- See:
-
Anterior Approach to the Humerus
-
Axillary Approach:
-
Posterior Approach
-
Posterior Approach to Humerus
-
Surgical Approach for Proximal Humeral Fractures;
- Positioning and Draping:
- supine or beach chair;
- small soft bolster is placed beneath the shoulder blades to protract the shoulder;
- head is stabilized to prevent hyperextension and subsequent brachial plexus palsy;
- place patient in a beach chair position w/ torso flexed 45 deg and the knees flexed to 30 deg;
- in the beach chair position, ensure that the patient is firmly fastened to prevent sliding;
- move patient to the edge of the table (operative side), and use a McConnel positioner
to prevent the patient from failing off the table;
- positioning is optimal when the scapula hangs over the edge of the table;
- place a folded towel under the spine and ipsilateral scapula;
- it is helpful to drape the should w/ a large Ioband sheet w/ a hole cut in the middle;
- several Iobrand strips (2-3 inches in width) are also helpful;
- consider the Mconnel Shoulder Positioner;
- Instruments:
- Balfour Self Retaining Retractor;
- Homan Retractors:
- Fukuda Humeral Head Retractor:
- Gelpi retractors;
- Superficial Dissection:
- Deep Dissection:
-
clavipectoral fascial incision:
- once the deltopectoral interval has been fully developed, the clavipectoral fascia
is exposed (which is most prominent lateral to coracoid muscles);
- clavipectoral fascia is differentiated from the deeper tissues, because it will
not move with internal and external rotation;
- tip of the coracoid and the conjoined tendon (short head of
biceps and the
coraco-brachialis) is identified;
- clavipectoral fascia is then divided vertically just lateral to the conjoined tendon, up
to coracoacromial ligament, exposing
subscapularis tendon & lesser tuberosity.
- proximally, the fascia is divided at a point just lateral to the coracoid;
- the incision is carried distally to the level of the
anterior circumflex;
- these vessels mark the level of the subscapularis tendon;
-
identification of the musculocutaneous nerve:
-
musculocutaneous nerve can usually be palpated on deep surface of coracobrachialis;
- nerve enters posterior of coracobrachialis about 5 cm distal to coracoid tip but can be as close as 1 to 2 cm;
-
identification of the axillary nerve:
-
retraction:
- often a "Charnley type" of self retaining retractor is inserted underneath the deltoid medially and the coracobrachialis laterally;
-
coraco-acromial ligament:
- in patients w/ traumatic arthritis or DJD, the shoulders may be tight and therefore, the ligament can be
partially incised for better exposure of the upper portion of the subscapularis;
- in patients w/ rheumatoid arthritis or cuff tear arthropathy, excision of the CA ligament may destabilize the shoulder arthroplasty;
- Transection of the Subscapularis:
-
subscapularis tendon and the underlying joint capsule are divided approximately 1 cm medial to the lesser tuberosity;
- medial retraction of the tendon and capsule will expose the glenoid;
- Caspsular Transection:
- external rotation of the humerus affords better capsular exposure and relaxes the nerve;
- insert a blunt retractor inferiorly to protect the
axillary nerve, insert two single pronged
skin hooks to elevate the capsule superiorly and place it under tension;
- vertically transect the capsule at a point midway between the lesser trochanter and the edgle of the glenoid;
- carry this vertical capsular incision superiorly into the rotator interval, which converts the
capsular incision into a T (since the rotator interval lies in a horizontal direction);
- at the end of the case, the superior and inferior capsular capsular flaps are closed (and shortened)
inorder to shift the inferior capsule in a superior direction;
- the vertical portion of the incision is closed anatomically (so that there will be no loss of external rotation);
- Distal Exposure:
- lower part of shaft is exposed by incising
brachialis longitudinally along lateral border of
biceps;
- lowest part of the front of the shaft can be approached between
brachioradialis which is retracted laterally and
brachialis
which is retracted medially;
