Although various methods such as percutaneous K-wire fixation, plate fixation, and arthroplasty have been proposed for the treatment of proximal humeral fracture with osteoporosis, a definite treatment method has not yet been established . In the case of complications such as infection and loss of reduction due to weakening of the fixation, pin fixation should be used when bone quality is good and in the absence of a comminuted fracture . According to Boudard , the study did not show that locking plates resulted in better functional outcome, radiographic results or reduction of postoperative complications than intramedullary nail. However, many other literatures have reported various complications for intramedullary nail surgery. It causes various complications such as distraction, nonunion, screw back-out, and rotator cuff tear.[3, 7, 27] In the case of arthroplasty, the incidence rate of complications such as dislocation, nerve damage, and infection ranges from 5% to 40% . Furthermore, Patients older than 70 years and patients with chronic debilitating disease showed significantly poorer clinical outcome after hemiarthroplasty for proximal humeral fracture.
Reverse total shoulder arthroplasty for complex proximal humeral fractures is still controversial but RSA has been increasingly used as an alternative to hemiarthroplasty in the recent years. However, RSA cause unique complications, including scapular notching, acromial fracture, and a higher incidence of implant instability. We need to long-term outcome studies to define RSA prosthesis longevity and possible late implant failure in elderly patients for proximal humeral fractures.[25, 29]
When we cannot achieve adequate reduction due to comminuted fracture at the surgical neck including medial calcar and severe bone loss, we can't expect a medial buttress even after reduction. In that cases, varus deformity and loss of fracture were reported. The reason for this is that medial comminuted fracture is associated with blood flow injury, poor bone quality, and high energy damage . The authors also reported that varus deformity was more severe in the medial comminuted fractures. After operation, we achieved restoration of the NSA but found no statistically significant difference at final follow-up. Clinical results also showed decreases in the range of motion and clinical performance. For this reason, Gardner et al.  proposed a fibular strut allograft augmentation and reported good results when the medial support was difficult.
It is often accompanied by shoulder stiffness and scapular dyskinesia after proximal humeral fracture. Thus, various rehabilitation methods have been introduced to prevent this [12, 28]. Aggressive rehabilitation can reduce the many discomforts associated with stiffness. The authors presented various exercise methods to patients, including scapular, stretching, and strengthening exercises. However, in elderly patients, compliance was poor and aggressive rehabilitation was difficult because of pain, and these factors are also considered to contribute to the poor clinical outcome.
Open plate fixation was generally good, but complication and reoperation rates of 15% and 12.7% were reported, respectively . Various complications such as malunion, loss of fracture reduction, metal failure, nonunion, and osteonecrosis have been reported. In 8% of patients, screw penetration was the most common cause of reoperation . Two patients had screw penetration, one of whom had reoperation to remove the screw. To prevent this, during the operation, the length of the screw should examined using C-arm imaging. Furthermore, the far-cortex should be examined with a depth gage, based on which the screw length can be decided.
Furthermore, we need to understand the screw configurations according to the plate type and proceed with the surgery. Of course, preoperatively we have to check evaluation of bone quality of the patient, accurate analysis of the fracture type, plate selection.
The incidence rate of osteonecrosis after surgical treatment of proximal humeral fractures is reported to be 3–35% . Especially in the proximal humeral head, after 48 hours, the frequency of this is high. In these patients, the frequency of shifting to arthroplasty was high.(80%) The authors also performed surgical treatment in 1 patient on postoperative day 4, which resulted in osteonecrosis. However, considering the age and activity of this patient, we decided to perform conservative treatment.
Recently, the number of reverse total shoulder arthroplasty cases has been increasing among complex humeral fractures. The results are excellent as compared with those of hemiarthroplasty, and the 5- and 10-year survival rates are 94% and 91%, respectively. However, the technique of reverse total shoulder arthroplasty for fractures was found to be more difficult than the procedure for rotator cuff disease, and the functional score decreased from 6 years after the procedure, so that the Constant-Murley score was maintained at ≥30 points in 60% of patients only . Generally, the complication rate of reverse total shoulder arthroplasty is reported to be 19–68%. Furthermore, complication rate of reverse total shoulder arthroplasty for fracture vary among studies and range from 5% to 40% such as periprothetic fracture, infection, dislocation and nerve paly. Cheung et al reported that treatment of the these complications is difficult. Therefore, reverse total shoulder arthroplasty is not an easy choice for treating proximal humeral fractures even in the elderly .
One of the study’s limitations is that, as a retrospective study, the findings may have been influenced by selection bias. Although we considered Neer classification and medial comminution, we did not make an analysis of the severity of fractures exactly. Second, the total number of cases are only 19, therefore it is difficult to anticipate a statistically significant difference. Third, because the study design consisted of a relatively short follow-up, long-term complication, such as osteonecrosis, arthritis, cannot be out-ruled. Lastly, It has the disadvantage of not comparing with other surgical methods.