Our technique was developed to use the advantages of traditional percutaneous pinning (eg, temporary fixation, preservation of the soft tissues, better cosmesis) and improve its limitations, in particular, the weak fixation in osteoporotic bone. The main modifications are the use of long threaded pins to achieve purchase in good-quality bone beneath the articular surface of the humeral head and in the lateral cortex of the metaphysis, which helps to obtain strong bicortical fixation, as well as the use of a dedicated external fixator to further increase pin stability. The surgical technique was standardized and divided into five steps, the first of which is the operating room setup, with the patient placed in the beach-chair position, the fluoroscopy unit placed on the contralateral side of the affected shoulder, and the x-ray beam oriented with the glenoid. Second, double skin preparation is done, first with 4% chlorhexidine gluconate and then with povidone iodine. Third, closed reduction of the fracture is done; the shoulder is forced into abduction with the scapula stabilized (to reduce varus displacement of the humeral head), after which a posteriorly directed force is applied to the arm (to reduce medial displacement of the humeral shaft and internal rotation of the head). Fourth, fracture fixation is done using six long, threaded Kirschner wires, which are inserted in a standard manner and then stabilized with the external fixator. Finally, postoperative care consists of early passive mobilization of the shoulder, placement of pins, and wound medication once per week, followed by pin removal approximately 40 days postoperatively.