Proximal Humerus Fractures: Pin, Plate, or Replace?

No definitive treatment algorithm exists regarding the optimal treatment for displaced proximal humerus fractures. Factors affecting decision making include facture type, bone quality, metaphyseal comminution, risk of head osteonecrosis, joint congruity, and patient functional demands. With good bone quality, percutaneous fixation is appropriate for 2-part fractures without metaphyseal comminution and select 3-part and 4-part valgus-impacted fractures with preserved medial hinge. Open reduction internal fixation is appropriate for displaced fractures with joint congruity. Hemiarthroplasty is preferred in head-splitting large impaction fractures or a devascularized head. Many displaced 4-part fractures are treated with open reduction and internal fixation, despite the risk of avascular necrosis in younger patients in whom implantation of a prosthesis is undesirable. This article reviews indications and surgical techniques to maximize successful outcomes of proximal humerus fracture treatment.