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OBJECTIVE To compare the clinical and radiological results of locking plate fixation with and without spine cage for the treatment of unstable proximal humeral fractures (PHFs) in elderly patients. DESIGN Retrospective. SETTING Level 1 Trauma Center.Patients/participants: A total of 62 patients with a mean age of 72.68 (60-88) years were included. Thirty-nine patients were treated with only a locking compression plate (LCP group) while 23 patients were treated with a locking compression plate and a spine cage (SC group). The mean follow-up was 32.26 (24-46) months. MAIN OUTCOME MEASURES Radiological outcomes were assessed using the humeral head height (HHH) and neck-shaft angle (NSA). The clinical results were evaluated using a visual analogue scale for pain, the Constant-Murley score (CMS), the American Shoulder and Elbow (ASES) score, and shoulder range of motion. RESULTS The average radiological changes in the HHH and NSA were significantly higher in the LCP group than in the SC group (p<0.001 and p<0.001, respectively). The final outcome scores were lower in the LCP group than in the SC group (CMS of 73.26 vs. 78.91 [p = 0.028] and ASES score of 72.36 vs. 78.57 [p = 0.011]). The SC group showed better forward elevation (p = 0.005) and abduction (p = 0.001); however, no significant differences were observed for shoulder external or internal rotation. The number of complications was higher in the LCP group (38.5%) than in the SC group (13.0%) (p=0.033). CONCLUSIONS For unstable PHFs with medial comminution in elderly patients, locking plate with an SC is a reasonable option to ensure satisfactory results and lower the postoperative complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.