Anterolateral Approach to the Humerus
Anterolateral Approach to the Humerus exposes the distal fourth of the humerus. Its major advantage over the brachialis-splitting anterior approach is that it can be extended both distally and proximally. It’s used for:
- Open reduction and internal fixation of humeral shaft fractures.
- Radial nerve exploration in the distal part of the arm.
- The patient is placed supine with arm on arm board, abducted 45-60 degrees.
Landmarks:
- Biceps brachii muscle.
- The flexion crease of the elbow.
Incision:
- Make a curved incision over the lateral border of the biceps centered over the fracture site.
There is No Internervous plane for the Anterolateral Approach to the Humerus:
- The interval is between:
- The brachialis muscle (musculocutaneous nerve and radial nerve).
- Brachioradialis muscle (radial nerve).
- Identify the lateral border of the biceps muscle and retract it medially,
- Ensure that the lateral antebrachial cutaneous nerve is retracted with the biceps muscle,
- This reveals the brachialis and brachioradialis muscles lying underneath.
- Incise the fascia overlying these muscles and develop the intermuscular plane,
- The radial nerve lies between the brachialis and brachioradialis muscles :
- The nerve is generally easiest to find in the distal arm, just proximal to the elbow.
- This must be traced proximally until it pierces the lateral intermuscular septum and be carefully protected.
- The brachialis and biceps muscles are retracted medially and the brachioradialis muscle laterally.
- Subperiosteal elevation of the brachialis reveals the humeral shaft underneath.
Proximal Extension of anterolateral approach to the humerus:
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- The incision can be extended proximally by developing the plane between the brachialis medially and the lateral head of the triceps posterolaterally.
- Stripping brachialis from the front of the anterior aspect of the humerus exposes the bone.
Distal Extension of anterolateral approach to the humerus:
-
- The anterolateral approach may be extended into an anterior approach to the elbow by continuing the skin incision distally and developing a plane between the brachioradialis muscle (which is
supplied by the radial nerve) and the pronator teres muscle (which is supplied by the median nerve). - Care should be taken to avoid the lateral cutaneous nerve of the forearm (the continuation of the musculocutaneous nerve), which emerges along the lateral side of the biceps tendon.
- The anterolateral approach may be extended into an anterior approach to the elbow by continuing the skin incision distally and developing a plane between the brachioradialis muscle (which is
The structures at risk during Anterolateral Approach to the Humerus include:
- Lateral cutaneous nerve of the forearm:
- This terminal branch of the musculocutaneous nerve is injured at the distal end of the incision as it exits the biceps laterally.
- Radial nerve:
- Must be identified before any incision is made into the brachialis muscle or before periosteal elevation of the brachialis off the humerus occurs.
- Surgical Exposures in Orthopaedics book - 4th Edition
- Campbel's Operative Orthopaedics book 12th