Article in clinical orthopaedics and related research 4725 december 20 with 206 reads. Minimally invasive plate osteosynthesis with a locking. A minimally invasive approach for plate fixation of the. Surgical approach of open reduction and internal fixation. Open repair of an anterior humeral avulsion of the. An anterosuperior approach for proximal humeral fractures.
The transdeltoid approach allows better access to the greater tuberosity and might facilitate periprosthetic reconstruction of. The axillary nerve can be palpated at the lower margin of the incision. B, cephalic vein as the indicator of deltopectoral interval. Curve it inferiorly, following the lateral border of the biceps. Do you want to use the redesigned ao sr like an app. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. Furthermore, excessive soft tissue stripping destroys the local blood supply and integrity of the deltoid, which may increase the risk of avascular necrosis and. A, the skin incision follows the deltopectoral groove and then the medial edge of the biceps muscle.
Background the deltopectoral approach is a welldescribed surgical approach to the proximal humerus and glenohumeral joint. For complex and unstable fractures locking proximal. Many surgeons are familiar with this procedure, but certain steps are still controversial. The key to achieve successful reduction in a 3part proximal humeral fracture is to try to convert a 3part fracture into a 2part fracture. Drawings illustrating the positioning of the patient and the skin incision for the infraclavicular approach. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1. Show full abstract macroscopic features and biomechanical behavior were analyzed on dynamic videos obtained during forearm rotation. 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. 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. One of the structures at risk during this approach is the axillary nerve. 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. For oncology applications, a modified deltopectoral approach to the proximal humerus is most often utilized.
The humerus articulates with the scapula proximally at the glenohumeral joint so it participates in the movements of the shoulder. Your browser does not currently recognize any of the video formats available. Ao surgery reference is a resource for the management of fractures, based on current clinical principles, practices and available evidence. 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. It consists of a proximal end, a shaft and a distal end, all which contain important anatomical landmarks. Learn about the humerus anterior approach brachial split, an online 3d video based course, accredited by the royal college of surgeons of england. Read deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. Surgical anatomy of the radial nerve in the deltopectoral.
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. Deltoidsplit or deltopectoral approaches for the treatment. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary nerve. 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. Dec 11, 20 proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society.
It provides excellent humeral exposure and preserves the deltoid origin, making it an ideal. Infraclavicular approach to the brachial plexus operative. Fibular strut graft augmentation for open reduction and. More videos of surgical techniques of the shoulder can be found. 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. For complex and unstable fractures locking proximal humerus plate. Live reverse total shoulder arthroplasty using a deltopectoral approach. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Arthroscopic removal of proximal humerus plates in chronic post. Superficially, the deltoid is split between the anterior and middle fibers in line with the skin incision video 1. However, many complications still occur with use of the phlp, such as avascular necrosis of.
The pectoralis fascia is incised lateral to the tendon of the short. Phillos proximal humerus locked plate proximal humerus multiple locked plate duration. This article is conceived as a toolkit for the inexperienced surgeons, describing our. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. 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. 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. The use of minimally invasive plate osteosynthesis mipo via anterolateral deltoid splitting has good outcomes in the management of proximal humerus fractures. 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. A prospective randomized study hura study orthopaedic trauma association 9400 w. The incidence of proximal humeral fracture is increasing gradually. Deltopectoral versus deltoid split approach for proximal humerus fracture fixation with locking plate. Subclavian vein thrombosis and fatal pulmonary embolism after. 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.
Approach a deltopectoral or transdeltoid approach is recommended. Debate exists over the optimal approach for addressing fractures of the proximal humerus. The proximal humeral locking plate phlp is a recently developed fixedangle implant that. Click here to visit our frequently asked questions about html5. The anterior humeral circumflex artery is seen here and must be ligated. The cephalic vein is identified proximally and usually retracted laterally while exposing the deltopectoral plane. Proximal humeral hemiarthroplasty is indicated for displaced three and fourpart fractures in elderly patients, fourpart fracture dislocations, headsplitting fractures and fractures that. 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. Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft. Unusual anatomic variant of the axillary nerve challenging. 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. Jan 16, 2015 the deltopectoral approach is a common surgical procedure for shoulder arthroplasty. The fracture site was identified and fragments were mobilized and the humeral head fragments removed.
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. This video demonstrates a technique for rsa for fracture using a tensionable suture construct placed circumferentially. 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. Advantage of minimally invasive lateral approach relative to. 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. This study aimed to evaluate the pros and cons of the minimally invasive lateral approach for the treatment of proximal humeral. Proximal extension can be obtained by developing the anterior approach to the shoulder with full deltopectoral dissection.
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. 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. Sound knowledge of surface anatomy is essential before any skin incision can be made. 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. Radius distal dorsal approach surgery video general. 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. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. If you would like a large, unwatermarked image for your web page or blog, please purchase the appropriate license. New position and landmark for the deltopectoral approach. Shoulder arthrodesis in the management of glenohumeral. Proximal humerus orif exposure and reduction techniques.
Anterior approach to the humerus orthopaedicsone articles. Immediate hemiarthroplasty remains the accepted treatment for 4part fracture dislocation. May 25, 20 ubc medicine neurology clinical skills motor, sensory, and reflex examination duration. The approach can be extended into an anterolateral approach to the humerus.
Deltopectoral approach to the shoulder lennard funk manchester. 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. Proximal humerus fracture fixation may be complicated by persistent. May 03, 2009 dorsal approach and plating of a proximal rd radius fracture. This article is from the open orthopaedics journal, volume 5. The diagnosis of a hagl lesion is particularly challenging. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder. You may not embed one of our images on your web page without a link back to our site. Im nailing and open reduction internal fixation can be done with anterolateral deltoid split rather than deltopectoral approach. Extraarticular proximal humeral fracture case for small group discussion. Up next principles of orif for proximal humerus fractures duration. Deltopectoral versus deltoid split approach for proximal. Humerus anterior approach brachial split incision academy. Electrophysiological assessment of the deltoid muscle after.
Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. Various articles have reported successful outcomes using the phlp when compared with other implant designs. Once this was done, the stem was prepared up to a size 10. Uses this approach is preferred for shoulder arthroplasty and for plateand screw fixation of proximal humeral fractures because it affords. The deltopectoral approach, first described by henry in 1957, is the workhorse to the shoulder that allows for extensile exposure. Autoplay when autoplay is enabled, a suggested video will automatically play next. Orthopedic trauma incl pediatrics your digital gateway to expertise, education, and innovation. Article information, pdf download for the deltoid lift. For displaced fractures that meet surgical indications, the traditional deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. Advantage of minimally invasive lateral approach relative. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated.
Deltoidsplit or deltopectoral approaches for the treatment of. A 66yearold sustained a left proximal humerus fracture. This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses. In fractures of the proximal humerus which consist of an anterior fragment one should take care to analyze the fracture pattern.
By current concepts in joint replacement featuring gilles walch. 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. 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. This approach has been described previously and, hopefully, the online video presentation will aid the novice peripheral nerve surgeon with this often difficult operation.
Its upper surface is rounded and marked by three flat impressions. The deltopectoral approach 10, 44 is the most commonly used approach for shoulder arthroplasty. Philos proximal humeral internal locking system plate length 90 mm, short, 3 shaft holes x41. Abstract the minimal anterolateral acromial approach offers a less invasive access to the proximal humerus. Functional impairment following this procedure may be caused by paresis of the deltoid muscle as a result of iatrogenic injury to the axillary ne. Fourpart fracture dislocation of the proximal humerus. Deltopectoral approach to shoulder joint netter images.
Upper extremity fracturesdecision making and methods of stabilization. May 12, 2020 the humerus is the longest and largest bone of the upper limb. 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. Shoulder lateral deltoid splitting approach approaches. Thirtythree patients were treated through a deltopectoral approach and 37 through an anterolateral deltoidsplitting approach. To avoid damaging the axillary nerve, do not split. For surgical management, the deltopectoral approach to the proximal humerus is the procedure of choice. 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. This video demonstrates the steps for exposure of the glenohumeral joint and the performance of a total shoulder replacement. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a. The technique described in this article uses the deltopectoral interval. A coracoid process b proximal humeral shaft on the level of the axilla c acromion.
Deltopectoral approach for total shoulder replacement vumedi. 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. Im nail can have less impingement of hardware laterally than a plate. 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. Standard deltopectoral approach was used and dissection was carried down to the fracture site. Electrophysiological assessment of the deltoid muscle. To arrive at an accurate diagnosis, the use of a magnetic resonance arthrogram is suggested along with high clinical suspicion. An anatomic study of the cephalic vein in the deltopectoral shoulder approach.
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