An alternative to replacement for complex proximal humerus fractures

The classic four-part proximal humerus fracture, in which the head is displaced from the tuberosities and shaft or is dislocated from the glenoid, is traditionally treated with hemiarthroplasty. Gray areas of treatment uncertainty have been the "valgus impacted" fractures or instances in which the tuberosities have stayed together. Early studies of conservative treatment of all four-part fractures have shown poor outcomes. Results of open reduction and internal fixation (ORIF) of four-part fractures have been disappointing. Subsequent hemiarthroplasty after failed ORIF is more difficult and has shown worse outcomes than after an acute primary fracture. Percutaneous pinning of certain four-part fractures offers a minimally invasive approach to fracture fixation. If an anatomic reduction is obtained, hemiarthroplasty for subsequent avascular necrosis may not be needed and, if it is, it is easier to perform.