7 In addition, although extensile approaches have been described for both, 15 the method to extend the DP approach is … Overview. Depending on the fracture morphology and foreseen osteosynthesis the extensions of the skin incision may vary but may not extend more than 5 cm distally to the acromion, to protect the axillary nerve. The space between these two lines is the danger zone on the lateral humerus. Copyright © 2020 Lineage Medical, Inc. All rights reserved. The anteri-or raphe allows better access to the supraspinatus insertion and is opti-mal for antegrade humeral nailing. Lateral approaches to the proximal humerus have been limited by the position of the axillary nerve. Lateral approach to proximal humerus (1st is deltopec) The split used in the lateral approach to the proximal humerus can be performed most easily through: EITHER raphe (although anterior raphe allows for better access to the supraspinatus insertion and is optimal for antegrade humeral nailing; posterior raphe used for more posterior cuff tears) This procedure can lead to a significant deterioration of the deltoid function, with a long and difficult postoperative rehabilitation. Indications. Campbell and Hoppenfeld describe this approach as the anterolateral approach to the humerus, and both describe splitting the brachialis muscle. The course of the axillary nerve must be kept in mind. Alternatively dissect bluntly under the central deltoid insertion to allow for plate placement. This finding is consistent with other authors' claims that the DP approach allows improved visualization and is potentially more utilitarian. Skin incision. Extensive surgical dissection through a deltopectoral approach may further damage the remaining tenuous blood supply in comminuted fractures. Lateral Approach The second most common ap-proach to the proximal humerus in-volves splitting the deltoid muscle. After surgery irrigate the wound. This incision is placed between the acromial part (2) and the spinal part (3) of the deltoid muscle, as illustrated. - with plate fixation of the humerus, the anterior approach is preferred for proximal and mid-diaphyseal frx w/ application of plate to anterolateral aspect of the humerus (see humeral shaft fractures); - interval lies between deltoid and pectoral nerve proximally and involves a brachalis spliting incision distally; ... Lateral approach to the humeral shaft: an alternative approach for fracture treatment. Partially release the deltoid insertion anteriorly, if necessary, and retract laterally to access the proximal humerus. Indications. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. Hemorrhagic subdeltoid bursal tissue may need to be excised to expose the humeral head. In 2004, Gardner et al. For fractures of the midshaft, this is an excellent approach. Palpate the axillary nerve on the deep surface of the deltoid muscle, distal to the incision. Note: The anterior motor branch of the axillary nerve crosses the humerus horizontally about 6 cm distal to the lateral border of the acromion. Make a skin incision from the lateral border of the acromion 5 cm distally, parallel to the axis of the humerus. 2. Join from wherever you are in the world. Our study confirms that more surface area of the proximal humerus is visible with the DP approach compared with the ALA approach. Lateral approaches to the proximal humerus have been limited by the position of the axillary nerve. The transdeltoid lateral approach can be used for various treatments of the proximal humeral fractures.It is especially useful for osteosynthesis of fractures of the greater tuberosity. it is not traditionally extensile -- to extend the approach distally, a second separate incision must be made or one long incision can be made, with identification of the axillary nerve being paramount. Lateral Approach The second most common ap-proach to the proximal humerus in-volves splitting the deltoid muscle. December 3-6, 2020, Hip periprosthetic fracture module is now online. As shown by cadaver studies, the axillary nerve does not have any branches in the anterior portion of the deltoid muscle, before going through the fibrous raphe that separates the anterior head from the middle head of the muscle. Note: The anterior motor branch of the axillary nerve... 3. This video is unavailable. Safely below the marked (blue lines) axillary nerve, stab incisions may be made for screws to fix a plate to the humeral shaft. Humeral shaft fractures are a common injury, representing 3% of all fractures.1 They occur in a bimodal distribution and are most commonly the result of a fall.2 Most humeral shaft fractures can be managed nonoperatively, frequently with functional bracing as described by Sarmiento et al.1–3However, some patients may benefit from operative treatment, including those with open fractures, associated articular fractures, neurovascular injuries, floating elbow injuries, polytrauma, interest in early return to activity, o… DISADVANTAGES. A special aiming device may be available for this purpose. The extended deltopectoral approach remains the most widely used for this purpose. Watch Queue Queue Expose the middle third (acromial) part of the deltoid muscle and split the muscle between its fibers. - See: Lateral Approach - Discussion: - allows exposure of the entire distal humerus as well as radial head, radial neck, and biceps tuberosity; - indications for this approach include frxs of distal humerus, old posterior elbow dislocations, radial head frx, radial head excisions, arthroplasties, fixation of distal biceps tendon rupture, and resection of proximal radial-ulnar synostosis; - it is also indicated for elbow flexion … But splitting the brachialis muscle risks denervating the lateral half of the muscle by cutting the small nerves crossing laterally. Pearl: stay sutureIn order to protect the axillary nerve from uncontrolled distal dissection, a stay suture may be placed at the inferior border of the deltoid split. This approach utilizes a relatively avascular plane, away from the anterior and posterior circumflex humeral arteries. Categories Nerves … We prefer this approach for the fixa- The anteri-or raphe allows better access to the supraspinatus insertion and is opti-mal for antegrade humeral nailing. This nerve encircles the proximal humerus a little less than half way from the lateral margin of the acromion to the insertion of the deltoid muscle. Anatomy. This distance does not significantly vary and is reliable. The transdeltoid lateral approach can be used for various treatments of the proximal humeral fractures. Transdeltoid lateral approach 1. The course of the axillary nerve must be kept in mind. Leave as much muscle attached to bone as possible to preserve vascularity and reattach the released portion at the end of the procedure. Axillary nerveBefore incising the skin, mark the distal limit of the approach, 5cm below the acromion, which is 1 cm above the course of the axillary nerve.If a plate is to be passed underneath the axillary nerve, as in minimally invasive plate osteosynthesis (MIPO), mark a second line 2 cm distal to the first, below which the axillary nerve should not be encountered. A split can be performed most easi-ly through either raphe. Sometimes, the deltopectoral approach does not allow for a complete exposure of the lateral and posterior parts of the proximal humerus and requires a partial detachment of the deltoid [17, 18]. - Pertinent Anatomy: - radial nerve & profunda vessels pass across medial head of triceps; beneath long & lateral heads which then continues distally to lateral humerus to pass into lateral intermuscular septum to enter flexor compartment; - as noted by Gerwin, et al, nerve crosses posterior aspect of humerus at 20-21 cm proximal to medial epicondyle and 14-15 cm