Skip to main content
Log in

Endosteal Strut Augment Reduces Complications Associated With Proximal Humeral Locking Plates

  • Symposium: Fractures of the Shoulder Girdle
  • Published:
Clinical Orthopaedics and Related Research®



Locking-plate technology has renewed interest in plate fixation for treating proximal humerus fractures. Complications associated with these devices, including loss of reduction, screw cutout, and intra-articular penetration, are frequent. Establishing a second column of support may reduce complications and improve clinical outcome scores.


We asked whether addition of an endosteal cortical allograft strut, used as an augment to locking-plate fixation for displaced proximal humerus fractures, would reduce complications and improve clinical outcome scores.

Patients and Methods

We retrospectively reviewed the charts and radiographs of 38 patients treated by this method. All patients were evaluated with serial radiographs, as well as the Disabilities of the Arm, Shoulder, and Hand and Constant-Murley scores. There were seven two-part, 19 three-part, and 12 four-part fractures. The minimum followup was 49 weeks (average, 75 weeks; range, 49–155 weeks).


No patient had intra-articular screw penetration or cutout. No patient had complete osteonecrosis, but one had partial osteonecrosis. The reduction was lost in one patient. The mean Disabilities of the Arm, Shoulder, and Hand score was 15 (range, 0–66.4). The mean Constant-Murley score was 87 (range, 51–95).


Low rates of complication and high clinical outcome scores can be achieved when treating complex proximal humerus fractures with locking-plate fixation and an endosteal strut augment.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

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

Instant access to the full article PDF.

Fig. 1A–B
Fig. 2A–B

Similar content being viewed by others


  1. Agudelo J, Schurmann M, Stahel P, Helwig P, Morgan SJ, Zechel W, Bahrs C, Parekh A, Ziran B, Williams A, Smith W. Analysis of efficacy and failure in proximal humerus fractures treated with locking plates. J Orthop Trauma. 2007;21:676–681.

    Article  PubMed  Google Scholar 

  2. Antuna SA, Sperling JW, Cofield RH. Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up. J Shoulder Elbow Surg. 2008;17:202–209.

    Article  PubMed  Google Scholar 

  3. Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52:243–249.

    Article  PubMed  CAS  Google Scholar 

  4. Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audigé L, Babst R. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23:163–172.

    Article  PubMed  Google Scholar 

  5. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–164.

    PubMed  Google Scholar 

  6. Den Hartog D, Van Lieshout EM, Tuinebreijer WE, Polinder S, Van Beeck EF, Breederveld RS, Bronkhorst MW, Eerenberg JP, Rhemrev S, Roerdink WH, Schraa G, Van der Vis HM, Van Thiel TP, Patka P, Nijs S, Schep NW. Primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly (ProCon): a multicenter randomized controlled trial. BMC Musculoskelet Disord. 2010;11:97.

    Article  Google Scholar 

  7. Edelson G, Safuri H, Salami J, Vigder F, Militianu D. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008;17:399–409.

    Article  PubMed  Google Scholar 

  8. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005;430:176–181.

    Article  PubMed  Google Scholar 

  9. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut support of proximal humerus fractures using an endosteal implant. J Orthop Trauma. 2008;22:195–200.

    Article  PubMed  Google Scholar 

  10. Gardner MJ, Evans JM, Dunbar RP. Failure of fracture plate fixation. J Am Acad Orthop Surg. 2009;17:647–657.

    PubMed  Google Scholar 

  11. 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;21:185–191.

    Article  PubMed  Google Scholar 

  12. Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascular necrosis of the humeral head. J Shoulder Elbow Surg. 1998;7:586–590.

    Article  PubMed  CAS  Google Scholar 

  13. Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004;86:848–855.

    Article  PubMed  CAS  Google Scholar 

  14. Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD. Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg. 1995;4:81–86.

    Article  PubMed  CAS  Google Scholar 

  15. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: The DASH (Disabilities of the Arm, Shoulder and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602–608.

    Article  PubMed  CAS  Google Scholar 

  16. Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008;90:1407–1413.

    Article  PubMed  CAS  Google Scholar 

  17. Lee CK, Hansen HR. Post-traumatic avascular necrosis of the humeral head in displaced proximal humeral fractures. J Trauma. 1981;21:788–791.

    Article  PubMed  CAS  Google Scholar 

  18. Lee CW, Shin SJ. Prognostic factors for unstable proximal humeral fractures treated with locking-plate fixation. J Shoulder Elbow Surg. 2009;18:83–88.

    Article  PubMed  Google Scholar 

  19. Mathison C, Chaudhary R, Beaupre L, Reynolds M, Adeeb S, Bouliane M. Biomechanical analysis of proximal humeral fixation using locking plate fixation with an intramedullary fibular allograft. Clin Biomech (Bristol, Avon). 2010;25:642–646.

    Article  Google Scholar 

  20. Müller ME. The Comprehensive Classification of Fractures of Long Bones. Berlin, Germany: Springer-Verlag; 1990.

    Book  Google Scholar 

  21. Neer CS 2nd. Displaced proximal humeral fractures. Part II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52:1090–1103.

    PubMed  Google Scholar 

  22. Neer CS 2nd. Displaced proximal humeral fractures. Part I. Classification and evaluation. 1970. Clin Orthop Relat Res. 2006;442:77–82.

    Article  PubMed  Google Scholar 

  23. 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;90:233–240.

    Article  PubMed  Google Scholar 

  24. Padua R, Bondi R, Ceccarelli E, Campi A, Padua L. Health-related quality of life and subjective outcome after shoulder replacement for proximal humeral fractures. J Shoulder Elbow Surg. 2008;17:261–264.

    Article  PubMed  Google Scholar 

  25. Reddix RN, Russell G, Woodall J, Jackson B, Dedmond B, Webb LX. Relationship between intraoperative femoral head bleeding and development of avascular necrosis after acetabular fracture surgery. J Surg Orthop Adv. 2009;18:129–133.

    PubMed  Google Scholar 

  26. Resch H, Beck E, Bayley I. Reconstruction of the valgus-impacted humeral head fracture. J Shoulder Elbow Surg. 1995;4:73–80.

    Article  PubMed  CAS  Google Scholar 

  27. Rose PS, Adams CR, Torchia ME, Jacofsky DJ, Haidukewych GG, Steinmann SP. Locking plate fixation for proximal humeral fractures: initial results with a new implant. J Shoulder Elbow Surg. 2007;16:202–207.

    Article  PubMed  Google Scholar 

  28. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009;91:1689–1697.

    Article  PubMed  Google Scholar 

  29. Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elbow Surg. 2009;18:837–844.

    Article  PubMed  Google Scholar 

  30. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–483.

    Article  PubMed  Google Scholar 

  31. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus. J Shoulder Elbow Surg. 1998;7:85–89.

    Article  PubMed  CAS  Google Scholar 

Download references


The authors thank Omesh Paul, MD, for his help in data collection for this study.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Andrew S. Neviaser MD.

Additional information

One of the authors (JSD) has received fees for consulting from BioMimetic Therapeutics (Franklin, TN), Tornier Sports Medicine (Edina, MN), and Arthrex, Inc (Naples, FL). Each of the other authors certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at The Hospital for Special Surgery.

About this article

Cite this article

Neviaser, A.S., Hettrich, C.M., Beamer, B.S. et al. Endosteal Strut Augment Reduces Complications Associated With Proximal Humeral Locking Plates. Clin Orthop Relat Res 469, 3300–3306 (2011).

Download citation

  • Published:

  • Issue Date:

  • DOI: