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Surgical Exposures of the Humerus 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
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