Posterior Approach to the Humerus

The midline posterior approach to the humerus is classically extensile, providing excellent access to the lower three fourths of the posterior aspect of the humerus.

It’s used for:

  1. Open reduction and internal fixation of fractures of the humerus: 
    • Often thought to be more cosmetic when compared to the anterolateral approach.
    • Provides good exposure to both middle and distal 1/3 humeral shaft fractures.
  2. Treatment of osteomyelitis.
  3. Biopsy and excision of tumors.
  4. Treatment of nonunion of fractures.
  5. Exploration of the radial nerve in the spiral groove.
  6. Insertion of retrograde humeral nails .

  • Prone position with arm on arm board, abducted 90 degrees.
  • Lateral position with arm over the top of the body.

  • Landmarks:
    1. The Acromion.
    2. The Olecranon fossa.
  • Incision:
    •  Longitudinal Incision in the midline of the posterior aspect of the arm  from 8 cm distal to the acromion to the olecranon fossa.

  • There is no internervous plane for posterior approach to the humerus.
  • It is a muscle splitting approach (through the heads of the triceps brachii muscle).

  • Fascia should be split in line with incision

  • Split the fascia between the long and lateral head of the triceps muscle:
    • Lateral head is retracted laterally and the long head medially.
  • Radial nerve will be identified along with the profunda brachii vessels in the spiral groove:
    • The radial nerve runs just proximal to the medial head of the triceps muscle which lies below the other two heads in the spiral groove.
    • Often times a tourniquet is beneficial until the nerve is identified.

Posterior Approach to the Humerus can be extensile through:

  • Proximal Extension:

    • The bone cannot be exposed effectively above the spiral groove using the posterior approach. At this point, the deltoid muscle (which is the outer layer of the musculature) also crosses the operative field.
    • More proximal exposures should be accomplished by the anterior route.
  • Distal Extension: 

    • The skin incision can be extended distally over the olecranon; deepening the approach provides access to the elbow joint via an olecranon osteotomy.

The structures at risk during Posterior Approach to the Humerus include:

  • Nerves:

    • The Radial Nerve is vulnerable in the spiral groove.
    • The ulnar nerve lies deep to the medial head of the triceps in the lower third of the arm.
  • Vessels

    • The profunda brachii artery lies with the radial nerve in the spiral groove and is similarly vulnerable to damage.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
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