Since Neer's first description, many authors have advocated the use of hemiarthroplasty for most 4-part fractures owing to the risk of avascular necrosis of the humeral head. Results of hemiarthroplasty, however, have shown to be unreliable, especially in patients older than 75 years. Recently, the use of the reverse shoulder replacement has been advocated as an alternative solution, as functional recovery may be possible without anatomic tuberosity healing. Preliminary results have been rather encouraging, with several reports of consistent improvement of both pain relief and function. Because restoration of external rotation is best achieved with tuberosity healing, emphasis has been placed on tuberosity repair. The purpose of the current paper was to describe a reliable and reproducible technique for managing 4-part proximal humeral fractures with reverse shoulder arthroplasty using a humeral head horseshoe graft to augment secure tuberosity fixation. Together with a prosthesis that uses a more anatomical center of rotation, this technique provides a means for anatomic restoration of the tuberosities and minimizes the risk of tuberosity migration associated with current prostheses.