Most proximal humeral fractures affect elderly patients and can be treated nonoperatively with good functional outcomes.The treatment of displaced three and four-part fractures remains controversial and depends on a variety of underlying factors related to the patient (e.g., comorbidity, functional demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience).Throughout the literature, open reduction and locking plate osteosynthesis is associated with considerable complication rates, particularly in the presence of osteoporosis.Low local bone mineral density, humeral head ischemia, residual varus displacement, insufficient restoration of the medial column, and nonanatomic reduction promote failure of fixation and impair functional outcome.The outcome of hemiarthroplasty is closely related to tuberosity healing in an anatomic position to enable the restoration of rotator cuff function. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with preexisting rotator cuff dysfunction or after the failure of first-line treatment.