Approaches
Anterior
Anterolateral
Posterior
Lateral (to distal humerus)
Anterior Approach
Concept
- elevate biceps and split brachialis
Indication
- ORIF of humerus shaft
- humeral osteotomy
- biopsy and resection of tumors
- treatment of osteomyelitis
Technique
Position
- arm on table and abducted 60o
- no tourniquet
Incision
- tip of coracoid process of scapula along the deltopectoral groove
- towards the deltoid insertion and then heads distally along the lateral border of biceps
- stop 5 cm proximal to elbow flexion crease
Internervous planes
- two
- proximally between the deltoid and pectoralis major
- distally between the two halves of Brachialis (musculocutaneous and radial nerve)
Superficial dissection
- mobilise cephalic vein in deltopectoral groove
- open fascia on lateral edge of biceps
- the biceps is reflected medially to expose the brachialis muscle
- musculocutaneous nerve identified between biceps and brachialis and protected
Deep dissection
Proximally
- incise periosteum lateral to pect major insertion and lateral side of LHB tendon
- ligate ACHA
Distally
- brachialis is split in midline
- lifted off the humerus subperiosteally
Dangers
- radial nerve at risk in two areas
- spiral groove on back of humerus (care with drilling AP)
- distal 1/3 (protected by lateral 1/2 of the brachialis muscle)
Extensile measures
- can extend proximally as anterior approach to shoulder
- cannot extend distally - need to extend as anterolateral approach of distal humerus into forearm
Anterolateral Approach
Concept
- between biceps / brachialis medially and BR / triceps laterally
- identify and protect radial nerve
Indication
- ORIF humerus
- exploration radial nerve in distal arm
Technique
Position
- supine with arm abducted on hand table
Incision
- from coracoid down deltopectoral groove
- lateral aspect of biceps
Internervous Plane
- no true internervous plane
- between brachialis and brachioradialis
Superficial dissection
- retract biceps medially
- find plane between the brachialis and brachioradialis
- identify and protect radial nerve distally
- retract brachioradialis laterally and brachialis and biceps medially
- stay on medial side of the radial nerve
- expose humerus subperiosteally
Extension
- proximal - deltopectoral groove
- distal - Henry's approach to forearm
Posterior Approach
Concept
- between long and lateral heads triceps
- medial head split
Indication
- ORIF of distal 2/3 humerus
- exploration of radial nerve in spiral groove
Technique
Position
- patient lateral decubitus
- arm over arm rest
- no tourniquet
Incision
- posterior midline incision from 8 cm below the acromion to olecranon fossa
No true internervous plane
Superficial dissection
- divide fascia in midline
- develop the plane between the long and lateral heads of triceps
- small blood vessels cross the muscle and need to be coagulated
Deep dissection
- the medial head of triceps lies deep to the other two heads
- radial nerve lies in spiral groove proximal medial head
- identify and protect the radial nerve
- incise the medial head in midline to bone and then dissect subperiosteal off the bone to avoid the ulnar nerve
- never dissect to bone until the radial nerve is safe
Extensile measures
- cannot extend proximal to spiral groove due to deltoid crossing the field
- can extend distally over the olecranon
Lateral Approach to Distal Humerus
Concept
- between BR and Triceps
Indications
- ORIF of lateral condyle fractures
- surgical treatment of tennis elbow
Technique
Position
- supine with arm abducted on hand table
Incision
- 4-6cm curved incision on lateral aspect of elbow over the supracondylar ridge
Internervous plane
- between brachioradialis and triceps
Superficial dissection
- BR anteriorly
- triceps posteriorly
- down onto supracondylar ridge
Extensile measures
- cannot extend proximally as radial nerve crosses the line of dissection
- distal - can extend to radial head via plane between the ECU and Anconeus (Kocher approach)