The axillary nerve may be encountered in the inferior margin of this interval where it runs along the subcapularis prior to diving into the quadrangular space. Deltopectoral approach to the shoulder lennard funk manchester. Arthroscopic removal of proximal humerus plates in chronic post. Live reverse total shoulder arthroplasty using a deltopectoral approach. The incidence of proximal humeral fracture is increasing gradually.
Shoulder arthrodesis in the management of glenohumeral. An anatomic study of the cephalic vein in the deltopectoral shoulder approach. A prospective randomized study hura study orthopaedic trauma association 9400 w. While using this approach has several advantages, including minimal soft tissue disruption, preservation of natural biology and minimal blood loss, there is an increased risk for axillary nerve damage. The deltopectoral approach is a welldescribed and commonly utilized surgical approach to the glenohumeral joint and proximal humerus for both shoulder arthroplasty and fracture fixation 1,2,3. Sound knowledge of surface anatomy is essential before any skin incision can be made. The cephalic vein is identified proximally and usually retracted laterally while exposing the deltopectoral plane. Mar 01, 2008 the infraclavicular approach is used for lesions involving the brachial plexus distal to the clavicle. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. However, accessing the lateral aspect of the proximal humerus using this approach requires extensive soft tissue dissection and retraction, as it is an indirect approach to the plating zone. This approach should facilitate removal of the biopsy tract en bloc with the resection specimen and most often includes a portion of the anterior third of the deltoid. Read deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. Surgical technique for open reductioninternal fixation of an.
For oncology applications, a modified deltopectoral approach to the proximal humerus is most often utilized. Advantage of minimally invasive lateral approach relative. New position and landmark for the deltopectoral approach. Proximal humeral hemiarthroplasty is indicated for displaced three and fourpart fractures in elderly patients, fourpart fracture dislocations, headsplitting fractures and fractures that.
Immediate hemiarthroplasty remains the accepted treatment for 4part fracture dislocation. Anterior approach to the humerus orthopaedicsone articles. For surgical management, the deltopectoral approach to the proximal humerus is the procedure of choice. The use of minimally invasive plate osteosynthesis mipo via anterolateral deltoid splitting has good outcomes in the management of proximal humerus fractures. Superficially, the deltoid is split between the anterior and middle fibers in line with the skin incision video 1. May 03, 2009 dorsal approach and plating of a proximal rd radius fracture. Preoperatively, we decided to operate with the patient in the beachchair position by use of the superolateral approach and to perform fixation with the proximal humerus interlocking system philos plate. Choosing surgical approaches to proximal humerus fractures. The deltopectoral approach to the shoulder requires extensive soft tissue dissection and muscle retraction to gain adequate exposure of the lateral aspect of the humerus.
Subclavian vein thrombosis and fatal pulmonary embolism after. Electrophysiological assessment of the deltoid muscle. Im nail can have less impingement of hardware laterally than a plate. Furthermore, excessive soft tissue stripping destroys the local blood supply and integrity of the deltoid, which may increase the risk of avascular necrosis and. One of the structures at risk during this approach is the axillary nerve. This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses. For complex and unstable fractures locking proximal humerus plate. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The key to achieve successful reduction in a 3part proximal humeral fracture is to try to convert a 3part fracture into a 2part fracture. The pectoralis fascia is incised lateral to the tendon of the short. More videos of surgical techniques of the shoulder can be found.
Open repair of an anterior humeral avulsion of the. Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. 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. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Feb 15, 2015 however, this approach provides limited exposure of the posterior aspect of the proximal humerus due to the pull of the cuff muscles and the lateral aspect where the plate is placed. Extended anterolateral approach cambridge orthopaedics. Learn about the humerus anterior approach brachial split, an online 3d video based course, accredited by the royal college of surgeons of england. Extensive dissection anteriorly may further compromise humeral head blood supply see, anterior circumflex humeral artery, humeral head blood supply. Surgical approach of open reduction and internal fixation. Approach a deltopectoral or transdeltoid approach is recommended. The purpose of this study was to objectively quantify the surface area of the humerus exposed using the deltopectoral dp and anterolateral acromial ala approaches and to compare visualized and palpable anatomic landmarks. Show full abstract macroscopic features and biomechanical behavior were analyzed on dynamic videos obtained during forearm rotation. The 4part fracture dislocation of the proximal humerus has been associated with a high complication rate, in which avascular necrosis is important.
Do you want to use the redesigned ao sr like an app. May 12, 2020 the humerus is the longest and largest bone of the upper limb. Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft. A minimally invasive approach for plate fixation of the. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1. The approach can be extended into an anterolateral approach to the humerus. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. As the locking plate is positioned on the greater tuberosity and lateral proximal humeral, this technique offers direct access to the laterally fractured planes for the placement of a locking plate, which is considered a difficult procedure with the deltopectoral approach. Proximal humerus orif exposure and reduction techniques. It provides excellent humeral exposure and preserves the deltoid origin, making it an ideal. A coracoid process b proximal humeral shaft on the level of the axilla c acromion. B, cephalic vein as the indicator of deltopectoral interval.
Drawings illustrating the positioning of the patient and the skin incision for the infraclavicular approach. Electrophysiological assessment of the deltoid muscle after. Deltopectoral versus deltoid split approach for proximal. Many surgeons are familiar with this procedure, but certain steps are still controversial. An anterosuperior approach for proximal humeral fractures. Many patients choose open reduction and internal fixation. If you would like a large, unwatermarked image for your web page or blog, please purchase the appropriate license. Thirtythree patients were treated through a deltopectoral approach and 37 through an anterolateral deltoidsplitting approach. Although anterior shoulder instability is most commonly treated with arthroscopic fixation, open labral repair with capsular shift may be best for select patients and in cases of revision stabilization without significant bone loss. The humerus articulates with the scapula proximally at the glenohumeral joint so it participates in the movements of the shoulder. This video demonstrates the steps for exposure of the glenohumeral joint and the performance of a total shoulder replacement. This study aimed to evaluate the pros and cons of the minimally invasive lateral approach for the treatment of proximal humeral. Curve it inferiorly, following the lateral border of the biceps.
The diagnosis of a hagl lesion is particularly challenging. The deltopectoral approach 10, 44 is the most commonly used approach for shoulder arthroplasty. Abstract the minimal anterolateral acromial approach offers a less invasive access to the proximal humerus. Ao surgery reference is a resource for the management of fractures, based on current clinical principles, practices and available evidence. A, the skin incision follows the deltopectoral groove and then the medial edge of the biceps muscle.
Proximal humerus fractures ota 11b are common in elderly individuals, reported as the thirdmostcommon fracture in this population behind distal radius and hip fractures at 105 per 100,000 patients per year. However, many complications still occur with use of the phlp, such as avascular necrosis of. Dec 11, 20 proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. May 25, 20 ubc medicine neurology clinical skills motor, sensory, and reflex examination duration. By current concepts in joint replacement featuring gilles walch.
Extraarticular proximal humeral fracture case for small group discussion. Deltopectoral versus deltoid split approach for proximal humerus fracture fixation with locking plate. It consists of a proximal end, a shaft and a distal end, all which contain important anatomical landmarks. Proximal humerus fracture fixation may be complicated by persistent. Its upper surface is rounded and marked by three flat impressions. A 66yearold sustained a left proximal humerus fracture. However, some authors have argued that this approach involves extensive soft tissue dissection and muscle retraction to gain adequate exposure to the lateral aspect of the. Extend the skin incision down the deltopectoral groove. Article information, pdf download for the deltoid lift. You may not embed one of our images on your web page without a link back to our site.
Deltoidsplit or deltopectoral approaches for the treatment of. Approximately 7080% of proximal humerus fractures occur in females, and they are the third most common osteoporotic fracture of old people after hip and distal radius fractures. Jan 16, 2015 the deltopectoral approach is a common surgical procedure for shoulder arthroplasty. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder. Orthopedic trauma incl pediatrics your digital gateway to expertise, education, and innovation.
This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a. Humerus anterior approach brachial split incision academy. Proximal humeral fracture classfication aoota classification is based on fracture location and presence of impaction, angulation, translation, or comminution of the fracture, as well as whether a dislocation is present. Upper extremity fracturesdecision making and methods of stabilization.
Once this was done, the stem was prepared up to a size 10. This is the case for the management of subscapularis, where surgeons must choose between tenotomy and the lesser tuberosity osteotomy. To avoid damaging the axillary nerve, do not split. This article is conceived as a toolkit for the inexperienced surgeons, describing our. Fibular strut graft augmentation for open reduction and. Surgical exposures of the humerus location procedure clinical example surgical approach concerns and limitations proximal total shoulder arthroplasty conventional or reverse prosthesis deltopectoral axillary nerve, anterior humeral circum. Deltopectoral approach to shoulder joint netter images. Article in clinical orthopaedics and related research 4725 december 20 with 206 reads. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. Up next principles of orif for proximal humerus fractures duration.
Uses this approach is preferred for shoulder arthroplasty and for plateand screw fixation of proximal humeral fractures because it affords. Click here to visit our frequently asked questions about html5. The main advantages of the deltopectoral approach are the preservation of the deltoid muscle, exposure of the lower pole of the glenoid to facilitate glenoid implant positioning, possibility of inferior extension to control the proximal humerus, and ability to perform a latissimus dorsi transfer as described by boileau et al. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary nerve. In fractures of the proximal humerus which consist of an anterior fragment one should take care to analyze the fracture pattern. Radius distal dorsal approach surgery video general. If the anterior fragment consists of the lesser tuberosity, the bicipital groove and the anterior part of the greater tuberosity, it is strongly recommended to use a supraspinatus split in line of the. Deltopectoral approach for total shoulder replacement vumedi. Proximal extension can be obtained by developing the anterior approach to the shoulder with full deltopectoral dissection. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosityinferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Deltoidsplit or deltopectoral approaches for the treatment. The axillary nerve can be palpated at the lower margin of the incision.
Philos proximal humeral internal locking system plate length 90 mm, short, 3 shaft holes x41. The deltopectoral approach, first described by henry in 1957, is the workhorse to the shoulder that allows for extensile exposure. Autoplay when autoplay is enabled, a suggested video will automatically play next. The transdeltoid approach allows better access to the greater tuberosity and might facilitate periprosthetic reconstruction of. As the most commonly used approach in the shoulder, deltopectoral approach is used for reduction and internal fixation of proximal humerus fractures, to treat bony glenoid injuries, shoulder.
The proximal humeral locking plate phlp is a recently developed fixedangle implant that. This video demonstrates a technique for rsa for fracture using a tensionable suture construct placed circumferentially. Unusual anatomic variant of the axillary nerve challenging. Background the deltopectoral approach is a welldescribed surgical approach to the proximal humerus and glenohumeral joint. Learn about the humerus deltopectoral approach, an online 3d video based course, accredited by the royal college of surgeons of england. Advantage of minimally invasive lateral approach relative to. Shoulder lateral deltoid splitting approach approaches.
This approach has been described previously and, hopefully, the online video presentation will aid the novice peripheral nerve surgeon with this often difficult operation. This article is from the open orthopaedics journal, volume 5. Surgical anatomy of the radial nerve in the deltopectoral. Im nailing and open reduction internal fixation can be done with anterolateral deltoid split rather than deltopectoral approach. For displaced fractures that meet surgical indications, the traditional deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. Fourpart fracture dislocation of the proximal humerus. To arrive at an accurate diagnosis, the use of a magnetic resonance arthrogram is suggested along with high clinical suspicion. The proximal humeral locking plate phlp is a recently developed fixedangle implant that is an option for open reductioninternal fixation of an unstable displaced proximal humeral fracture. The advantages of the deltopectoral approach include the excellent exposure of the joint space and the easy extension to the humeral shaft in case of need. The technique described in this article uses the deltopectoral interval. For complex and unstable fractures locking proximal. Your browser does not currently recognize any of the video formats available. B, if supra and infraclavicular exposure is needed, the skin incision parallels the posterior border of the sternocleidomastoid muscle and angles over the clavicle into the deltopectoral.
Various articles have reported successful outcomes using the phlp when compared with other implant designs. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary ne. Using a modification of this approach, we describe its use in a group of patients requiring either internal fixation or hemiarthroplasty for proximal humeral fracture and the effect of this approach on the postoperative function on the axillary nerve and deltoid muscle. Anatomical landmarks for the anterior deltopectoral approach are. A humeral avulsion of the glenohumeral ligament, or hagl lesion, is an uncommon yet disabling shoulder injury, which leads to complaints of pain and overall inability to properly use the shoulder from patients.
The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Minimally invasive plate osteosynthesis with a locking. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. With the maturity of surgical technology and thought, people begin to think about the optimization of surgical effect from the surgical incision, including less trauma, less bleeding, less postoperative complications and fast postoperative recovery. The anterior humeral circumflex artery is seen here and must be ligated. Debate exists over the optimal approach for addressing fractures of the proximal humerus.
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