Infraclavicular approach to the brachial plexus operative. Learn about the humerus deltopectoral approach, an online 3d video based course, accredited by the royal college of surgeons of england. Proximal humerus orif exposure and reduction techniques. A prospective randomized study hura study orthopaedic trauma association 9400 w.
Phillos proximal humerus locked plate proximal humerus multiple locked plate duration. 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. This video demonstrates the steps for exposure of the glenohumeral joint and the performance of a total shoulder replacement. 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. Extend the skin incision down the deltopectoral groove. Your browser does not currently recognize any of the video formats available. Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures.
Debate exists over the optimal approach for addressing fractures of the proximal humerus. Background the deltopectoral approach is a welldescribed surgical approach to the proximal humerus and glenohumeral joint. A coracoid process b proximal humeral shaft on the level of the axilla c acromion. Abstract the minimal anterolateral acromial approach offers a less invasive access to the proximal humerus.
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. The humerus articulates with the scapula proximally at the glenohumeral joint so it participates in the movements of the shoulder. Humerus anterior approach brachial split incision academy. This approach has been described previously and, hopefully, the online video presentation will aid the novice peripheral nerve surgeon with this often difficult operation. Sound knowledge of surface anatomy is essential before any skin incision can be made. 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. Deltopectoral approach to the shoulder lennard funk manchester. It provides excellent humeral exposure and preserves the deltoid origin, making it an ideal.
The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Approach a deltopectoral or transdeltoid approach is recommended. Surgical approach of open reduction and internal fixation. 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. Orthopedic trauma incl pediatrics your digital gateway to expertise, education, and innovation. The axillary nerve can be palpated at the lower margin of the incision. Electrophysiological assessment of the deltoid muscle after. 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. Jan 16, 2015 the deltopectoral approach is a common surgical procedure for shoulder arthroplasty. 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. For complex and unstable fractures locking proximal. A minimally invasive approach for plate fixation of the. 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. An anatomic study of the cephalic vein in the deltopectoral shoulder approach.
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. Deltopectoral approach to shoulder joint netter images. 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 transdeltoid approach allows better access to the greater tuberosity and might facilitate periprosthetic reconstruction of. Upper extremity fracturesdecision making and methods of stabilization.
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. Furthermore, excessive soft tissue stripping destroys the local blood supply and integrity of the deltoid, which may increase the risk of avascular necrosis and. 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. Article in clinical orthopaedics and related research 4725 december 20 with 206 reads. Once this was done, the stem was prepared up to a size 10. Minimally invasive plate osteosynthesis with a locking. Radius distal dorsal approach surgery video general. Read deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. The diagnosis of a hagl lesion is particularly challenging. This study aimed to evaluate the pros and cons of the minimally invasive lateral approach for the treatment of proximal humeral.
To arrive at an accurate diagnosis, the use of a magnetic resonance arthrogram is suggested along with high clinical suspicion. The use of minimally invasive plate osteosynthesis mipo via anterolateral deltoid splitting has good outcomes in the management of 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. The pectoralis fascia is incised lateral to the tendon of the short. Proximal humerus fracture fixation may be complicated by persistent. Deltoidsplit or deltopectoral approaches for the treatment. Various articles have reported successful outcomes using the phlp when compared with other implant designs.
Anatomical landmarks for the anterior deltopectoral approach are. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. More videos of surgical techniques of the shoulder can be found. Show full abstract macroscopic features and biomechanical behavior were analyzed on dynamic videos obtained during forearm rotation.
Shoulder lateral deltoid splitting approach approaches. Philos proximal humeral internal locking system plate length 90 mm, short, 3 shaft holes x41. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. Proximal humeral hemiarthroplasty is indicated for displaced three and fourpart fractures in elderly patients, fourpart fracture dislocations, headsplitting fractures and fractures that. Electrophysiological assessment of the deltoid muscle.
Im nailing and open reduction internal fixation can be done with anterolateral deltoid split rather than deltopectoral approach. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary nerve. Curve it inferiorly, following the lateral border of the biceps. B, cephalic vein as the indicator of deltopectoral interval. Anterior approach to the humerus orthopaedicsone articles. For displaced fractures that meet surgical indications, the traditional deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. 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. Uses this approach is preferred for shoulder arthroplasty and for plateand screw fixation of proximal humeral fractures because it affords. 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 versus deltoid split approach for proximal. This article is conceived as a toolkit for the inexperienced surgeons, describing our. The 4part fracture dislocation of the proximal humerus has been associated with a high complication rate, in which avascular necrosis is important. Ao surgery reference is a resource for the management of fractures, based on current clinical principles, practices and available evidence. The deltopectoral approach 10, 44 is the most commonly used approach for shoulder arthroplasty. This video demonstrates a technique for rsa for fracture using a tensionable suture construct placed circumferentially. Do you want to use the redesigned ao sr like an app. 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. 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. May 03, 2009 dorsal approach and plating of a proximal rd radius fracture.
Im nail can have less impingement of hardware laterally than a plate. Extended anterolateral approach cambridge orthopaedics. 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. Fibular strut graft augmentation for open reduction and. Advantage of minimally invasive lateral approach relative to. This is the case for the management of subscapularis, where surgeons must choose between tenotomy and the lesser tuberosity osteotomy. Immediate hemiarthroplasty remains the accepted treatment for 4part fracture dislocation. This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses. Superficially, the deltoid is split between the anterior and middle fibers in line with the skin incision video 1. Its upper surface is rounded and marked by three flat impressions. 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. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a. Surgical anatomy of the radial nerve in the deltopectoral. Open repair of an anterior humeral avulsion of the.
For surgical management, the deltopectoral approach to the proximal humerus is the procedure of choice. The approach can be extended into an anterolateral approach to the humerus. Extensive dissection anteriorly may further compromise humeral head blood supply see, anterior circumflex humeral artery, humeral head blood supply. Many surgeons are familiar with this procedure, but certain steps are still controversial. Autoplay when autoplay is enabled, a suggested video will automatically play next. However, many complications still occur with use of the phlp, such as avascular necrosis of. To avoid damaging the axillary nerve, do not split. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder. For complex and unstable fractures locking proximal humerus plate.
New position and landmark for the deltopectoral approach. By current concepts in joint replacement featuring gilles walch. Surgical technique for open reductioninternal fixation of an. Many patients choose open reduction and internal fixation. Dec 11, 20 proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. Arthroscopic removal of proximal humerus plates in chronic post. The incidence of proximal humeral fracture is increasing gradually. May 25, 20 ubc medicine neurology clinical skills motor, sensory, and reflex examination duration. Learn about the humerus anterior approach brachial split, an online 3d video based course, accredited by the royal college of surgeons of england. Advantage of minimally invasive lateral approach relative. 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.
Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft. May 12, 2020 the humerus is the longest and largest bone of the upper limb. Choosing surgical approaches to proximal humerus fractures. Deltoidsplit or deltopectoral approaches for the treatment of. Subclavian vein thrombosis and fatal pulmonary embolism after. Deltopectoral versus deltoid split approach for proximal humerus fracture fixation with locking plate. One of the structures at risk during this approach is the axillary nerve.
Deltopectoral approach for total shoulder replacement vumedi. A 66yearold sustained a left proximal humerus fracture. Mar 01, 2008 the infraclavicular approach is used for lesions involving the brachial plexus distal to the clavicle. Extraarticular proximal humeral fracture case for small group discussion. Unusual anatomic variant of the axillary nerve challenging. In fractures of the proximal humerus which consist of an anterior fragment one should take care to analyze the fracture pattern. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. Fourpart fracture dislocation of the proximal humerus. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. 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. Click here to visit our frequently asked questions about html5. Drawings illustrating the positioning of the patient and the skin incision for the infraclavicular approach. Article information, pdf download for the deltoid lift.
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. The anterior humeral circumflex artery is seen here and must be ligated. Thirtythree patients were treated through a deltopectoral approach and 37 through an anterolateral deltoidsplitting approach. 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. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1. Live reverse total shoulder arthroplasty using a deltopectoral approach. 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. Shoulder arthrodesis in the management of glenohumeral.
The proximal humeral locking plate phlp is a recently developed fixedangle implant that. For oncology applications, a modified deltopectoral approach to the proximal humerus is most often utilized. The deltopectoral approach, first described by henry in 1957, is the workhorse to the shoulder that allows for extensile exposure. 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. 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. Proximal extension can be obtained by developing the anterior approach to the shoulder with full deltopectoral dissection. The cephalic vein is identified proximally and usually retracted laterally while exposing the deltopectoral plane.
Standard deltopectoral approach was used and dissection was carried down to the fracture site. If you would like a large, unwatermarked image for your web page or blog, please purchase the appropriate license. This article is from the open orthopaedics journal, volume 5. Tuberosity healing improves outcomes in rsa for fracture excessive lateralization may place increased stress on the repair in the fracture setting circumferential sutures help reduce the tuberosities to the prothesis, and this tensionable constructe improves. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. It consists of a proximal end, a shaft and a distal end, all which contain important anatomical landmarks. Up next principles of orif for proximal humerus fractures duration. An anterosuperior approach for proximal humeral fractures. 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. 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. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary ne. You may not embed one of our images on your web page without a link back to our site.
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