of GT fracture of the humerus.

The rationale for choosing this combined fixation technique was as follows. First, the patient presented at the 4th week post-injury, representing a subacute stage in which local fibrous tissue formation and mild osteoporotic changes were expected, making conventional screw fixation potentially less reliable. Second, preoperative MRI confirmed a concomitant rotator cuff tear involving the supraspinatus tendon, which required soft tissue repair in addition to bony fixation. Third, the fracture fragment was of moderate size and displaced, rendering isolated suture anchor fixation insufficient for mechanical stability while isolated plate fixation could not address the rotator cuff injury. Fourth, the patient’s age and bone quality suggested a risk of screw pullout; therefore, a low-profile distal radius locking plate with suture anchors was selected to provide angular stability, allow rotator cuff reattachment, and minimize soft tissue irritation. This integrated approach aimed to achieve both anatomical fracture reduction and functional rotator cuff repair, facilitating early postoperative rehabilitation.

The patient was intubated under general anesthesia and positioned supine on a beach chair with a pillow placed under the shoulders. A longitudinal incision of approximately 6–8 cm was made along the center of the shoulder. After careful dissection between the anterior and middle bundles of the deltoid muscle, the fracture site was reached, revealing a fracture fragment of GT measuring 3 × 2.5 cm. The fracture exhibited a longitudinal line with small bone fragments in the central region, which were displaced toward the proximal end. A large tear was observed at the rotator cuff insertion site, with the supraspinatus tendon retracted approximately 2 cm from the rupture point.

A 5.0-mm-diameter suture anchor was placed at the proximal end of the humeral GT, parallel to the acromion. The screw was advanced to a depth exceeding the safety line at the distal end by 1 mm, enhancing resistance to pullout torque. To prevent penetration of the suture anchors into the articular cartilage, the tail-end suture was placed at the proximal end of the humeral greater tubercle fracture. The tail-end 1 is sutured to exit near the proximal end of the torn rotator cuff (supraspinatus muscle), while the tail-end 2 is sutured to exit at the distal end of the torn rotator cuff tissue and cover the fracture site of the large head. The suture is a double-strand woven line made up of ultra-high molecular weight polyethylene and nylon. The suture was then passed outward in an umbrella-shaped pattern and pulled distally, achieving reduction in the GT fragment.

Next, a distal radius T-shaped locking plate (25 × 47 × 2.4 mm, as shown in Figure 2) was used to secure the reduced humeral fragment, positioned 5–10 mm from the acromion at the proximal end to prevent impingement. The plate has a slight curvature, which is conducive to the snug fit of the humeral head. If necessary, secondary shaping can be performed according to the shape around the GT of the humerus. The suture anchors were pulled distally to maintain tension and fix the large articular fragment to the rotator cuff. Two locking screws were inserted proximally into the T-shaped plate, followed by two screws distally. Finally, they passed the tail-end 1 through the central hole at the proximal end of the T-shaped locking plate, then passed tail line 2 through the farthest end hole of the plate. After pressing it against the fracture, finally knot and fix tail-ends 1 and 2 outside of the plate, as shown in Figure 3(a) and (b). The remaining sutures were used to repair the rotator cuff tear. Passive shoulder movement was performed, demonstrating no obvious acromial impingement, stable humeral head fixation, and appropriate tension in the rotator cuff. Follow-up X-rays showed proper reduction in the humeral head fragment, correct positioning of the locking plate and suture anchors, and no displacement, as shown in Figure 3(c). No iatrogenic nerve or blood vessel damage occurred during the operation, and there were no complications such as massive bleeding or hematoma formation.

Figure 2.

(a) Length of the plate (b) Width of the plate.

Figure 3.

(a, b) Intraoperative view of the internal fixation devices and sutures (c) Radiography at the first week after surgery.

On the first day post-surgery, the patient’s shoulder pain was significantly reduced, with the visual analog scale (VAS) score dropping from 7 to 2 points. Local cold therapy was administered intermittently every 6–8 h, with each session lasting 15–20 min at a temperature of 4°C. On the second day postoperatively, pendulum exercises were initiated to prevent shoulder joint adhesions. By the third day, passive abduction of the shoulder joint to 90° was achieved without pain. One week after surgery, the patient demonstrated active contraction of the biceps brachii and deltoid muscles. The post-operative rehabilitation protocol consisted of three phases: phase I (weeks 1–4): immobilization with pendulum and passive forward flexion exercises up to 90°; phase II (weeks 5–8): active-assisted motion and isometric strengthening; phase III (weeks 9–12): progressive resistance training with elastic bands. Full active range of motion was achieved by week 10, and the patient returned to daily activities by week 12 without complications. The patient adhered to this protocol under the guidance of a physical therapist. No rehabilitation-related complications, such as re-rupture or shoulder stiffness, were observed. At the 18-month follow-up, radiographs confirmed stable positioning of the humeral condylar fragment and the internal fixation device, with no signs of displacement, as shown in Figure 4(a) and (b). The patient had regained normal active and passive range of motion in the right shoulder, including horizontal position, posterior extension and internal rotation, abduction and external rotation, flexion and external rotation, with no functional limitations or residual deformities, as shown in Figure 4(c), (d), (e), and (f). At the last follow-up, the CMS and UCLA score was 95 and 34, respectively.

Figure 4.

(a, b) Anteroposterior and lateral radiographs at the 18th month postsurgery (c, d, e, f) The patient’s right shoulder exhibits normal range of motion without dysfunction at the 18th month postsurgery.

Discussion

The GT fractures of the humerus are typically categorized as those where effective treatment has not been administered within 3 weeks of injury, by which time fibrous tissue has often formed at the fracture site, potentially accompanied by bone resorption and a tendency toward malunion. ¹⁴ Patients with chronic fractures present with complex clinical manifestations, including mechanical pain due to nonunion or malunion, as well as dynamic pain and limited mobility resulting from rotator cuff dysfunction. ¹⁵ Mutch classified GT fractures based on the injury mechanism into three types: Type I—avulsion fracture, Type II—splinter fracture, and Type III—depressed fracture. ¹⁶ As understanding of GT fractures deepens and treatment approaches evolve, the treatment goal has shifted from merely achieving fracture healing to optimizing shoulder joint function restoration. This shift requires clinicians to not only focus on anatomical reduction but also preserve rotator cuff function and consider the possibility of early rehabilitation when choosing treatment options.

ORIF has long been considered the gold standard for surgical management of GT fractures, especially in cases with large fracture fragments and significant displacement. ¹⁷ The advantage of locking plates lies in their angular stability, offering rigid fixation for fracture ends, making them particularly suitable for patients with osteoporosis or comminuted fractures. However, multiple studies have shown that the extensive soft tissue dissection required for this procedure not only increases surgical trauma but also contributes to postoperative shoulder stiffness and subacromial adhesions, hindering functional recovery.^18,19 Furthermore, the long-term presence of the plate as a foreign body may cause discomfort, especially in lean patients, often necessitating a second surgery for removal, thus increasing both patient suffering and the economic burden.^20,21 Compared with conventional proximal humeral plates, the distal radius T-shaped locking plate offers several advantages. Its smaller volume makes it more suitable for use in the periarticular region. ²² The locking hole design allows multi-angle screw fixation, which enhances holding strength in osteoporotic bone. The plate also demonstrates good conformability, enabling better adaptation to the anatomical contour of the proximal humerus. ²³ Furthermore, it incorporates a dedicated suture fixation structure that facilitates suture passage and knotting during surgery, thereby overcoming a common limitation of traditional plates in accommodating rotator cuff repair.

Hollow screws and suture anchors tension bands represent two significant internal fixation methods for GT fractures of the humerus, each offering unique biomechanical properties and clinical applications, thereby providing diverse treatment options based on fracture characteristics. Minimally invasive hollow screw fixation is particularly suitable for simple GT fractures with large bone fragments and good bone quality. This technique involves percutaneous placement of hollow screws to achieve compression fixation of the fracture fragments. The biomechanical advantage of screw fixation lies in its ability to providing rigid compression, facilitating close contact between fracture ends, promoting callus formation, and accelerating early healing. Guan et al. conducted a biomechanical experiment using two standard parallel screws to fix split GT fractures, followed by a traction test at 45° shoulder abduction. The results demonstrated that the screws provided strong structural stiffness and fracture load, maintaining fracture stability under physiological traction forces. ²⁴ Chang et al. ²⁵ enhanced the fixation by adding cerclage wire, demonstrating superior mechanical performance for humeral fractures compared with the traditional double-screw structure. However, for patients with osteoporosis, the risk of internal fixation failure is higher due to early tensile traction on the shoulder sleeve.

Arthroscopic anchor fixation has gained popularity for smaller avulsion fractures or those with minimal displacement. This technique allows concurrent diagnosis and treatment of intra-articular pathologies, preserves the deltoid origin, and avoids a large incision. ²⁶ However, for large or comminuted fragments, anchor fixation alone may provide insufficient mechanical strength to resist rotator cuff traction forces during early rehabilitation. Biomechanical studies have shown that suture anchor constructs have lower load to failure compared with plate fixation in split-type GT fractures. A clinical study showed that compared with open plate fixation, arthroscopic anchor fixation resulted in better clinical outcomes, with significant improvements in VAS scores, shorter surgical duration, and no complications observed during a long-term follow-up. ²⁷ Park et al. reported that the arthroscopic-assisted anatomical plate fixation technique can effectively reduce large-sized, displaced, and comminuted GT fractures, and can simultaneously address intra-articular lesions and facilitate early functional rehabilitation. Compared with traditional plate fixation or arthroscopic suture anchor fixation techniques, arthroscopic-assisted plate fixation can accurately restore the medial footprint of GT fractures and provide effective support for large GT fracture fragments. ²⁸ More recently, Ye et al. reported the use of a locking plate combined with suture anchors for proximal humeral fractures, demonstrating improved functional outcomes compared with plate alone. However, both studies utilized standard proximal humeral plates, which have inherent limitations in profile height and anatomical conformity to the GT region. ²⁹

Based on the patient’s imaging results, a technique involving a distal radius T-shaped locking plate combined with suture anchors was designed to treat subacute humeral condyle fractures accompanied by rotator cuff injuries. This treatment protocol for the technique involving a miniaturized distal radius T-shaped locking plate combined with suture anchors is rooted in the concept of “integrated fracture fixation and soft tissue repair.” The core principle is to achieve stable fixation of bony structures while also functionally repairing the rotator cuff through an integrated system, which is consistent with a previous study. ²⁹ In this combined fixation scheme, suture anchors serve two primary functions: first, reattaching the rotator cuff tendon to its anatomical position via sutures; second, assisting in the fixation of fracture fragments, working in synergy with the plate for stable fixation. After 18 months of follow-up, the patient’s right shoulder joint range of motion returned to normal, with no residual functional impairments or complications, and no iatrogenic injuries occurred during surgery. In conclusion, the use of a distal radius T-shaped locking plate combined with anchors to treat subacute humeral GT fractures with rotator cuff injuries represents a significant advancement in orthopedic sports medicine. This approach integrates the dual requirements of fracture fixation and soft tissue repair. With further clinical experience and the refinement of long-term follow-up data, this combined fixation strategy is expected to become a standard method for treating GT fractures with rotator cuff injuries, especially in cases of delayed fracture healing, significant bone fragment displacement, or severe rotator cuff dysfunction.

Although this case report demonstrated positive clinical outcomes, there are several limitations. (1) The case report lacks a control group or a systematic comparison of clinical efficacy, of which conclusion needs prospective cohort studies or randomized controlled trials to prove. (2) We only conducted a short-term follow-up and longer is needed to track whether there are any complications related to the internal fixation. (3) The plate’s slight curvature is based on intraoperative observation rather than on validated biomechanical evidence. Cadaveric or biomechanical studies are needed to confirm the conformity and fixation stability of the distal radius plate when applied to the humeral greater tuberosity.

Conclusion

In conclusion, this single case demonstrates that the use of a distal radius locking plate combined with anchors can be applied to treat subacute humeral GT fractures with rotator cuff injuries. This approach was able to address the dual requirements of fracture fixation and soft tissue repair in this patient. However, with further clinical experience and the refinement of long-term follow-up data, this combined fixation strategy may prove to be a useful option for treating GT fractures with rotator cuff injuries, particularly in cases where bone quality is compromised or delayed presentation has occurred.