6/21/2015

ProximalhumerusApproachDeltopectoralapproachtotheproximalhumerusAOSurgeryReference

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ExecutiveEditor:
PeterTrafton
Authors:Martin
Jaeger,FrankieLeung,
WilsonLi

Proximal
humerus

Deltopectoralapproachtothe
proximalhumerus
Indication
The(anterior)deltopectoralapproachcanbeusedfor
almostanyproximalhumeralfracturetreatmentand
isoftenthepreferredapproach.

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Thisapproachisalsohighlyrecommendforrevision

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surgery.

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AllPreparations

Anatomy

AllApproaches

Neurovascular

AllReductions&

structures

Fixations

Thecourseofthe
following
neurovascular
structuresshouldbe
keptinmind:
Cephalicvein
Anteriorcircumflexhumeralartery
Ascendingbranchoftheanteriorcircumflex
humeralartery
Posteriorcircumflexhumeralartery
Musculocutaneusnerve
Axillarynerve
Furtherneurovascularstructures,eg,thebrachial
plexus,areonlyatriskifthereisarigorous
retraction.

Skinincision
Anatomicallandmarks
Anatomicallandmarksfortheanteriordeltopectoral
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ProximalhumerusApproachDeltopectoralapproachtotheproximalhumerusAOSurgeryReference

approachare:
A)Coracoidprocess
B)Proximalhumeral
shaft(onthelevelof
theaxilla)
Bothlandmarkscan
easilybepalpated.

Skinincision
Makea1214cmlong
skinincisionbetween
thecoracoidprocess
andtheproximal
humeralshaft.The
shapeoftheskin
incisioncanbestraight
orcurveddependingonsurgeonspreference.
Foranarthroplasty,aratherverticalincisionmaybe
preferred(dashedline).

Exposureof
deltopectoral
grooveandcephalic
vein
Exposethe
deltopectoralgroove
withthecephalicvein.
Thesestructurescan
beidentifiedby:
Thecourseofthemusclefibers
Thecephalicveinitself
Fattissuesurroundingthevein
Ifindoubt,lookforthedeltopectoralgrooveatthe
proximaland/ordistalendoftheskinincision.(The
sulcusisslightlymorepronouncedandincasesof
revisionsurgerylessscared)
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Dissectiondownto
thedeltopectoral
groove
Retractthecephalic
veinlaterallyor
medially,andopen
alongthegroove.If
retractedlaterally,the
anatomicaldrainageofbloodfromthedeltoidmuscle
isrespectedbutitisatriskofdamagebyretractors
duringsurgery.Inanycase,thecephalicveinshould
bepreservedinordertoreducethesurgicaledemaof
thelimb.
Failuretofindthedeltopectoralgroovecanleadto
difficultyindissectionofthedeltoidandpossiblyto
denervationoftheanteriorportionofthedeltoid.
Bluntlydissectbetweenandunderthedeltoidand
pectoralismusclesdowntoexposetheclavipectoral
fascia.

Exposure
Identifythecoracoid
processandthe
conjoinedtendon.
Incisethe
clavipectoralfascia
lateraltothe
conjoinedtendonand
inferiorthecoracoacromialligament.

Retractthedeltoidmusclelaterallyusingadelta
(modifiedHohmann)retractorandtheconjoint
tendonmediallyusingaLangenbeckretractor.The
musculocutaneousnerveentersthecoracobrachialis
muscleascloseas2.5cmdistaltothetipofthe
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coracoid.Retractors
placedunderthe
conjoinedtendoncan
causeneuropraxia
thereforevigorous
retractionmustbe
avoided.
Exposetheproximal
humerusandconfirmtheanatomicallandmarks
(subscapularistendon,lessertuberosity,bicipital
groovewiththebicipitaltendonandthegreater
tuberosity).Evaluatethefracturemorphology.
Hemorrhagicbursatissuehastoberesectedif
needed.
Distally,exposethepectoralismajor.
Pitfall:axillarynervedamage
Beawareofretractorpositioning(RouxorHohmann
retractor)inordertopreventiatrogenicdamageof
theaxillarynerve.

Pearls:
Usinganadditional
deltaretractormight
behelpfultoincrease
exposureofthe
proximalhumerus.
Exposuremaybe
increasedadditionally
bypartiallyreleasingtheinsertionsofdeltoid
and/orpectoralismajor.
Shoulderabductiondecreasestensiononthe
deltoid,andmakesiteasiertoretractlaterally.

Anteriorshoulderarthrotomy
Satisfactoryreductionofanatomicalneckfractures
(eg,C1.3orC3.1)mayrequireananteriorshoulder
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arthrotomy.Accessis
improvedbydoingan
osteotomyofthe
coracoidprocessto
allowreflectionofthe
coracobrachialisand
bicepsmuscles.Drill
thecoracoidfirstfor
laterfixation.

Takecareregarding
themusculocutaneous
nerveandunderlying
brachialplexus.Avoid
excessivetraction.

Thesubscapularis
tendonisidentified
anddividedvertically
lateraltothe
musculotendinous
junction.Remember
theaxillarynervejust
distaltothe
subscapularisandmedialtotheproximalhumerus.

Reflectthe
subscapularisfromthe
underlyingjoint
capsuleandenterthe
jointthroughavertical
capsulotomy,medial
tothelateralstumpof
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subscapularis.
Thearthrotomyisrepairedbysutureclosureofthe
capsuleandthenthesubscapularis.Thecoracoidis
repairedwithascreworsuturesplacedthroughthe
drillhole.

Woundclosure
Irrigatethewound.
Placementofa
drainageunderneath
thedeltoidmuscle
mightbeconsidered.
Closethedeltopectoral
groove,the
subcutaneoustissuesandtheskin.
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