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Introduction
  • Indications
    • Open reduction and internal fixation of humeral shaft fractures
    • Humeral tumor biopsy/resection
    • Humeral osteotomy
 
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)
 
Preparation
  •  Postion
    • Supine with arm on arm board, abducted 60 degrees
 
Approach
  • 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




 
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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