| Introduction |
- Indications
- Open reduction and internal fixation of humeral shaft fractures
- Humeral tumor biopsy/resection
- Humeral osteotomy
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| Surgical Plane |
- Internervous plane
- proximal
- Deltoid muscle (axillary nerve) and pectoralis major (medial and lateral pectoral nerves)
- distal
- Medial brachialis (musculocutaneous nerve) and lateral brachialis (radial nerve)
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| Approach |
- Position
- Supine with arm on arm board, abducted 60 degrees
- Incision
- Make a curved incision from the tip of the coracoid process distally in line with deltopectoral groove along the lateral aspect of the humerus
- Incision should end approximately 5 cm short of elbow flexion crease (lateral antebrachial cutaneous nerve at risk)
- Superficial dissection
- Identify the cephalic vein - can take medially or laterally
- Proximally, develop the interval between the deltoid and pectoralis major muscle
- Distally, incise the deep fascia of the arm in line with the skin incision
- Identify the interval between the biceps and brachialis
- Biceps can be retracted medially or laterally (typically is taken medially)
- Deep dissection
- Proximally, incise the periosteum lateral to the pectoralis major tendon insertion, staying lateral to the long head of the biceps tendon
- The anterior humeral circumflex artery is seen here and must be ligated
- Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft
- Extension
- Proximal extension can be obtained by developing the anterior approach to the shoulder with full deltopectoral dissection
- Distal extension cannot be obtained with this approach
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| Dangers |
- Anterior circumflex humeral artery
- At risk proximally between the pectoralis major and deltoid muscle
- Axillary nerve
- Can be injured with vigorous retraction of the deltoid
- Radial nerve
- must be identified before any incision is made into the brachialis muscle or before periosteal elevation of the brachialis off the humerus occurs
- also at risk on the middle 1/3 of the humerus where it lays in the spiral groove on the posterior humerus
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