Locking plate fixation for proximal humerus fractures—when do I use a fibular strut?

Displaced proximal humerus fractures, particularly in osteoporotic bone, often require open reduction and internal fixation (ORIF). Locking plate technology has enhanced our ability to treat these fractures. However, there is a high failure rate when used alone in cases with posteromedial comminution, metadiaphyseal fracture extension, and nonunions. Supplementing medial support with the use of intramedullary fibular strut allograft has been described to prevent a number of complications including humeral head collapse, screw penetration, and overreduction of the greater tuberosity. The purpose of this article is to highlight the principles and technique of open reduction internal fixation of proximal humerus fractures with an intramedullary fibular strut. The function of the fibular strut is to improve construct stability, support the medial calcar and prevent over reduction of the greater tuberosity.