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Anterior approach to the humerus

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Introduction

Indications

  • Internal fixation of proximal and upper middle diaphyseal humeral fractures.
  • Osteotomy of the humerus.
  • Biopsy and resection of bone tumors.
  • Treatment of osteomyelitis.

Disadvantage

  • Fractures with distal diaphyseal extension.

Position of patient

The patient is placed supine on the operating table, with the arm on an arm board, abducted about 60°.

Landmarks and incision

Landmarks

  • The coracoid process of the scapula felt immediately below the junction of the middle and outer thirds of the clavicle.
  • The long head of the biceps brachii as it crosses the shoulder and runs down the arm. The lateral border of its freely moving muscular belly lies on the anterior surface of the arm.

Incision

  • Start a longitudinal incision over the tip of the coracoid process of the scapula, extend it distally and laterally in the line of the deltopectoral groove to the insertion of the deltoid muscle on the lateral aspect of the humerus, about halfway down its shaft.
  • Following the lateral border of the biceps muscle. The incision is continued distally.
  • The incision is stopped about 5 cm above the flexion crease of the elbow.

Internervous plane

Two different internervous planes

  • Proximally, the plane lies between the deltoid muscle (axillary nerve) and the pectoralis major muscle (medial and lateral pectoral nerves).
  • Distally, the plane lies between the medial fibers of the brachialis muscle (musculocutaneous nerve) medially and the lateral fibers of the brachialis muscle (radial nerve) laterally

Superficial dissection

Proximal Humeral Shaft

  • The cephalic vein is used as a guide to identify the deltopectoral groove.
  • Separate the two muscles, retracting the cephalic vein either medially with the pectoralis major or laterally with the deltoid.
  • The muscular interval developed distally down to the insertion of the deltoid into the deltoid tuberosity and the insertion of the pectoralis major into the lateral lip of the bicipital groove.

Distal Humeral Shaft

  • The deep fascia is incised of the arm in line with the skin incision.
  • The muscular interval between the biceps brachii and the brachialis is identified and developed by retracting the biceps medially (be careful of the musculocutaneous nerve); beneath it lies the anterior aspect of the brachialis.

Deep dissection

Proximal Humeral Shaft

  • The periosteum is incised longitudinally to expose the upper part of the humeral shaft, just lateral to the insertion of the tendon of the pectoralis major.
  • Continue the incision proximally, staying lateral to the tendon of the long head of the biceps.
  • Detach part or all of the insertion of the pectoralis major muscle subperiosteally from the lateral lip of the bicipital groove of the humerus to expose the bone fully.

Distal Humeral Shaft

  • The fibers of the brachialis are splited longitudinally along its midline to expose the periosteum on the anterior surface of the humeral shaft.
  • The periosteum incised longitudinally in line with the muscle dissection and strip the brachialis off the anterior surface of the bone.

Dangers

Nerves
Radial nerve

  • The dissection of the musles to expose the bone should remain in a strictly subperiosteal plane to avoid damage to the radial nerve, which lies in the spiral groove of the humerus and crosses the back of the middle third of the bone in a medial to lateral direction.
  • In the anterior compartment of the distal third of the arm. At this point, the nerve has pierced the lateral intermuscular septum and lies between the brachioradialis and brachialis muscles. Avoid damaging the nerve by spliting the brachialis along its midline, the lateral portion of the muscle then serves as a cushion between the retractors that are being used in the exposure and the nerve itself.

Axillary nerve

  • Overuse of the retractor placed underside of the deltoid muscle may paralyze the anterior half of the muscle by causing a compression injury to the axillary nerve.

Vessels

  • The anterior circumflex humeral artery crosses the field of dissection in a medial to lateral direction in the upper third of the arm between the pectoralis major and deltoid muscles and must be ligated.

How to enlarge the approach

  • The anterior approach in its upper end can be extended easily into an anterior approach to the shoulder.
  • The anterior approach cannot be extended distally.

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