APPROACHES TO HUMERUS

DR NAVENDU GOYALRESIDENT

DEPARTMENT OF ORTHOPAEDICSCMC , LUDHIANA

ANTERIOR DELTOPECTORAL APPROACH

INCISION : - coracoid process running along the deltopectoral groove towards the deltoid insertion. The incision length is dependent on the procedure and build of patient. Deepen into subscapularis fat, expose deltopectoral groove (the cephalic vein and the coracoid are landmarks to the interval).

INDICATIONS

1. INTERNAL FXATION OF FRACTURES OF THE HUMERUS

2. OSTEOTOMY OF THE HUMERUS3. BIOPSY AND RESECTION OF BONE TUMOURS4. TREATMENT OF OSTEOMYELITIS

• PLACE THE PATIENT SUPINE WITH ARM ON ARM BOARD ABDUCTED ABOUT 60 DEGREES

• CORACOID PROCESS AND LATERAL BORDER OF BICEPS BRACHII

• TIP OF CORACOID IN LINE OF DELTOPECTORAL GROOVE TO THE INSERTION OF DELTOID STOPPED 5 CM ABOVE FLEXION CREASE OF ELBOW.

INTERNERVOUS PLANESPROXIMALLY DELTOID (AXILLARY NERVE ) PECTORALIS MAJOR ( MEDIAL AND LATERAL PECTORAL N.)DISTALLY MEDIAL FIBRES OF BRACHIALIS (MUSCULOCUTANEOUS N.) LATERAL FIBRES OF BRACHIALIS ( RADIAL N. )

Deltopetoral groove and cephalic vein exposure

Identification of tuberosities and humeral head

• Expose – subscapularis tendon long head of the biceps. • Distally - expose the pectoralis major. • The musculocutaneous nerve - vigorous retraction must be avoided

to prevent neuropraxia .

Distal humeral shaft

• Split brachialis longitudinally along midline to expose the periosteum

• Incise periosteum and strip off brachialis• Flex the elbow to make the task easier

Possible complications• Radial nerve damage – 2 main points – a. spiral groove ( dissect the muscle subperiosteally ) b. anterior compartment of the distal 1/3rd Axillary nerve damage – as a compression injury due to vigorous

compressionAnterior circumflex humeral vessels ligated / subjected to diathermy

ANTEROLATERAL APPROACH TO THE HUMERUS (HENRY’S)

INCISION distally between biceps and the mobile wad deltopectoral interval proximallyLateral edge of biceps and the anterior edge of the deltoid.

SUPERFICIAL DISSECTION

Incise fascia – b/w biceps/brachialis and the mobile wad lateral cutaneous nerve of the forearm crossing distally.Radial nerve - identify b/w biceps and the mobile wad Proximally, look for the cephalic vein in deltopectoral interval.

SUPERFICIAL DISSECTION CONTD..

Retract the biceps and brachialis medially, and the mobile wad laterally in order to identify radial nerve. Extend the dissection proximally, as needed, to the anterior border of the deltoid and along the deltopectoral interval.

DEEP DISSECTION

Distally, the anterior humerus has been exposed to the elbow joint, between the mobile wad and brachialis. Mobilize the radial nerve, as needed, to access the bone. Follow the nerve to the point where it passes through the lateral intermuscular septum

DEEP DISSECTION CONTD..

Partially release the deltoid insertion anteriorly, if necessary, and retract laterally to access the proximal humerus. Leave as much muscle attached to bone as possible in order to preserve vascularity.

LATERAL APPROACH TO THE HUMERAL SHAFT (INDICATIONS)

1. OPEN REDUCTION AND INTERNAL FIXATION OF FRACTURES OF THE LATERAL CONDYLE

2. SURGICAL TREATMENT OF TENNIS ELBOW

POSITION : - SUPINE WITH ARM ACROSS THE CHEST

LATERAL APPROACH TO THE HUMERAL SHAFT

INCISION - deltoid insertion to the lateral epicondyle.

SUPERFICIAL DISSECTION

DEEP DISSECTION

DEEP DISSECTION

Find the posterior antebrachial cutaneous nerve,followed proximally to the radial n.(Distally this cutaneous nerve passes through the fascia over brachioradialis.) Develop the interval between the lateral intermuscular septum and triceps, .In the middle third of the humerus find the radial nerve within fat immediately adjacent to the triceps.

Deep dissection

Follow radial n. b/w brachialis and brachioradialisRetract the nerve to expose the humerusRelease intermuscular septum

Deep dissection contd..

Follow the radial nerve proximally, posterior to the humerus and anterior to the triceps

PROXIMAL EXTENSION OF THE APPROACH

Proximally - along the deltopectoral intervalOR extended along the posterior deltoid and into the posterior compartment .

POSTERIOR APPROACH TO THE HUMERUS (HENRY)

INDICATIONS1.ORIF – FRACTURES OF THE HUMERUS2. OSTEOMYELITIS TREATMENT3. BIOPSY AND EXCISION OF TUMOURS4. TREATMENT OF FRACTURE NONUNION5. EXPLORATION OF RADIAL NERVE6. INSERTION OF RETROGRADE HUMERAL NAILS

POSITION OF THE PATIENT

2 POSITIONS POSSIBLE1.LATERAL POSITION . 2.PRONE POSITION WITH ARM ABDUCTED 90

DEGREE .

POSTERIOR APPROACH TO THE HUMERUS (HENRY)

INCISION Beginning at the tip of the olecranon. proximally in a straight line along the posterior midline of the armrosses the radial nerve in the mid-humeral region and the axillary nerve proximallyto the acromion .

Superficial dissection

Superficial dissection contd..

By palpation with a finger, identify the interval between the lateral and long heads of the triceps. The opening of this interval will be developed from proximal to distal, remembering that the radial nerve lies beneath the triceps as it crosses the humerus.

Deep dissection

Develop the proximal interval between the two heads by blunt dissection, retracting the lateral head laterally and the long head medially. Within the spiral groove, identify the radial nerve and profunda brachii artery. Distally, split the common triceps tendon by sharp dissection.

Deep dissection contd..

Release the medial head of triceps proximally and incise distally Protect the ulnar nerve mediallyDissect proximally and locate the axillary nerve

Extending the approach

Distal extension Splitting the triceps tendon limits distal exposure, improved by approaching the humerus from the lateral side of this muscleProximal extension Limited proximal extension, even beyond the axillary nerve, is possible with careful mobilization and retraction of both radial and axillary nerves and their accompanying vessels.

POSSIBLE COMPLICATIONS

RADIAL NERVE – VULNERABLE N THE SPIRAL GROOVE

ULNAR NERVE – LIES DEEP TO MEDIAL HEAD OF TRICEPS , VULNERABLE IF MUSCLE ELEVATED OFF THE HUMERUS

PROFUNDA BRACHII ARTERY – LIES WITH RADIAL NERVE IN SPIRAL GROOVE