Anterior Approach to Humerus Shaft
Anterior Approach to Humerus Shaft is used to treat the following conditions:
- Open reduction and internal fixation of humerus shaft fractures.
- Humeral tumor biopsy/resection.
- Humeral osteotomy.
- Treatment of osteomyelitis.
Position of the Patient
- Place the patient supine on the operating table, with the arm on an arm board, abducted about 60 degrees.
Landmarks and Incision
- The Coracoid process.
- The long head of the biceps brachii muscle.
- Make a curved incision from the tip of the coracoid process distally in line with deltopectoral groove along the lateral aspect of the humerus.
- Incision should be stopped approximately 5 cm above the flexion crease of the elbow (lateral antebrachial cutaneous nerve is at risk here).
Proximally the Internervous plane in Anterior Approach to Humerus Shaft lies between:
- Deltoid muscle which is innervated by the the axillary nerve.
- Pectoralis major muscle which is innervated by the the medial and lateral pectoral nerves.
Distally the Internervous plane in Anterior Approach to Humerus Shaft lies between:
- Medial brachialis muscle which is innervated by the the musculocutaneous nerve.
- Lateral brachialis muscle which is innervated by the the radial nerve.
- Identify the cephalic vein – can be taken medially or laterally.
- Proximally, develop the interval between the deltoid and pectoralis major muscle.
- Distally, incise the deep fascia of the arm in line with the skin incision.
- Identify the interval between the biceps muscle and brachialis muscle:
- Biceps muscle can be retracted medially or laterally (typically it’s taken medially).
- Proximally, incise the periosteum lateral to the pectoralis major tendon insertion, staying lateral to the long head of the biceps tendon:
- The anterior humeral circumflex artery is seen here and must be ligated.
- Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft.
- Proximal Extension:
- Because the anterior approach uses the deltopectoral interval, its upper end can be modified easily into an anterior approach to the shoulder (Deltopectoral approach).
- Distal Extension:
- The anterior approach to humerus shaft cannot be extended distally.
Structures at risk during anterior approach to humerus include:
- Anterior circumflex humeral artery:
- The Anterior circumflex humeral artery is at risk proximally between the pectoralis major and deltoid muscles.
- Axillary nerve:
- The Axillary nerve can be injured with vigorous retraction of the deltoid.
- Radial nerve:
- The Radial nerve must be identified before any incision is made into the brachialis muscle or before periosteal elevation of the brachialis muscle off the humerus occurs.
- It’s also at risk on the middle 1/3 of the humerus where it lays in the spiral groove on the posterior humerus.
- Surgical Exposures in Orthopaedics book – 4th Edition
- Campbel’s Operative Orthopaedics book 12th