Four-Part Fractures of the Proximal Humerus: Open Reduction and Internal Fixation versus Hemiarthroplasty

One of the more challenging issues in upper extremity surgery is the four-part proximal humeral fracture. Humeral fractures of this variety carry a higher risk of avascular necrosis and associated worse prognosis than many others. Despite this risk, this fracture in younger patients is best treated with internal fixation and restoration of anatomic alignment. The valgus impacted fracture often lends itself toward better outcomes with open reduction and internal fixation. In contrast, the displaced four-part proximal humeral fracture and/or dislocation, more frequently seen in the elderly, is best treated with humeral head replacement, which more predictably results in a pain-free shoulder and acceptable range of motion.