These fractures are unstable. They typically occur in older patients. Signs of instability are a translation of the humeral shaft of more than 33% and/or a metaphyseal comminution. In these cases, the risk of a nonunion is increased up to 8-10%, so surgery may be recommended. If operative reduction and fixation are chosen, the technique will depend upon surgical skill, available implants and equipment. Fixation without open reduction may be attempted initially, but the surgeon should be prepared to open the fracture if the attempt is unsuccessful.
If fixation is chosen in multifragmentary fractures, nailing or angular stable plates might be preferable because they offer more stable fixation in a short or osteoporotic proximal humeral segment.