الفهرس 
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Abstract
Proximal humeral fractures with a dual age distribution occurs either in young people following high energy trauma or in those older than 50 years with low velocity injuries like simple fall. Three fourths of the fractures occur in older individuals with an occurrence three times more often in women than in men.(1)
The first step of appropriate management is an appropriate diagnosis. High quality imaging and thorough examination are very essential. Understanding the fracture pattern, the bone quality and taking in consideration the patient’s expectations and life style are crucial for a proper decision making.
The priorities in surgical stabilization of proximal humerus fractures are (1) restoring the anatomical relationship between the tuberosities and the articular head fragment and (2) maintaining vascularity of the articular fragment. (4)
The treatment of displaced proximal humeral fractuers is complex and requires careful assessment of patient factors such as (age and activity level) and fracture related factors such as (bone quality, fracture pattern, degree of comminution and vascular status ).(26)
The goal of treatment is a pain free shoulder with restoration of the pre injured function.
The surgical management of displaced two and three parts fractures of the proximal humerus in a surgically fit patient includes many options; two of the most commonly used are percutaneous pinning and open reduction and internal fixation.
The decision to use either of these surgical modalities must depend on certain points. The most important points on which the surgeon can build his decision can be summarized as: the fracture type and pattern, the patient’s age, and the bone quality.
Proper surgical technique and precise application of the recommended surgical rules can save the patient from many intraoperative and post-operative complications.
A percutaneous method of fixation allows for minimal soft tissue dissection thereby protecting the blood supply to the fracture fragments which promotes rapid healing and minimizes the chances of avascular necrosis. This is even more important in the elderly population as it allows a rapid return of function and independence. Numerous reports describe percutaneous techniques of fixation of the proximal humerus fractures. Percutaneous fixation is believed to be best suited for two-part and some three-part fractures. (7)
Close follow-up is necessary, and the pins should be removed at the conclusion of therapy or whenever migration is noted
The key element of success in this series is perhaps
Reduction of anatomical relation between tuberosities and articular segment in 3 parts, minimal soft tissue dissection, the early rehabilitation program, which allowed a rapid return of function as compared to longer periods of immobilization in other series.
Surgeons should avoid open reductions as much as they can and should attempt this technique in two-part fractures to start with and gradually applying it to all other proximal humerus fractures.