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Introduction
  • Indications
    • open reduction and internal fixation of humeral shaft fractures
    • radial nerve exploration
 
Plane  
  • Internervous plane (none)
    • between the brachialis (musculocutaneous n. and radial n.) and brachioradialis (radial n.)
Preparation  
  • Position
    • supine with arm on arm board, abducted 45-60 degrees
Approach
  • Incision 
    • make a curved incision over the lateral border of the biceps centered over the fracture site

  • Superficial dissection
    • identify the lateral border of the biceps muscle and retract medially
    • Ensure that the lateral antebrachial cutaneous nerve is retracted with the biceps
    • This reveals the brachialis and brachioradialis muscles lying underneath
  • Deep dissection
    • Incise the fascia overlying these muscles and develop the intermuscular plane
    • The radial nerve lies between the brachialis and brachioradialis muscles 
      • The nerve is generally easiest to find in the distal arm, just proximal to the elbow
      • This must be traced proximally until it pierces the lateral intermuscular septum and be carefully protected
    • The brachialis and biceps are retracted medially and the brachioradialis laterally
    • Subperiosteal elevation of the brachialis reveals the humeral shaft underneath
  • Extension
    • Proximal extension can be obtained by developing the interval between the brachialis medially and the lateral head of the triceps posterolaterally.
    • Distal extension can be obtained by extending into an anterior approach to the elbow
      • This distal interval lies between the brachioradialis (radial n.) and pronator teres (median n.)
      • Care must be taken to avoid iatrogenic injury to the lateral antebrachial cutaneous nerve in this extensile approach


 

 

Dangers
  • Lateral cutaneous nerve of the forearm
    • This terminal branch of the musculocutaneous nerve is injured at the distal end of the incision as it exits the biceps laterally
  • 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
 
 

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