Goals of reduction
The goal of reduction is to restore the normal location of all fracture components. For simple 3-part fractures, the humeral head and separated tuberosity must be reduced properly.
The optimal reduction and fixation procedure for the fracture subtypes depends on the involved tuberosity, and whether or not the calcar region is comminuted.
Proximal humeral reconstruction
Reduce and fix the lesser/greater tuberosity to the humeral head (thereby converting the 3-part fracture into a 2-part situation)
Reduce the metaphyseal fracture component to the shaft and fix it
In the following procedure, involvement of the greater tuberosity is assumed. For specific details on reduction of the lesser tuberosity see Open reduction and preliminary fixation of lesser tuberosity and humeral head.
In fractures with medial metaphyseal fragmentation, it is necessary to realign the medial column fragments as accurately as possible while preserving their soft-tissue attachments and vascularity. Once healed, the restored medial bony buttress helps prevent varus collapse. With medial fragmentation, initial fixation must be secure enough to resist varus collapse.
It is also crucial to reduce the humeral head adequately since the combination of remaining varus displacement and medial fragmentation predisposes to secondary varus collapse and/or implant failure.