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 split 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