• INTRODUCTION
    • The shoulder strap approach involves an anterolateral deltoid split with use of an inverted U incision, providing excellent lateral exposure for locked plate fixation of complex proximal humeral fractures.
  • STEP 1 POSITIONING OF THE PATIENT AND THE IMAGE INTENSIFIER
    • Proper positioning of the image intensifier is important for uninterrupted fluoroscopy.
  • STEP 2 SKIN INCISION
    • The tip of the acromion is a useful landmark and serves as the proximal extent of the incision.
  • STEP 3 RAISE THE DISTALLY BASED FASCIOCUTANEOUS FLAP
    • Raise a broad-based full-thickness fasciocutaneous flap.
  • STEP 4 CREATION OF THE PROXIMAL WORKING WINDOW
    • Split the deltoid anteriorly to minimize the chances of denervation.
  • STEP 5 IDENTIFICATION AND PROTECTION OF THE AXILLARY NERVE
    • Leave a cuff of deltoid muscle to protect the axillary nerve.
  • STEP 6 PLACEMENT OF TRACTION CUFF SUTURES
    • The cuff sutures are helpful in reduction of the proximal fracture segments and improve stability of three and four-part fractures.
  • STEP 7 REDUCTION OF THE HEAD AND TUBEROSITY FRAGMENTS
    • Avoid varus reduction and reestablish the relationship between the humeral head and the greater tuberosity.
  • STEP 8 PLATE PLACEMENT
    • Proper plate positioning is important to maximize the possibility of using all proximal screw options and to minimize chances of impingement.
  • STEP 9 FRACTURE FIXATION
    • As is necessary with all locked internal fixators, reduce the fracture before fixing the plate; the order of fixation may vary with the type of fracture.
  • RESULTS
    • In our study of fifty patients with a displaced three or four-part fracture treated with this approach, all flaps healed well without any necrosis and no infections were seen.IndicationsContraindicationsPitfalls & Challenges.