Since these fractures are impacted, pure traction alone may not be effective to reduce the fracture.
While longitudinal traction is applied to the limb, insert a periosteal elevator into the fracture gap to disimpact the fracture. The elevator should be inserted from the front and pointed medially and superiorly.
Due to the overlap, the periosteal elevator might not be inserted easily from anterior. If so, insert it into the gap between the fracture fragments. The periosteal elevator might then be used as a lever to disimpact the fragments.
Confirm proper rotational alignment
Correct rotational alignment must be confirmed. This can be done by matching the fracture configurations on both sides of the fracture. This would be useful in the more transverse fracture configuration as shown in the illustration.
Pearl: check retroversion
The bicipital groove might be a good indicator for correct rotation. In case of correct rotation, no gap/angulation is visible at the level of the fracture.
In these fractures the combined forces of the tendons are normally neutral, therefore, the humeral head is in neutral version. Remember that the humeral head is normally retroverted, facing approximately 25° posteriorly (mean range: 18°-30°) relative to the distal humeral epicondylar axis. This axis is perpendicular to the forearm with the elbow flexed to 90°.
Holding the reduction manually or with a pointed reduction forceps, temporarily secure it with 2 K-wires. Place them outside the foreseen plate position. The illustration shows two such K-wires placed from distal to proximal. Alternatively, they might be inserted from proximal to distal.
Avoid the path of the axillary nerve.
The correct reduction must be confirmed in both AP and lateral views by image intensification.