Skip to main content


Log in

Outcomes of Proximal Humerus Fracture Open Reduction Internal Fixation with Concomitant Ipsilateral Shoulder Girdle Injuries: a Case Control Study

  • Original Article
  • Published:
HSS Journal ®



Proximal humerus fractures treated in the face of ipsilateral injuries to the shoulder girdle may be predisposed to worse clinical outcomes.


The purpose of this investigation was to examine outcomes of proximal humerus fractures treated with open reduction internal fixation (ORIF) using an endosteal augment in the presence of a concomitant shoulder girdle injury in comparison to isolated proximal humerus fractures treated with ORIF and endosteal augment.


A prospective database was used to identify proximal humerus fractures with ipsilateral shoulder girdle injuries (glenohumeral and acromioclavicular dislocation, fractures of the acromion, clavicle, scapula, or humeral diaphysis). These were compared to isolated proximal humerus fractures treated in the same fashion (ORIF with endosteal augment). Minimum of 1 year follow-up was required for inclusion. Outcomes assessed included range of motion (ROM), development of avascular necrosis (AVN), hardware-related complications, reoperation, and subjective outcome assessments including the Disabilities of Arm Shoulder and Hand questionnaire (DASH), Constant score, UCLA rating scale, and the Short Form-36 (SF-36).


Fifteen ipsilateral injuries were seen in 14 patients. Seventy-seven isolated proximal humerus fractures were available for comparison. The ipsilateral injury group had significantly worse forward flexion (141 vs 156°, p = 0.02), external rotation (56 vs 64°, p = 0.03), higher rates of avascular necrosis (4 of 14, 28.6% vs 1 of 77, 1.3%, p = 0.002), and inferior SF-36 physical health scores (48.5 vs 63.5; p = .04). Despite these differences, no significant differences were seen with hardware-related complications or DASH, Constant score, or UCLA rating scale results. No patients required secondary reconstructive procedures.


Despite a statistically higher rate of AVN and decreased ROM, patient-based outcomes of proximal humerus fractures with ipsilateral shoulder injuries approached those seen in isolated proximal humerus fractures. This suggests that these injuries can achieve similarly good clinical results provided any associated shoulder pathology is identified and treated appropriately.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others


  1. Bastian JD, Hertel R. Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elb Surg. 2008; 17(1): 2-8.

    Article  Google Scholar 

  2. Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humeral fractures. An anatomical cadaver study. J Bone Joint Surg (Br). 1993; 75(1): 132-136.

    CAS  Google Scholar 

  3. Flint JH, Carlyle LM, Christiansen CC, Nepola JV. Case report and literature review anterior shoulder dislocation with three-part proximal humerus fracture and humeral shaft fracture. Iowa Orthop J. 2009; 29: 105-113.

    PubMed  PubMed Central  Google Scholar 

  4. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007; 21(3): 185-191.

    Article  PubMed  Google Scholar 

  5. Garnavos C, Lasanianos N. Intramedullary nailing of combined/extended fractures of the humeral head and shaft. J Orthop Trauma. 2010; 24(4): 199-206.

    Article  PubMed  Google Scholar 

  6. Geiger EV, Maier M, Kelm A, Wutzler S, Seebach C, Marzi I. Functional outcome and complications following PHILOS plate fixation in proximal humeral fractures. Acta Orthop Traumatol Turc. 2010; 44(1): 1-6.

    Article  PubMed  Google Scholar 

  7. Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomical study. J Bone Joint Surg Am. 1990; 72(10): 1486-1494.

    CAS  PubMed  Google Scholar 

  8. Greiner S, Kaab MJ, Haas NP, Bail HJ. Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures. Injury. 2009; 40(2): 186-191.

    Article  CAS  PubMed  Google Scholar 

  9. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elb Surg. 2004; 13(4): 427-433.

    Article  CAS  Google Scholar 

  10. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am. 2010; 92(4): 943-948.

    Article  PubMed  Google Scholar 

  11. Kim SH, Lee YH, Chung SW, et al. Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft. Injury. 2012; 43(10): 1724-1731.

    Article  PubMed  Google Scholar 

  12. Kofoed H. Revascularization of the humeral head. A report of two cases of fracture-dislocation of the shoulder. Clin Orthop Relat Res. 1983; 179: 175-178.

    Article  PubMed  Google Scholar 

  13. Neviaser AS, Hettrich CM, Beamer BS, Dines JS, Lorich DG. Endosteal strut augment reduces complications associated with proximal humeral locking plates. Clin Orthop Relat Res. 2011; 469(12): 3300-3306.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Neviaser AS, Hettrich CM, Dines JS, Lorich DG. Rate of avascular necrosis following proximal humerus fractures treated with a lateral locking plate and endosteal implant. Arch Orthop Trauma Surg. 2011; 131(12): 1617-1622.

    Article  PubMed  Google Scholar 

  15. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008; 90(2): 233-240.

    Article  PubMed  Google Scholar 

  16. Robinson CM, Akhtar A, Mitchell M, Beavis C. Complex posterior fracture-dislocation of the shoulder. Epidemiology, injury patterns, and results of operative treatment. J Bone Joint Surg Am. 2007; 89(7): 1454-1466.

    Article  PubMed  Google Scholar 

  17. Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg (Br). 2006; 88(4): 502-508.

    Article  CAS  Google Scholar 

  18. Schliemann B, Siemoneit J, Theisen C, Kosters C, Weimann A, Raschke MJ. Complex fractures of the proximal humerus in the elderly—outcome and complications after locking plate fixation. Musculoskelet Surg. 2012; 96(Suppl 1): S3-S11.

    Article  PubMed  Google Scholar 

  19. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009; 23(2): 113-119.

    Article  PubMed  Google Scholar 

  20. Spross C, Platz A, Rufibach K, Lattmann T, Forberger J, Dietrich M. The PHILOS plate for proximal humeral fractures—risk factors for complications at one year. J Trauma Acute Care Surg. 2012; 72(3): 783-792.

    Article  PubMed  Google Scholar 

  21. Srinivas S, Kasis A. Co-existing fractures of the proximal humerus and humeral shaft without shoulder dislocation—a rare injury. Ann R Coll Surg Engl. 2010; 92(2): W25-W28.

    Article  CAS  PubMed  Google Scholar 

  22. Sudkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009; 91(6): 1320-1328.

    Article  CAS  PubMed  Google Scholar 

  23. Zhang H, Ni W, Gao S, Liang X, Zhou A. Long PHILOS locking compression plate for treatment of proximal humerus and humeral shaft fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2009; 23(4): 419-422.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Marschall B. Berkes MD.

Ethics declarations

Conflict of Interest

Marschall B. Berkes, MD, Milton T.M. Little, MD, Nadine C. Pardee, BS, Patrick C. Schottel, MD, Lionel E. Lazaro, MD, and Dean G. Lorich, MD have declared that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Informed Consent

Informed consent was waived from all patients for being included in the study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Additional information

Level of Evidence: Level 3: Therapeutic.

Electronic supplementary material

Below is the link to the electronic supplementary material.


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)


(PDF 1224 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Berkes, M.B., Little, M.T.M., Pardee, N.C. et al. Outcomes of Proximal Humerus Fracture Open Reduction Internal Fixation with Concomitant Ipsilateral Shoulder Girdle Injuries: a Case Control Study. HSS Jrnl 12, 105–110 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: