Attempt to reduce these fractures with distal traction on the arm. In transverse  fractures with translation, proper placement of the shaft against the proximal fragment may be stable. An oblique or fragmentary fracture is usually unstable.

Care should be taken to restore the medial calcar. To gain more stability slight impaction of the humeral shaft into the humeral head might be considered.
If there is medial fragmentation, special attention must be paid to prevent varus malalignment.


Use the plate as reduction aid
In these fractures, the fracture may be reduced with the help of the plate. This is most effective when the shaft is medially displaced or the fracture is in valgus malalignment. As illustrated, the plate is positioned on the lateral side of the humeral shaft. A single non-locking screw is placed perpendicularly into the shaft.

By tightening this screw, the humeral shaft will be pulled toward the plate. This maneuver “fine-tunes” the reduction.

Confirm proper rotational alignment. enlarge

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.

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°.

Confirmation of overall reduction
The correct reduction must be confirmed by image intensification in both AP and lateral views.