Functional demand, age, bone quality, and fracture characteristics such as type and entity of displacement, comminution, and associated shoulder injuries (i.e., rotator cuff tears) must be considered as a whole to define the best surgical treatment for surgical neck fractures. In the elderly and low-demanding patients who are often affected by arthritic or cuff-deficient shoulders, surgical intervention should aim to avoid a nonunion rather than to achieve anatomic reduction. In our opinion, in such cases a modified palm tree technique helps to achieve fracture union despite possible malreductions. Advantages of the technique are an elastic fixation which is preferable in the osteopenic bone to limit fixation failure, limited blood loss, reduced surgical time, and the avoidance of general anesthesia. Furthermore, postoperative immobilization is tolerated better in elderly patients who are usually not very compliant to immediate post-op rehabilitation. Conversely, in younger and high-demanding patients, the aim of the intervention must be anatomic reduction, stable fixation, and early mobilization. An immediate post-op rehabilitation program that includes pendulum movements and passive mobilization on all planes prevents shoulder stiffness and a more prompt return to daily living activities. In these patients, the reduction and fixation with a locking plate or a nail represent the best option (Fig. 11.3). The use of minimally invasive techniques is encouraged whenever possible, especially because surgical neck fractures are their most suitable indication. To clarify, minimally invasive techniques in proximal humeral fractures do not refer to small skin incisions but to the absolute respect of vascularity, anatomic structures, and fracture site biology [35]. Therefore, both nails and plates can be implanted in this fashion, especially if an anterolateral deltoid-splitting approach is used. The latter is also a valuable solution in patients requiring a better cosmetic result. The extension of the approach can vary according to the characteristics of the fracture and of the implant used. The nail requires a more aggressive deltoid-splitting approach (i.e., partial subperiosteal elevation of the deltoid from the acromion) in order to reach the rotator cuff, which is crucial to guarantee optimal functional results. This is the only way to longitudinally split the supraspinatus medial to the footprint avoiding the risk to detach it from the greater tuberosity. Side-to-side stitches allow us to repair the approach accordingly. At the end of the procedure, the deltoid must be safely reinserted on the acromion with transosseous sutures to prevent iatrogenic lesions and undesirable functional results. In our opinion, if the deltoid is not detached from the acromion, the rotator cuff is poorly visualized, thus leading to over-retraction and consequent unrepairable iatrogenic damage to the muscle fibers. The nail should always be straight, and its entry point should be at the top of the humeral head in order to facilitate the reduction of the proximal fragment on the diaphysis. Wide proximal metadiaphyseal canals are more prone to residual translation of the proximal fragment with respect to the diaphysis, although this does not generally affect the final outcome. Intramedullary nailing is relatively contraindicated in fractures extending to the tuberosities . Most fractures of the humerus neck with infraction of the tuberosity are not typically associated with displacement of the latter. Nonetheless, the risk of displacement of the tuberosity still exists. This is particularly true in older patients with poor bone quality in which the bone bridge between the entry point of the nail and the tuberosity fracture line could more easily collapse. Therefore, a CT scan could be useful for preoperative planning, not only to assess the head-tuberosity relationship but also to precisely locate the entry point with respect to the fracture line. The minimally invasive locking plate is indicated in young patients with optimal bone quality, valgus deformity, and/or medial translation of the diaphysis. In these cases cortical screws can be used to reduce the valgus deformity and the translation (Fig. 11.4). The plate may also be used instead of the nail to treat fractures extending to the tuberosity. Furthermore, the plate is less invasive than the nail as it spares the rotator cuff and does not require us to detach the deltoid from the acromion. The latter advantage may be lost in cases requiring the use of sutures between the plate and the cuff, where partial detachment of the deltoid from the acromion could be required. Such cases include patients with a poor bone quality and fractures with metaphyseal comminution in which stabilization with inferomedial screws is not achievable as per the minimally invasive plate technical configuration. Patients affected by metaphyseal comminution may be better off if treated with a nail instead of a minimally invasive locking plate (Fig. 11.5). Intramedullary nailing has the advantage of providing mechanical stability of the proximal fragment with both the screws and the subchondral bone-nail interface [29, 36]. To maximize this effect while avoiding rotator cuff secondary damage and subacromial impingement by an overriding nail, the optimal depth of nail insertion should be 3–4 mm under the cartilage surface [6, 29]. In any case, both the nail and the plate allow us to optimally intervene on the rotator cuff through an anterolateral deltoid-splitting surgical approach should the surgeon suspect rotator cuff lesions. The use of a locking plate implanted through a traditional deltopectoral approach is our preferred choice in particular cases. These include complex lesions requiring significant reduction maneuvers, varus deformity associated with a significant bone loss requiring bone grafts, cases with a fixable medial calcar fragments , and a poor-quality bone requiring substantial use of osteosutures . The technique must be rigorous, and particular attention should be given to the soft tissue envelope. Periosteal elevation should be avoided. The transverse ligament above the bicipital groove and the anterior circumflex vessels must all be identified and respected in order to protect the ascending branch and the vascularization of the head. It is our belief that complex fractures always require osteosutures. Furthermore, the plate should be placed meticulously in terms of height and screw insertion so as to avoid subacromial impingement and violation of the articular surface. In conclusion, we recommend using a minimally invasive plate technique in young active patients, especially for valgus/medial translation deformity of the fracture. The bone quality should be optimal. Intramedullary nailing is the best option to treat comminuted metaphyseal fractures in older patients with fair bone quality. The abovementioned cases must be addressed through an anterolateral deltoid-splitting approach with minimal soft tissue manipulation. The remaining complex fractures and/or patients with poor bone quality may be treated with a locking plate through a traditional deltopectoral approach. Nonetheless, a rigorous surgical technique that is respectful of the vascularization and biology of the fracture is paramount. Finally, CRPP—especially the modified palm tree technique—may play a role in the elderly, low-demanding patients to prevent nonunions.