Clinical Faceoff: Are Distal-third Diaphyseal Humerus Fractures Best Treated Nonoperatively?

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D istal-third diaphyseal fractures of the humerus are so variably treated that they seem to be a paradigm for bias and misconceptions in surgery. Conceptually, a functional brace seems ‘‘too low,’’ but the fractures almost always heal, although some fractures heal with varus deformity. The surgery is not easy because there is often a butterfly fragment—meaning that the plate must extend proximal, placing the radial nerve at risk. In order to get good fixation, one needs to extend the plate down the posterior, nonarticular part of the lateral column, which makes it difficult to use a straight plate. Consequently, the most distal screws might be unicortical, and subject to pull out in osteoportic bone. I invited two experts in the field of orthopaedic surgery to discuss the many treatment options associated with distal-third diaphyseal fractures of the humerus. Andrew Jawa MD is an orthopaedic surgeon at New England Baptist Hospital in Boston, MA, USA, whose primary clinical interests include shoulder reconstruction for instability, arthritis, and trauma. Lisa K. Cannada MD is an orthopaedic traumatologist from Saint Louis University Hospital and St. John’s Mercy Medical Center in Saint Louis, MO, USA. Her major interests include long bone malunion, pilon fractures, and general trauma orthopaedics.