Surgical Exposures of the Humerus

Dan A. Zlotolow, MD The neurovascular and muscular anatomy about the humerus Louis W. Catalano III, MD precludes the use of a truly “safe” fully extensile approach. O. Alton Barron, MD Working around a spiraling radial nerve at the posterior midshaft Steven Z. Glickel, MD requires either a transmuscular dissection or a triceps-avoiding paramuscular technique. To gain maximal exposure, the radial nerve must be mobilized at the spiral groove. For exposure of only

Dr. Zlotolow is Assistant Professor of the proximal humeral shaft, many surgeons prefer the anterolateral Orthopaedics, University of Maryland approach because it uses the internervous plane between the School of Medicine, Baltimore, MD. Dr. axillary and deltoid nerves proximally and the radial and Catalano is Assistant Clinical Professor of Orthopaedic Surgery, Columbia musculocutaneous nerves distally. Proximally, the deltopectoral College of Physicians and Surgeons, approach to the shoulder continues to be the most widely used. New York, NY, and Attending Physician, However, the lateral deltoid-splitting approach is a viable, less C. V. Starr Hand Surgery Center, St. invasive approach for both rotator cuff repair and fixation of valgus- Luke’s–Roosevelt Hospital Center, New York. Dr. Barron is Assistant Clinical impacted proximal humeral fractures. Distally, intra-articular Professor of Orthopaedic Surgery, exposure is dependent on triceps mobilization, either by olecranon Columbia College of Physicians and osteotomy or triceps release; this exposure can be coupled with Surgeons, New York, and Attending Physician, C. V. Starr Hand Surgery either a triceps-splitting or a paratricipital approach for proximal Center, St. Luke’s–Roosevelt Hospital extension. Center, New York. Dr. Glickel is Associate Clinical Professor of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, urgical approaches to the hu- paths, crossing intermuscular septae. and Attending Physician, C. V. Starr Smerus are designed to circumnav- Techniques for avoiding injury to Hand Surgery Center, St. Luke’s– igate the complicated neural anat- these structures while providing am- Roosevelt Hospital Center, New York. omy of the shoulder and brachium. ple visualization are compiled from None of the following authors or the These approaches are frequently used the literature and from our experi- departments with which they are for the spectrum of upper extremity ence. affiliated has received anything of value procedures, from fracture fixation to Patient positioning varies based from or owns stock in a commercial arthroplasty. The humerus can be di- on both the involved region of the company or institution related directly or vided into three zones: proximal humerus and the desired exposure. indirectly to the subject of this article: humerus, humeral shaft, and distal For the proximal humerus, the pa- Dr. Zlotolow, Dr. Catalano, Dr. Barron, humerus. There are indications, ad- tient may be positioned in the beach and Dr. Glickel. vantages, and disadvantages to the chair, lateral, supine, or prone posi- Reprint requests: Dr. Zlotolow, classic surgical exposures to the hu- tion. Dorsal approaches to the mid- Department of Orthopaedics, Kernan merus as well as to some of the most shaft and distal humerus include the Hospital, 2200 Kernan Drive, Suite recently developed more extensile lateral decubitus or prone position 1154, Baltimore, MD 21207. exposures. Of paramount importance with the arm over a post, or the su- is the neurovascular anatomy of the pine position with the arm resting J Am Acad Orthop Surg 2006;14:754- brachium (Table 1). Proximally, the across the patient’s chest on a bol- 765 circumflex humeral vessels and the ster. The supine position with the Copyright 2006 by the American axillary nerve divide the humerus at arm on a hand table may be used for Academy of Orthopaedic Surgeons. the surgical neck. Distally, the radial anterior approaches to the midshaft and ulnar nerves travel in circuitous and distal humerus.

754 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal

Table 1 Surgical Exposures of the Humerus

Concerns and Location Procedure Clinical Example Surgical Approach Limitations

Proximal Total shoulder Conventional or reverse Deltopectoral Axillary nerve, anterior arthroplasty prosthesis humeral circumflex artery ORIF of the proximal Three- or four-part Deltopectoral Axillary nerve, deltoid humerus fractures requiring insertion, anterior open reduction humeral circumflex artery Valgus-impacted or Deltoid split Axillary nerve, deltoid isolated greater detachment tuberosity fractures Rotator cuff tear Supra-/infraspinatus Deltoid split Axillary nerve, deltoid tear detachment Subscapularis tear Deltopectoral Axillary nerve, musculocutaneous nerve, anterior humeral circumflex artery Middle ORIF of humeral Proximal to mid third Anterolateral Divides the brachialis, fracture fracture lateral antebrachial cutaneous, and radial nerves All diaphyseal fractures Lateral paratricipital Radial nerve, posterior antebrachial cutaneous nerve Distal third fracture Triceps split Radial nerve, less extensile proximally Distal ORIF of intercondylar Simple fracture requiring Medial and lateral Ulnar and radial nerves, fracture bicolumnar fixation paratricipital poor intra-articular visualization Intra-articular fracture Medial triceps reflection Ulnar nerve, without anterior tendon-to-bone healing comminution Intra-articular fracture Olecranon osteotomy Ulnar and radial nerves, with anterior olecranon nonunion comminution Elbow arthroplasty Implant or interposition Medial triceps reflection Ulnar nerve, arthroplasty tendon-to-bone healing Extensile ORIF of segmental Diaphyseal and distal Lateral paratricipital Radial and axillary humeral fracture intra-articular fracture with lateral reflection nerves, tendon-to-bone healing, anconeus Proximal humeral Deltopectoral with Radial, axillary, and fracture with proximal anterolateral lateral antebrachial to mid third shaft cutaneous nerves

ORIF = open reduction and internal ﬁxation

Anatomy teres minor and deltoid muscles (Fig- tially. The nerve to each head of the ure 1). The nerve lies between 4.3 deltoid does not branch until it The axillary nerve is a continuation and 7.4 cm from the lateral edge of crosses each raphe. of the posterior cord. The nerve trav- the acromion.1 After entering the The radial nerve is the other ter- els anterior to the subscapularis, posterior third of the deltoid, the minal branch of the posterior cord. wraps around the surgical neck of nerve travels along the deep deltoid This nerve begins anteromedially the humerus, and passes through the fascia to innervate the middle and and travels along the subscapularis quadrangular space to innervate the anterior thirds of the deltoid sequen- to join with the deep brachial artery

Volume 14, Number 13, December 2006 755 Surgical Exposures of the Humerus

Figure 1

A, Posterior view of the neural anatomy of the brachium with reference measurements (in cm) from prominent anatomic landmarks. The area between the axillary nerve and the spiral groove is the proximal safe zone of the posterior humerus. The distal safe zone is distal to the spiral groove. B, Anterior view of the shoulder. Note the relationship of the axillary nerve and the anterior circumflex humeral artery to the inferior margin of the subscapularis muscle. During the deltopectoral approach, the “three sisters” (anterior humeral circumflex artery and its two venous communicantes) are often ligated separately to minimize blood loss and gain adequate exposure of the humeral metaphysis.

at the triangular interval. Beginning courses posteriorly along the humer- Although rarely encountered in 97 to 142 mm from the lateral acro- us, and emerges anterolaterally in surgical exposures to the humerus, mion, the nerve and artery then trav- the distal brachium. the brachial artery and median nerve el along the spiral groove, separating The ulnar nerve arises from the warrant mention. The median nerve the medial and lateral heads of the medial cord and travels anterior to the receives contributions from the me- triceps. The nerve exits the spiral medial intermuscular septum (Figure dial and lateral cords and travels just groove 101 to 148 mm proximal to 1, B). At the arcade of Struthers, ap- medial to the brachial artery along the lateral epicondyle.2 As the nerve proximately 8 cm from the medial epi- the anterior surface of the medial in- passes into the anterior brachium condyle, the nerve crosses into the termuscular septum. At the elbow, through the lateral intermuscular posterior compartment4 (Figure 1, A). the median nerve and the brachial septum, the nerve is, on average, It then courses posterior to the inter- artery can be found between the pro- 10 cm from the distal articular sur- muscular septum and the medial epi- nator teres muscle and the biceps face of the elbow but never closer condyle to enter the cubital tunnel. tendon. than 7.5 cm.3 Distally, the radial The ulnar nerve gives off an articular The deltoid enshrouds the proxi- nerve travels deep between the bra- branch to the elbow joint that can be mal humerus and is divided into chialis and brachioradialis muscles sacrificed during surgical exposure. three heads by two fibrous raphes. before bifurcating at the level of the Distally, the nerve passes into the an- The anterior, middle, and posterior radiocapitellar joint. Hence, the radi- terior forearm between the two heads heads originate from the distal clav- al nerve originates anteromedially, of the flexor carpi ulnaris. icle, lateral acromion, and scapular

756 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal spine, respectively. These three heads of a proximal humeral fracture, supraspinatus insertion and is opti- converge into a broad, 4-cm–wide shoulder arthroplasty, anterior cap- mal for antegrade humeral nailing. tendinous insertion along the lateral sular shift, and subscapularis repair. We prefer this approach for the fixa- humerus, approximately 9 to 13 cm We prefer this approach for shoulder tion of two-part greater tuberosity distal to the lateral acromion. The arthroplasty and for plate-and-screw fractures or other proximal humeral anterior head originates from both fixation of proximal humeral frac- fractures amenable to treatment the anterior acromion and the clav- tures because it affords greater visu- with a combination of suture fixa- icle and forms a discrete insertion, alization than does the lateral ap- tion and/or intramedullary devices. constituting approximately one fifth proach. We also use this approach to manage the width of the deltoid insertion. The axillary nerve should be pal- valgus impacted three- and four-part Therefore, partial anterior deltoid re- pated as it passes inferior to the sub- fractures (Figure 2). The more poste- lease of more than one fifth of the in- scapularis and the inferior capsule, rior rotator cuff tear can be accessed sertion, frequently performed during and it should be protected through- via the posterior raphe. A stay suture plate fixation, completely detaches out the procedure. External rotation is placed in the distal-most apex of the anterior head of the deltoid.5 The of the shoulder during subscapularis the split to prevent unwanted prop- clinical sequelae of anterior deltoid release moves the dissection away agation and, thus, injury to the axil- detachment is unknown. from the axillary nerve and decreas- lary nerve. For greater visualization, In the brachium, the most often es tension on the nerve. Dissection a portion of the deltoid can be re- encountered muscles are the triceps medial to the conjoined tendon leased from the anterolateral acro- and the brachialis. The long head of should be avoided because it places mion. At the time of closure, the the triceps originates from the infe- the musculocutaneous nerve at risk. crescentic deltoid origin should be rior glenoid tubercle, the lateral head Care should be taken to isolate and repaired to the lateral acromion from the humeral shaft superolater- ligate the anterior humeral circum- through small bone tunnels made al to the spiral groove, and the medi- flex artery, along with, if necessary, with a towel clamp. al head inferomedial to the spiral its two venous communicantes at The deltopectoral and deltoid- groove. The lateral and long heads the distal margin of the subscapu- splitting approaches may be com- are superficial, with a visible, often laris tendon during the exposure bined to provide an extensile ap- palpable, cleft proximally, terminat- (Figure 1, B). To maintain the blood proach to the proximal humerus ing in a common tendon. The medi- supply to the humeral head, surgical without risking denervation of the al head is deep and is accessible by dissection should not extend to the deltoid itself. This dual approach is dividing the long and lateral heads of inferior margin of the subscapularis. helpful for concurrent subscapularis the triceps. Innervation is provided A cuff of muscle must be main- and posterosuperior rotator cuff tears by branches of the radial nerve. The tained to protect the anterior humer- as well as for anterior shoulder stabi- radial nerve then passes through the al circumflex vessels. Likewise, by lization procedures with associated lateral intermuscular septum to in- releasing the subscapularis medial to rotator cuff tears.8 nervate the lateral third of the bra- its tendinous insertion, the arcuate Traditionally, the deltoid-splitting chialis. The medial two thirds of the artery is not sacrificed at the point at approach has been limited by the brachialis muscle and the remainder which it enters the humeral head course of the axillary nerve to within of the anterior compartment are in- along the lateral border of the bicip- 5 cm distal to the acromion. A re- nervated by the musculocutaneous ital groove.6,7 cently described technique exploits nerve. When a greater exposure of the the fact that the axillary nerve does lateral humeral shaft is needed, less not branch to innervate each deltoid 9 Proximal Humerus than one fifth of the anterior deltoid head before crossing each raphe. Ex- insertion can be released.5 Distal extending the deltoid split through the Anterior Approach tension may be accomplished via the raphe after protecting the main axil- The deltopectoral approach is the anterolateral approach to the hu- lary trunk allows a more distal expo- workhorse exposure for the proximal merus. sure of the proximal humerus with- humerus. This approach develops out denervating the anterior deltoid9 the internervous plane between the Lateral Approach (Figure 3). This approach provides deltoid (axillary nerve) and the pec- The second most common ap- sufficient visualization to perform toralis major (medial and lateral pec- proach to the proximal humerus in- plate-and-screw fixation of proximal toral nerves). The cephalic vein is volves splitting the deltoid muscle. humeral fractures, with the plate the landmark for this interval. The A split can be performed most easi- placed deep to the isolated and pro- deltopectoral approach is useful for ly through either raphe. The anteri- tected axillary nerve and circumflex open reduction and internal fixation or raphe allows better access to the arteries.

Volume 14, Number 13, December 2006 757 Surgical Exposures of the Humerus

Figure 2 can be reflected medially off the humerus to approximately 10 cm from the posterior aspects of the acromion.2 At the midline of the posterior humerus, a safe zone exists proximal to the spiral groove between the axillary and radial nerves. With the deltoid retracted laterally, the proximal humeral shaft can be exposed.11 This approach can be extended distally to expose the entire humeral diaphysis by continuing to reflect the triceps medially and elevating the radial nerve from the spiral groove. This approach allows for A, Anteroposterior radiograph demonstrating a valgus impacted three-part proximal placement of plate-and-screw con- humeral fracture managed with a lateral deltoid-splitting approach without structs spanning the length of the di- detachment of the deltoid or mobilization of the axillary nerve. B, Anteroposterior aphysis. It is particularly useful for radiograph. The humeral head was disimpacted, and the valgus angulation was long oblique or spiral shaft fractures corrected. An Interpore coral spacer (Interpore Cross International, Irvine, CA) was with proximal extension. Alterna- used to fill the cancellous void. The greater tuberosity was then sutured to the tively, the dissection can be contin- humeral shaft via heavy nonabsorbable braided sutures threaded through drill holes. ued along the lateral margin of the radial nerve as it spirals around the Posterior Approach fraspinatus and teres minor. Occa- humerus, across the lateral inter- Posterior approaches to the prox- sionally, the tubercle of the teres mi- muscular septum, and between the imal humerus are less commonly per- nor can be found at the superior lateral and middle third of the bra- formed because of the difficulty of the margin of the teres minor insertion. chialis muscle.12 exposure and the infrequency of in- Exposure of the posterior gleno- dications. The most common indica- humeral joint capsule can be Humeral Shaft tions are posterior glenohumeral in- achieved by retracting the supra- stability and tumor surgery. The scapular nerve–innervated infraspi- The spiral groove divides the humer- patient is usually placed in either a natus muscle superiorly. When fur- us nearly in half and prevents so- beach chair or lateral position, with ther capsular exposure is needed called safe extensile exposure along the arm draped free to allow unre- superiorly, the infraspinatus tendon the entire length of the humerus. Se- stricted mobility of the glenohumeral may be released 1 cm from its inser- lection of surgical approach to the joint. To allow release of the posterior tion onto the greater tuberosity and humeral shaft depends on fracture deltoid origin from the scapular spine, reflected medially. This additional location and surgeon preference. the incision is made at a 45° angle to exposure allows greater mobiliza- Most commonly, an anterolateral the scapular spine, halfway between tion of the infraspinatus, potentially approach is used for proximal and the spine and the humerus (Figure 4). placing undue tension on the supras- middle third shaft fractures. Distal The teres minor is then retracted with capular nerve as it enters the in- extension is difficult because the lat- the deltoid, along with their common fraspinatus muscle just distal to the eral antebrachial cutaneous and radi- neurovascular pedicle, the axillary spinoglenoid notch of the scapula.10 al nerves converge on the anterolat- nerve, and the posterior humeral cir- One limitation of this approach is eral aspect of the elbow. The cumflex artery. The plane between the lengthy deltoid detachment re- posterior approach can be used for the infraspinatus and teres minor can quired. The posterior approach is fractures along the entire diaphysis be difficult to identify. It is best seen also limited in that it cannot be ex- and can be extended distally for closer to the tendinous insertion at tended distally. Thus, it is not rec- intra-articular fractures. Many sur- the level of the joint with the shoul- ommended for addressing patholog- geons shun this technique, however, der held in internal rotation. Sweep- ic conditions distal to the anatomic because it can require dissection and ing the fascia off the two muscle bel- neck of the humerus. mobilization of the radial nerve and lies of the infraspinatus and the one For exposure of the proximal hu- deep brachial artery at the midshaft. muscle belly of the teres minor often merus just distal to the surgical Among the various trauma surgeons, reveals a fat stripe between the in- neck, the lateral head of the triceps there is no consensus on which ap-

758 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal

Figure 3 Figure 4

Posterior view of the shoulder demonstrating the approach via the internervous plane between the suprascapular nerve (infraspinatus muscle) and the axillary nerve (teres minor and Lateral view of the shoulder demonstrating an extended deltoid muscles). With the shoulder held in internal rotation, deltoid-splitting approach with mobilization of the axillary a fat stripe can usually be found between the two muscles at nerve. The axillary nerve enters each head of the deltoid as a the level of the joint. The skin incision is oriented 45° from single trunk, allowing for separation of the anterior and middle the scapular spine, allowing access to the scapular spine for heads of the muscle along the anterior raphe without detachment of the posterior deltoid origin while providing denervation of the anterior head. adequate visualization of the joint.

proach is preferable for each seg- The lateral portion of the brachialis The paratricipital approaches offer ment. protects the radial nerve from retrac- several advantages over triceps- tors placed within the split. Care splitting approaches. Some surgeons Anterolateral Approach must be taken distally not to injure advocate using these approaches The anterolateral approach is a the lateral antebrachial cutaneous without a tourniquet because the ap- distal continuation of the deltopec- nerve as it exits between the biceps proaches exploit relatively bloodless toral approach. Proximally, the in- and brachialis muscles. The radial planes.13,14 Avoiding injury to the tri- ternervous plane between the del- nerve is likewise at risk from distal ceps muscle itself also may limit in- toid and biceps muscles is used. extension and must be identified be- tramuscular adhesions and scar for- Distally in the brachium, there is no tween the brachialis and brachiora- mation and may, at least in theory, true internervous plane because the dialis. help lessen elbow contracture and brachialis receives dual innervation improve postoperative triceps func- from the radial and musculocutane- Posterior Approaches tion. By staying outside the muscle, ous nerves. The anterolateral ap- Posterior approaches involve ei- there is less risk of denervating a proach, therefore, splits the brachi- ther mobilizing the triceps from lat- portion of the triceps or the anco- alis muscle along the middle and eral to medial (paratricipital) or split- neus. Moreover, extending the expo- lateral thirds of the muscle belly. ting the muscle belly along its fibers. sure proximally and distally can be

Volume 14, Number 13, December 2006 759 Surgical Exposures of the Humerus

Figure 5 less plane. Complete visualization of the radial nerve on both sides of the intermuscular septum also is possi- ble with this approach. The triceps-splitting approach separates the long head of the triceps from the lateral head superficially to reveal the medial head as it originates from the distal-medial aspect of the spiral groove. The interval between the two superficial heads is easier to locate proximally, before the formation of a common tendon, and is best identified by palpation. The radial nerve, which may lie directly on bone or may be separated from the humerus by several milli- meters of the medial head of the triceps muscle, can be mobilized to allow a plate to be slid beneath it. Without mobilization of the radial A, Anterposterior view of a periprosthetic mid diaphyseal humeral shaft fracture. nerve, only the distal 55% of the hu- B, A lateral paratricipital approach was used to gain access to the entire humeral shaft. The deltoid (D) limits exposure proximally, and the triceps (T) is reflected meral shaft can be exposed. With medially. A fixed-angle plate with proximal cables was used to secure the fracture mobilization of the radial nerve, the and contain the two fibular strut grafts. The radial nerve (R) and profunda brachii distal 76% of the humeral shaft is artery (A) can be seen overlying the plate. C, Six months postoperatively, the accessible.15 Distally, plating is lim- fracture is healed, with maintenance of reduction and incorporation of the fibular ited not by the exposure but by en- grafts. An anterolateral approach was not selected for this fracture because it limits croachment of the plate across the distal plate placement and does not allow direct visualization or mobilization of the olecranon fossa. Proximally, the tri- radial nerve for placement of circumferential cables. Blind cable placement from an ceps becomes difficult to split, thus anterior exposure at the level of the spiral groove is not recommended. limiting an extensile exposure (Fig- ure 7). A tourniquet may be used for accomplished more easily, particu- termuscular septum. It is important the initial exposure; significant larly on the lateral side, by mobiliz- not to confuse the posterior antebra- bleeding may be encountered on re- ing the radial nerve and elevating the chial cutaneous nerve, which can be lease of the tourniquet. triceps off the humerus. rather large, with muscular branch- The lateral paratricipital ap- es to the triceps. Distal Humerus proach uses the tissue plane between Once the radial nerve and its the lateral head of the triceps and the branches are identified and protect- Approaches to the distal humerus al- lateral intermuscular septum (Figure ed, the triceps is elevated subperi- low exposure distal to the spiral 5). The critical aspect of this ap- osteally and reflected medially. The groove, with a “safe zone” of 10 cm proach is identification of the radial approach may be extended proximal- from the elbow joint.2 Unlike the nerve as it exits the spiral groove ap- ly between the posterior deltoid and knee, where the patella and its at- proximately 14 cm proximal to the the lateral head of the triceps; it is tached extensor mechanism can be lateral epicondyle and pierces the in- limited by the axillary nerve. Ap- mobilized for visualization of the termuscular septum 10 cm from the proximately 94% of the humeral di- joint surfaces, the olecranon and tri- articular surface.3,15 The nerve is iso- aphysis can be exposed with this ap- ceps tendon are fixed, thus limiting lated and mobilized from the spiral proach15 (Figure 6). Distally, the direct visualization of the elbow groove, taking care to preserve the approach can be combined with ole- joint. Multiple exposures to the dis- posterior antebrachial cutaneous cranon osteotomy, triceps reflection tal humerus have been described to nerve. The posterior antebrachial cu- off the olecranon, or a modified address this limitation. These expo- taneous nerve emerges from the ra- Kocher approach. Another advantage sures can be divided into two catego- dial nerve as the radial nerve exits of this technique is that it can be ries: procedures that detach the ex- the spiral groove, and it travels along performed without a tourniquet be- tensor mechanism and those that the posterior aspect of the lateral in- cause it exploits a relatively blood- mobilize it. In general, detachment

760 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal

Figure 6 Figure 7

The lateral triceps slide approach. Releasing the medial intermuscular septum facilitates subperiosteal mobilization of the medial and lateral heads of the triceps in a medial direction. When only limited exposure is necessary, either the The posterior triceps-splitting approach provides access to proximal portion of the approach (before the spiral groove) the distal 76% of the humeral diaphysis once the radial nerve or the distal portion of the approach (distal to the spiral is mobilized. With this approach, the long and lateral heads groove) can be performed without the need to mobilize the of the triceps are separated, after which intramuscular radial nerve. Extended distally, an intra-articular exposure division of the medial head of the triceps is performed. similar to the medial triceps slide can be achieved. (Adapted Proximal extension is limited by the lateral head of the triceps. with permission from Gerwin M, Hotchkiss RN, Weiland AJ: (Adapted with permission from Gerwin M, Hotchkiss RN, Alternative operative exposures of the posterior aspect of the Weiland AJ: Alternative operative exposures of the posterior humeral diaphysis: With reference to the radial nerve. J Bone aspect of the humeral diaphysis: With reference to the radial Joint Surg Am 1996;78:1690-1695.) nerve. J Bone Joint Surg Am 1996;78:1690-1695.)

of the extensor mechanism enables to the olecranon by first palpating medial head of the triceps if its nerve improved visualization of the joint and then dividing the interval be- branches are not preserved. surfaces but at increased risk of post- tween the long and lateral heads. Some surgeons advocate a straight operative extensor mechanism com- The medial head, which lies adja- midline split, which can be extended promise. cent to the humerus just distal to the distally to reflect both the medial spiral groove, can then be split in and lateral triceps insertions subpe- Maintaining Extensor line with its fibers. Care must be riosteally off the olecranon, provid- Continuity taken when dividing the muscle ing excellent intra-articular visual- Triceps-splitting or triceps- proximally because the radial nerve ization without extensor mechanism avoiding approaches have been rec- most commonly overlies the origin detachment.16-18 Others have recom- ommended for extra-articular frac- of the medial head for two thirds of mended a 75% lateral/25% medial tures or simple T-type intra-articular the circumference of the spiral split.19 When combining a triceps- fractures. The triceps can be split groove.2 Another concern is partial splitting approach with an olecranon from just distal to the spiral groove denervation of the lateral half of the osteotomy, however, the triceps split

Volume 14, Number 13, December 2006 761 Surgical Exposures of the Humerus

Figure 8 fixation of fractures with no proximal extension into the humeral shaft. The lateral paratricipital approach may be used for lateral column intra-articular fractures, particularly for the fracture extending into the humeral shaft. For simple intra- articular or distal extra-articular fractures requiring bicolumnar fixation, the medial and lateral paratricipital approaches may be combined without reflecting the triceps off the olecranon. However, complex intra- articular fractures with proximal extension beyond the distal third of the humeral diaphysis may require medial and lateral paratricipital approaches, with the addition of medial triceps reflection and ulnar nerve mobilization. Midline posterior skin incision may be used for any of the paratricipital approaches because the skin flaps can be mobilized widely to allow access to both the medial and lateral sides. Midline skin incision also allows further exposure. The medial approach requires complete release and transposition of the ulnar nerve to the level of the first mo- tor branch within the flexor carpi ul- The triceps-splitting approach can be extended distally with the addition of an naris. This approach takes advantage olecranon osteotomy. The osteotomy can be performed as illustrated, with reflection of the internervous plane between of the olecranon medially with the medial soft-tissue attachments intact (arrow). the triceps and the brachialis mus- (Adapted with permission from Ebraheim NA, Andreshak TG, Yeasting RA, cles. Proximal extension of this ap- Saunders RC, Jackson WT: Posterior extensile approach to the elbow joint and proach is blocked by the ulnar nerve distal humerus. Orthop Rev 1993;22:578-582.) piercing the intermuscular septum at the arcade of Struthers. Care must be taken not to injure the nerve at should retain more of the medial- ized muscle bed for the lateral el- this level with zealous retraction. sided triceps insertion onto the ole- bow.21 The medial column and medial as- cranon. The osteotomized olecranon Paratricipital approaches may be pect of the trochlea can be visualized can then be retracted medially with performed medial to the triceps with this approach (Figure 9, A). the bulk of the triceps attached, and mechanism, lateral to the triceps, or Distally, the dissection may be ex- the lateral triceps and anconeus re- both, with subperiosteal reflection of tended along the dorsal ridge of the flected laterally20 (Figure 8). Unlike a the triceps insertion in continuity ulna in the internervous plane be- standard olecranon osteotomy, re- with the periosteum of the dorsal ul- tween the extensor and flexor carpi flecting the anconeus with the lat- na.14,21,22 The medial paratricipital ulnaris, allowing the extensor mech- eral triceps preserves the innervation approach with triceps reflection, anism to be subperiosteally reflected of the anconeus, maintaining the an- combined with mobilization of the off the olecranon while maintaining coneal branch of the radial nerve as ulnar nerve, provides excellent visu- tendofascial continuity of the exten- it courses along the lateral triceps alization of the entire distal humer- sor mechanism.22 In extreme flex- muscle. Although small, the anco- us and proximal ulna. This approach ion, this approach allows direct visu- neus assists with dynamic stability is best suited for elbow arthroplasty alization of the joint surface nearly of the elbow and provides a vascular- and intra-articular distal humeral equal to that of an olecranon osteot-

762 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal

Figure 9

A, Posteromedial view of the distal humerus, right arm. Medial paratricipital approach to the distal humerus. Anterior transposition of the ulnar nerve allows excellent visualization of the medial column. B, Posterolateral view of the distal humerus, right arm. Lateral paratricipital approach to the distal humerus. Distal extension can be achieved via the modified Kocher approach. Proximally, mobilization of the radial nerve allows access to the entire humeral shaft up to the level of the axillary nerve. (Adapted with permission from Shildhauer TA, Nork SE, Mills WJ, Henley MB: Extensor mechanism-sparing paratricipital posterior approach to the distal humerus. J Orthop Trauma 2003;17:374-378.) omy, with the exception of the ante- evation of the mobile wad is not rec- ence, this is rarely necessary, except rior trochlea (Figure 10). Early active ommended because it places the in fractures with comminution ex- motion can be initiated after repair radial nerve at risk. Moreover, any tending into the anterior trochlea or of the triceps to bone using nonab- proximal extension should identify for total elbow arthroplasty. sorbable sutures. As the triceps re- and preserve both the radial nerve as mains in continuity, postoperative it pierces the intermuscular septum Detaching the Extensor weakness is minimized. In their se- just proximal to the brachioradialis Mechanism ries of 49 total elbow arthroplasties, origin and the posterior antebrachi- O’Driscoll21 combined a medial Bryan and Morrey22 reported no tri- al cutaneous nerve as it branches off (triceps-reflecting) paratricipital and ceps discontinuity or significant the radial nerve just distal to the spi- lateral (modified Kocher) paratricip- weakness. ral groove.13 ital approach with distal extension On the lateral side, the interval Provided the distal extension of to allow the entire extensor mecha- between the triceps and the mobile any paratricipital approach has not nism to be reflected proximally. As a wad of three (brachioradialis, exten- detached the extensor mechanism unit, the triceps and anconeus mus- sor carpi radialis longus and brevis) from the olecranon, such approach- cles are freed from their fascial at- can be used to visualize the lateral es can be combined with olecranon tachments medially and laterally, column. When visualization of the osteotomy if, after inspecting the maintaining only their distal attach- radiocapitellar joint is needed, the fracture site, further exposure of the ment to the olecranon. Via the dissection can be extended to in- joint is deemed necessary. If the tri- triceps-reflecting anconeus pedicle clude a Kocher approach. This main- ceps has already been detached, an- approach, the triceps and anconeus tains the anconeus with the lateral other option is to osteotomize and are released subperiosteally from the triceps flap, preserving both its in- remove the proximal tip of the olec- ulna in a V-shaped tendofascial flap nervation and blood supply.14 The ranon. Removing the olecranon tip with the apex distal.21 The rationale entire anconeus/triceps flap also can provides better intra-articular visual- behind this approach is to provide an be elevated subperiosteally off the ization for complex intra-articular exposure similar to that of an olecra- posterior humerus to allow direct fractures and simplifies intramedul- non osteotomy without the risk of posterior plating (Figure 9, B). Ante- lary preparation of the proximal ulna olecranon nonunion, as well as for rior extension of the exposure by el- for elbow arthroplasty. In our experi- surgeries in which an osteotomy is

Volume 14, Number 13, December 2006 763 Surgical Exposures of the Humerus

Figure 10 medial triceps from the medial intermuscular septum, and the lateral triceps from the anconeus and lateral intermuscular septum. The anconeus is denervated by this approach. When only distal exposure is re- quired, we do not attempt to identify the radial nerve. However, when the exposure requires triceps mobilization >10 cm proximal to the lateral epicondyle, the radial nerve should be identified and protected. Repair of the osteotomy can be performed at the close of the procedure with a variety of techniques, in- cluding a tension band construct with Kirschner wires or an intramedullary screw, an intramedullary screw without a tension band, or plate-and-screw fixation. We prefer a tension band technique with Kirschner wires and figure-of-8 fixation. Proximal extension can involve either a lateral paratricipital approach with mobilization of the entire triceps muscle medially and elevation Medial triceps-reflecting approach as described by Bryan and Morrey.22 The of the radial nerve24 or a triceps- extensor mechanism remains in continuity with the deep fascia and periosteum of the proximal ulna. The ulnar nerve is transposed to gain better visualization of the splitting approach proximal to the distal humerus and to protect the nerve. Excision of the olecranon tip provides spiral groove with paratricipital ex- excellent intra-articular visualization. (Adapted with permission from Bryan RS, tensions distal to the spiral groove.25 Morrey BF: Extensive posterior exposure of the elbow: A triceps-sparing approach. For isolated lateral condyle fractures, Clin Orthop 1982;166:189.) we prefer a lateral paratricipital approach combined with a chevron osteotomy, leaving all medial periosteal contraindicated (eg, total elbow ar- gration and prominence, delayed and muscular attachments intact. throplasty). However, unlike an os- union, and nonunion.23 The proce- The osteotomy is hinged open on the teotomy, which requires bone-to- dure involves elevating the anconeus lateral side, allowing excellent visu- bone healing, recovery of triceps insertion and the proximal aspect of alization of the lateral column and function requires tendon-to-bone the extensor and flexor carpi ulnaris articular surface without the need to healing, which may represent a lim- origins so as to expose the olecranon violate the cubital tunnel or mobilize itation of this technique. Further- while maintaining the triceps attach- the ulnar nerve. more, although the joint exposure ment. Unless exposure of the medial achieved with the O’Driscoll tech- column is not necessary, we routinely Summary nique is nearly equivalent to that transpose the ulnar nerve before per- provided by either an extended me- forming the osteotomy. Humeral exposures are limited by dial or lateral paratricipital approach Ideally, an apex distal osteotomy the axillary nerve proximally, the ul- alone,22 it adds the potential compli- is made at the bare spot on the troch- nar nerve medially, and the radial cations of extensor detachment. lear notch. Most of the osteotomy nerve posteriorly and laterally. A The olecranon osteotomy is the can be performed with a sagittal saw, thorough understanding of the in- most commonly used technique for although the articular side should be ternervous planes about the hu- intra-articular fracture of the distal breached with an osteotome to cre- merus is essential before undertak- humerus. Of the techniques de- ate an irregular joint surface for lat- ing any exposure of the humerus, scribed, olecranon osteotomy affords er interdigitation. The olecranon particularly of the shaft. In general, the best exposure of the joint surfaces. with the attached triceps is then re- nerves at risk should be identified Complications include hardware mi- flected proximally, separating the and protected throughout the proce-

764 Journal of the American Academy of Orthopaedic Surgeons DanA.Zlotolow,MD,etal dure. For the proximal humerus, the 1. Burkhead WZ Jr, Scheinberg RR, Box 14. Schildhauer TA, Nork SE, Mills WJ, deltoid-splitting and deltopectoral G: Surgical anatomy of the axillary Henley MB: Extensor mecha- approaches are familiar to most or- nerve. J Shoulder Elbow Surg 1992;1: nism-sparing paratricipital posterior 31-36. approach to the distal humerus. thopaedic surgeons; a healthy respect 2. Guse TR, Ostrum RF: The surgical J Orthop Trauma 2003;17:374-378. for the potential dangers is essential anatomy of the radial nerve around 15. Gerwin M, Hotchkiss RN, Weiland to avoid neurovascular injury. For the humerus. Clin Orthop Relat Res AJ: Alternative operative exposures of the diaphysis, we prefer the lateral 1995;320:149-153. the posterior aspect of the humeral di- paratricipital approach, for both its 3. Uhl RL, Larosa JM, Sibeni T, Martino aphysis with reference to the radial clean intermuscular dissection and LJ: Posterior approaches to the humer- nerve. J Bone Joint Surg Am 1996;78: us: When should you worry about the its extensibility. Distally, for less 1690-1695. radial nerve? J Orthop Trauma 1996; 16. Ziran BH, Smith WR, Balk ML, Man- comminuted fractures, we use either 10:338-340. ning CM, Agudelo JF: A true triceps- 4. Eaton D: Anterior subcutaneous or both paratricipital approaches splitting approach for treatment of transposition, in Gelberman RH (ed): (with or without triceps reflection); distal humerus fractures: A prelimi- Operative Nerve Repair and Recon- for severely comminuted intra- nary report. J Trauma 2005;58:70-75. struction. Philadelphia, PA: Lippin- articular fractures, we use an olecra- cott, 1991, pp 1077-1085. 17. McKee MD, Kim J, Kebaish K, non osteotomy. Once the triceps is 5. Klepps S, Auerbach J, Calhon O, Lin J, Stephen DJ, Kreder HJ, Schemitsch reflected off the olecranon, however, Cleeman E, Flatow E: A cadaveric EH: Functional outcome after open supracondylar fractures of the humer- olecranon osteotomy no longer can study on the anatomy of the deltoid us: The effect of the surgical approach. be performed. insertion and its relationship to the deltopectoral approach to the proxi- J Bone Joint Surg Br 2000;82:646-651. mal humerus. J Shoulder Elbow Surg 18. McKee MD, Wilson TL, Winston L, Acknowledgment 2004;13:322-327. Schemitsch EH, Richards RR: Func- 6. Gerber C, Schneeberger AG, Vinh TS: tional outcome following surgical We thank Dori Kelly, MA, Senior Ed- The arterial vascularization of the hu- treatment of intra-articular distal humeral head: An anatomical study. meral fractures through a posterior itor and Writer, for professional J Bone Joint Surg Am 1990;72:1486- approach. J Bone Joint Surg Am 2000; manuscript editing. 1494. 82:1701-1707. 7. Brooks CH, Revell WJ, Heatley FW: 19. Shahane SA, Stanley D: A posterior Vascularity of the humeral head after approach to the elbow joint. J Bone proximal humeral fractures: An ana- Joint Surg Br 1999;81:1020-1022. Additional Resources tomical cadaver study. J Bone Joint 20. Ebraheim NA, Andreshak TG, Yeast- Surg Br 1993;75:132-136. ing RA, Saunders RC, Jackson WT: CD-ROM: Selective Exposures in 8. Levy O, Pritsch M, Oran A, Greental Posterior extensile approach to the el- Orthopaedic Surgery: “Common A: A wide and versatile combined sur- bow joint and distal humerus. Approaches to the Shoulder,” by gical approach to the shoulder. Orthop Rev J Shoulder Elbow Surg 1999;8:658- 1993;22:578-582. Dan Guttmann, MD, and Andrew 21. O’Driscoll SW: The triceps-reflecting S. Rokito, MD, editors: http:// 659. 9. Gardner MJ, Griffith MH, Dines JS, anconeus pedicle (TRAP) approach for www5.aaos.org/product/product Lorich DG: A minimally invasive ap- distal humeral fractures and non- page.cfm?code=02545 proach for plate fixation of the proxi- unions. Orthop Clin North Am 2000; mal humerus. Bull Hosp Jt Dis 2004; 31:91-101. Related clinical topics articles 62:18-23. 22. Bryan RS, Morrey BF: Extensive poste- available on Orthopaedic Knowl- 10. Hoppenfeld S, deBoer P: The shoulder, rior exposure of the elbow: A triceps- edge Online: “Four-Part Proximal in Hoppenfeld S, deBoer P (eds): Surgi- sparing approach. Clin Orthop Relat Humerus Fractures,” by Joesph cal Exposures in Orthopaedics: The Res 1982;166:188-192. Anatomic Approach, ed 2. Philadel- 23. Ring D, Gulotta L, Chin K, Jupiter JB: Zukerman, MD, Arash Araghi, phia, PA: Lippincott, 1994, pp 38-41. Olecranon osteotomy for exposure of MD, and Derek Plausinis, MD: 11. Berger RA, Buckwalter JA: A posterior fractures and nonunions of the distal http://www5.aaos.org/oko/ surgical approach to the proximal part humerus. J Orthop Trauma 2004;18: shoulder_elbow/proximal_hume of the humerus. J Bone Joint Surg Am 446-449. ral/pathophysiology/pathophysi 1989;71:407-410. 24. Gerwin M, Hotchkiss RN, Weiland 12. Mekhail AO, Checroun AJ, Ebraheim AJ: Alternative operative exposures of ology.cfm NA, Jackson WT, Yeasting RA: Exten- the posterior aspect of the humeral di- sile approach to the anterolateral sur- aphysis with reference to the radial face of the humerus and the radial nerve. J Bone Joint Surg Am 1996;78: References nerve. J Shoulder Elbow Surg 1999;8: 1690-1695. 112-118. 25. Archdeacon MT: Combined olecranon Citation numbers printed in bold 13. Moran MC: Modified lateral approach osteotomy and posterior triceps split- type indicate references published to the distal humerus for internal fix- ting approach for complex fractures of ation. Clin Orthop Relat Res 1997; the distal humerus. J Orthop Trauma within the past 5 years. 340:190-197. 2003;17:368-373.

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