A relatively high percentage of fractures of the proximal third of the humerus in which the fragments are completely displaced are difficult or impossible to reduce satisfactorily by manipulation. This is especially true of the fracture-dislocations and of those fractures in which the head of the humerus is also broken into two or more pieces. These fractures are likewise difficult to treat by traction, because the short proximal fragment tends to be abducted and rotated outward while the pectoralis major and subscapularis muscles tend to draw the proximal end of the distal fragment inward and forward. When traction is applied in abduction, the proximal end of the distal fragment is drawn forward and downward by the pectoralis major and latissimus dorsi muscles (fig. 1 A).
On account of the difficulties mentioned, it is my custom to treat these fractures by open reduction, frequently without even attempting treatment by closed manipulation