Simultaneous Bilateral Lesser Tuberosity Fracture Fixation Using Suture Osteosynthesis in Porotic Bone: A Case Report

Isolated bilateral fractures of the lesser tuberosity of the humerus represent an exceptionally rare subset of proximal humerus fractures. A 66‑year‑old active woman with chronic steroid‑induced osteoporosis presented with bilateral shoulder pain after a ground‑level fall down a step. Clinical examination demonstrated marked bilateral loss of internal rotation strength with positive belly‑press and bear‑hug tests, whereas external rotation was preserved. Standard radiographs, CT, and MRI confirmed displaced bilateral lesser tuberosity avulsion fractures in porotic bone, with the subscapularis tendon attached to the fragments and an otherwise intact rotator cuff. Given the degree of displacement, functional impairment, and high functional demands, a single‑stage bilateral open surgical procedure was performed in the beach‑chair position through a deltopectoral approach, consisting of long head biceps tenotomy with tenodesis using a 5‑mm titanium anchor (ArthroVims®; VIMS, Villeneuve-lès-Bouloc, France) and suture‑based fixation of the lesser tuberosity fragments using nonabsorbable Smartloop® and SmartTape™ sutures (FX Solutions, Viriat, France), tailored to the small, porotic fragments. Postoperative management consisted of sling immobilization for six weeks, immediate pendulum exercises, passive external rotation limited to 0° from week 3, and active mobilization from week 6, resulting in excellent shoulder function at only three months' follow‑up. This case illustrates the feasibility of simultaneous bilateral surgery in an osteoporotic patient, with fixation adapted to poor bone quality (suture fixation rather than screw fixation) and systematic management of the long head of the biceps in the setting of pulley involvement. Only three cases of isolated bilateral lesser tuberosity fractures have been reported to date, underscoring the rarity of this injury pattern, the value of advanced imaging, and the role of operative treatment in displaced fractures.