Anterolateral Approach of

Proximal Humerus
The minimally invasive approach to the proximal humerus is used for
the insertion of intramedullary nails for the treatment:
1. Acute humeral shaft fractures
2. Pathologic humeral shaft fractures
3. Delayed union and nonunion of humeral shaft fractures
• The presence of the acromion and the upper end of the humerus is
covered entirely with articular cartilage mean that most nails are
angled at their upper end and are inserted via the lateral cortex of the
humerus.
• The entry point for an intermedullary nail into the humerus is
determined radiographically. The entry point depends on the specific
design of the nail. The most usual entry point is just lateral to the
articular surface of the humeral head and just medial to the greater
tuberosity
Position of The Patient
• Place the patient in a supine position.
• Elevate the upper portion of the table to approximately 60 degrees
• Position the patient so that the shoulder lies over the edge of the
table.
• Ensure that the cervical spine is adequately supported and that lateral
flexion of the cervical spine is avoided to prevent a traction lesion of
the brachial plexus
Landmark ( Acromion )
• The acromion is rectangular. Its bony dorsum and lateral border are
easy to palpate on the outer aspect of the shoulder
Incision
• Make a 2-cm incision from the outer aspect of the acromion down the
lateral aspect of the arm
• This approach does not exploit an internervous plane. The dissection
involves splitting the deltoid muscle.
Superficial and Deep Surgical Dissections
• Insert a wire under image intensifier control through the skin incision,
down through the substance of the deltoid muscle and rotator cuff to
the correct insertion point on the humerus.
• This position has been determined on the preoperative x-ray plan.
Confirm that the wire is in the correct position by the use of a C-arm
image intensifier in both anterior–posterior and lateral planes.
• Withdraw the wire and insert a point-ended scalpel blade, following
the track of the wire using a C-arm image intensifier to confirm
position.
• Incise a small portion of the deltoid and make a small clean-edged
incision through part of the supraspinatus tendon.
• Withdraw the blade and reinsert the wire.
• Enter the proximal end of the humerus using an awl or drill,
depending on the nail to be used
Anterior Approach to the
Forearm shaft (Henry
approach)
Function
• The anterior approach offers an excellent, safe exposure of the radius,
exposing the entire length of the bone.
• Although the approach can be used for exposure of the volar surface
of the distal radius, alternative approaches are available for volar
plating in the treatment of wrist fractures
• Exposing the proximal third of the radius endangers the posterior
interosseous nerve
The uses of the anterior approach :
1. Open reduction and internal fixation of fractures
2. Bone grafting and fixation of fracture nonunions
3. Radial osteotomy
4. Biopsy and treatment of bone tumors
5. Excision of sequestra in chronic osteomyelitis
6. Anterior exposure of the bicipital tuberosity
7. Treatment of compartment syndrome
Position of the planet
• Place the patient supine on the operating table, with the arm on an
arm board.
• Place a tourniquet on the arm, but do not exsanguinate it fully before
inflating the tourniquet. Venous blood left in the arm makes the
vascular structures easier to identify.
• Finally, supinate the forearm
Landmarks
• Palpate the biceps tendon, which is a long, taut structure that crosses the
front of the elbow joint just medial to the brachioradialis muscle.
• Palpate the brachioradialis, which is a fleshy muscle that arises with the
extensor carpi radialis longus muscle from the lateral supracondylar ridge of
the humerus.
• These two muscles and extensor carpi radialis brevis which arises from the
common extensor origin on the front of the lateral epicondyle form a “mobile
wad” of muscle that runs down the lateral aspect of the supinated forearm.
• Palpate the styloid process of the radius. Note that this bony process is truly
lateral when the hand is in the anatomic (supinated) position. The styloid
process is the most distal part of the lateral side of the radius.
Incision
• Make a straight incision from the anterior flexor crease of the elbow
just lateral to the biceps tendon down to the styloid process of the
radius.
• The length and site of the incision depends on the amount of bone
that needs to be exposed and the position of the lesion to be exposed
• Distally, the internervous plane lies between the brachioradialis
muscle, which is innervated by the radial nerve, just proximal to the
elbow joint, and the flexor carpi radialis muscle, which is innervated
by the median nerve.
• Proximally, the internervous plane lies between the brachioradialis
muscle, which is innervated by the radial nerve, and the pronator
teres muscle, which is innervated by the median nerve.
Superficial Surgical Dissection
• Incise the deep fascia of the forearm in line with the skin incision. Identify
the medial border of the brachioradialis as it runs down the forearm, and
develop a plane between it and the flexor carpi radialis distally.
• More proximally, the plane lies between the pronator teres and
brachioradialis muscles. Note that the medial border of the brachioradialis
is surprisingly far across the forearm.
• At the level of the elbow the brachioradialis extends almost halfway across
the forearm. It is surprisingly easy to mistake the plane between
brachioradialis and extensor carpi radialis for the correct intermuscular
plane. The presence of the sensory branch of the radial nerve serves as a
guide since this nerve runs on the underside of the brachioradialis muscle.
• Begin dissection distally and work proximally.
• Identify the superficial radial nerve running on the undersurface of
the brachioradialis and moving with it. The brachioradialis receives a
number of arterial branches from the radial artery just below the
elbow joint.
• Ligate this recurrent leash of vessels. Take time and care to ligate
these vessels and not avulse them, as avulsion is a potent cause of
postoperative hematoma formation. Many vessels are present and all
will need to be ligated and divided to allow the brachioradialis to be
mobilized laterally.
• Each artery is usually accompanied by two veins The radial artery lies beneath
the brachioradialis in the middle part of the forearm; therefore, it is quite close
to the medial edge of the wound. It runs with its two venae comitantes, which
remain prominent if the limb is not exsanguinated before the tourniquet is
applied.
• Often, the artery may have to be mobilized and retracted medially to achieve
adequate exposure of the deeper muscular layer, particularly at the upper and
lower ends of the approach.
• The superficial radial nerve, which is a sensory nerve in the forearm, also runs
under cover of the brachioradialis muscle. Preserve the nerve, because damage
to it may create a painful neuroma at the operative site. It is retracted laterally
with the brachioradialis muscle
Deep Surgical Dissection
• Proximal Third The key to safe exposure of the proximal radius in fixation of very high
fractures is the biceps tendon. Follow the biceps tendon to its insertion into the
bicipital tuberosity of the radius. Just lateral to the tendon is a small bursa; incise the
bursa to gain access to the proximal part of the shaft of the radius. Because the radial
artery lies superficial and just medial to the tendon at this point, deepen the wound
on the lateral side of the biceps tendon T
• he proximal third of the radius is covered by the supinator muscle, through which the
posterior interosseous nerve passes on its way to the posterior compartment of the
forearm. The posterior interosseous nerve is the single most important structure left
vulnerable by this approach. To displace the nerve laterally and posteriorly (away
from the surgical area), fully supinate the forearm, exposing, at the same time, the
insertion of the supinator muscle into the anterior aspect of the radius. Next, incise
the supinator muscle along the line of its broad insertion.
• Ensure that the muscle is detached by dividing its insertion and not by splitting the
muscle. Continue subperiosteal dissection laterally, stripping the muscle off the bone.
• This is one of the rare examples where the safety obtained by staying in a
subperiosteal plane outweighs the vascular damage to the bone caused by stripping
off periosteum.
• Lateral retraction of the muscle lifts the posterior interosseous nerve clear of the
operative field, but be careful! Excessive retraction may cause a neurapraxia of the
nerve, and it recovers very slowly, taking up to 6 to 9 months.
• Finally, do not place retractors on the posterior surface of the radial neck, because
they may compress the posterior interosseous nerve against the bone in patients
whose nerve comes into direct contact with the posterior aspect of the radial neck
(about 25% of all patients).
Middle Third
• The anterior aspect of the middle third of the radius is covered by the
pronator teres and flexor digitorum superficialis muscles. To reach the
anterior surface of the bone, pronate the arm so that the insertion of
the pronator teres onto the lateral aspect of the radius is exposed
• Detach this insertion from the bone and strip the muscle off medially.
Preserve as much soft tissue as you can compatible with accurate
reduction and fixation of the fracture.
• This maneuver partially detaches the origin of the flexor digitorum
superficialis from the anterior aspect of the radius as well
Distal Third
• Two muscles, the flexor pollicis longus and the pronator quadratus, arise from
the anterior aspect of the distal third of the radius. To reach bone, partially
supinate the forearm and incise the periosteum of the lateral aspect of the
radius lateral to the pronator quadratus and the flexor pollicis longus.
• Then, continue the dissection distally, retracting the two muscles medially and
lifting them off the radius. Controversy exists as whether detaching the origin
of pronator quadratus gives superior clinical results to just dividing the muscle
in the line of the skin incision.
• Detaching the muscle would appear to give a better prospect of repair during
closure and to provide a soft tissue pad between the superficial tendons and a
volar plate. This is however as yet unproven