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Introduction
  • Indications
    • open reduction and internal fixation of humeral shaft fractures
      • often thought to be more cosmetic when compared to the anterolateral approach
      • provides good exposure to both middle and distal 1/3 humeral shaft fractures
 
Internervous plane 
  • There is no internervous plane and this is a muscle splitting approach

 
Preparation
  • Anesthesia
    • general
    • local
  • Position
    • prone with arm on arm board, abducted 45-60 degrees
    • lateral with arm over the top of the body
  • Tourniquet
  • Intraoperative Imaging
 
Approach
  • Incision 
    • incision from 8 cm distal to the acromion to the olecranon fossa
  • Superficial dissection
    • fascia should be splint in line with incision
  • Deep dissection
    • split the fascia between the long and lateral head of the triceps 
      • lateral head is retracted laterally and the long head medially
    • radial nerve will be identified along with the profunda brachii vessels in the spiral groove
      • often times a tourniquet is beneficial until the nerve is identified
  • Extension
    • proximal extension can be obtained by elevating the lateral head of the triceps
      • allows for radial nerve to be elevated in superior direction
      • limited by branch of radial nerve to medial head of triceps
    • Gerwin's modification of this approach allows for great proximal extension than the classic approach
      • this modification retracts the triceps medially after the lateral IM septum is released, protecting the radial nerve
 


Dangers
  • Radial nerve
    • nerve crosses posterior aspect of humerus at 20-21 cm proximal to medial epicondyle and 14-15 cm proximal to lateral epicondyle
 
 

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