Standard deltopectoral approach was used and dissection was carried down to the fracture site. If you continue browsing the site, you agree to the use of cookies on this website. We help you diagnose your proximal humerus case and provide detailed descriptions of how to manage this and hundreds of other pathologies. The rotator cuff surrounding the proximal humerus is at high risk of being simultaneously injured by the fracture, which is a critical factor that leads to pain, engorgement, and limitation of motion of the shoulder after the operation. Proximal humeral fractures can be addressed with different approaches, depending on the type of fracture, surgical technique, bone quality, patients needs, and. Oct 11, 2019 the authors preferred technique is an open reduction through the deltopectoral approach using a precontoured proximal humerus locking plate for fixation.
For displaced fractures that meet surgical indications, the traditional deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. Residents who recently specialized in shoulder surgery primarily chose the deltopectoral approach, especially when the fracture was associated with dislocation 86. The majority of proximal humerus fractures are lowenergy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The extended deltoidsplitting approach to the proximal. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. A cadaveric study on the anatomy of the deltoid insertion and its relationship to the deltopectoral approach to the proximal humerus. Review article metaanalysis comparing deltoidsplitting. Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. In vivo, manual rotation of the humerus following each exposure. The deltoid split ds approach, developed according to minimally invasive surgery principles, and the classic deltopectoral dp approach, believed to increase the risk of avascular necrosis and making access to the greater tuberosity more dif.
Proximally directed force on the elbow while the arm is in extension. Indications include an unacceptable deformity, need for stability and early mobilization, and osteoporotic bone. The approach can be extended into an anterolateral approach to the humerus. The deltopectoral approach is commonly used for surgical treatment of proximal humerus fractures. Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal. The deltopectoral approach for reverse shoulder arthroplasty. Remember the axillary nerve just distal to the subscapularis and medial to the proximal humerus. In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1. May 03, 2009 open reduction and internal fixation of displaced pediatric lateral condyle fractures of the humerus duration. This approach is a useful alternative to the deltopectoral or the deltoid splitting approaches in the treatment of proximal humeral fractures. Figures 18a, 18b approximate the location of the anatomic neck. Surgical anatomy of the radial nerve in the deltopectoral.
Management of proximal humerus fractures in adults europe. Proximal humerus plating system is designed to minimize the risk of some of the complications commonly associated with treating proximal humerus fractures by its design to. Incidence of proximal fractures increases with age, with about 75% of cases occurring among people over the age of 60. In addition, the approach can be extended both proximally and distally, providing the surgeon a dynamic exposure to the humerus for the treatment of fractures and other pathologies. Deltopectoral approach proximal humeral fracture demo by. The use of a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures yielded excellent outcomes.
Management of proximal humerus fractures in adults f6publishing. Debate exists over the optimal approach for addressing fractures of the proximal humerus. 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. Shoulder hemiarthroplasty is considered to be the gold standard option for complex proximal humeral fractures, particularly in patients with 3 or 4part fractures, osteoporotic fractures, or nonviable headsplitting fractures. A number of studies have revealed very good functional results in conservatively managed minimally displaced, stable fractures of the proximal humerus 10,18,24. 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. Deltopectoral approach to the shoulder lennard funk manchester. The anteriorportion iscontiguousto the clavicularheadof the pectoralis major, only separated by the deltopectoral sulcus hosting the cephalic vein. Approach ligation of the anterior humeral circumflex vessels figure 18a. Proximal humerus plating system is designed to provide intraoperative flexibility and efficiency to the surgical team. Humerus anterior approach brachial split incision academy.
The anterolateral acromial approach for fractures of the proximal. The anterolateral approach to the humerus provides excellent exposure to the humeral shaft, especially to more proximal aspects. Deltopectoral interval and the cephalic vein and in. In rare occasions, this sulcus is absent and the two muscles merge together. Jan 28, 2016 it was only necessary to develop the proximal portion because dissection to the forearm was unnecessary for the approach. Shoulder hemiarthroplasty for proximal humeral fractures. Pdf management of proximal humerus fractures in adults.
Approach the approach must normally be lengthened because of the plate. Deltoid splitting approach, especially with aoasif b and c type fractures, enables reduction and plate fixing under 270 degree control of the proximal humerus without forceful retraction and soft tissue damage, providing easy access to posterior tubercular fragment. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3 and 4part proximal humeral fractures. One of the structures at risk during this approach. Deltoidsplit or deltopectoral approaches for the treatment. Surgical approaches to distal humerus fractures dr. Learn about the humerus deltopectoral approach, an online 3dvideobased course, accredited by the royal college of surgeons of england. Any surgical intervention should have clear aims and indications and the appropriate technique should be selected for each individual patient. Overview this approach can be a fairly extensile exposure, allowing access to the anterior, medial, and lateral aspects of the shoulder. The use of precontoured proximal humerus locked plates has yielded excellent results, with enhanced fixation in osteoporotic bone. The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Extensive dissection anteriorly may further compromise humeral head blood supply see, anterior circumflex humeral artery, humeral head blood supply.
All procedures were performed by 2 fellowshiptrained shoulder surgeons who perform a high volume of shoulder arthroplasty. Modified combined approach for distal humerus shaft fracture. Anterior approach to the humerus orthopaedicsone articles. 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. Dec 11, 20 proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The vdo demonstrated the deltopectoral approach in shoulder surgery. Pdf anatomical variation in formation of brachial plexus. A 66yearold sustained a left proximal humerus fracture. Deltopectoral vs deltoid split approach for proximal. Nov 17, 2019 in proximal humerus fractures, the severity is often described by how many of the major parts of the proximal humerus fracture are displaced. There is currently insufficient evidence to suggest superiority of one treatment option over the others. Bimodal anterolateral and lateral approach for distal humerus shaft fracture clinics in orthopedic surgery vol.
Request pdf the anterolateral acromial approach for fractures of the. With the deltopectoral approach, the humeral osteotomy should be. Distal humeral component distal end accepts bearing insert, axle bushing and axle pin and provides an. The cephalic vein is identified proximally and usually retracted laterally while exposing the deltopectoral plane. A lateral approach to the distal humerus following. The most common location of proximal fractures is at the surgical neck of the humerus. 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. Among proximal fractures, 80% are onepart, 10% are twopart, and the remaining 10% are three and fourpart. Proximal lateral tibial plate the axsos locking plate system is designed to treat periarticular or intraarticular fractures of the proximal humerus, distal femur, proximal tibia, and the distal tibia. Such fractures were classified by neer as group i fractures, and were estimated to comprise over 85% of all proximal humerus fractures. Humeral neck exposure substep structure actions specification 3a skin incise extend the incision proximally, lateral to the coracoid process.
Pdf the deltopectoral approach for reverse shoulder. In 15 cases 83% it emerged directly from the posterior compartment into the subcutaneous tissue and perforated the posterior brachial. Steven klepps, md, joshua auerbach, md, oren calhon, ms, jason lin, ms, edmond cleeman, md, evan flatow, md. Despite the advantages described above, the most outstanding advantage of the minimally invasive approach is. Deltopectoral approach it is more commonly used approach. 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. 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. In these cases, it is possible to combine the anterosuperior approach. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. Combining screws in the hybrid configuration used in the present study did not. The deltopectoral approach is an anterior approach to the shoulder that utilizes. More videos of surgical techniques of the shoulder can be found. The deltoid split ds approach, developed according to minimally invasive surgery principles, and the classic deltopectoral dp approach, believed to increase the risk of avascular necrosis and making access to the. The system design is based on clinical input from an international panel of experienced surgeons, data from literature, and both practical and.
The anterior deltopectoral approach to the proximal humerus slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder. Open reduction and internal fixation with a locking plate. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. Advantage of minimally invasive lateral approach relative.
This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses. Failure to find the deltopectoral groove can lead to difficulty in dissection of the deltoid and. As incidence increases worldwide, further increased incidence for proximal humeral fractures can be expected as a result of an aging society. Surgical approaches in shoulder arthroplasty intechopen. We describe the surgical technique for the dp approach for primary and revision. Compared to deltopectoral approach, patients treated with deltoid splitting approach achieved higher constant scores at an earlier stage. There are four parts of the proximal humerus, so a displaced fracture can either be 2part, 3part, or 4part a nondisplaced fracture is, by definition, 1part. In rare occasions, this sulcus is absent and the two muscles merge.
As the most commonly used approach in the shoulder, deltopectoral approach is used for reduction and internal fixation of proximal humerus fractures, to. The upper or proximal extremity of the humerus consists of the bones large rounded head joined to the body by a constricted portion called the neck, and two eminences, the greater and lesser tubercles. Several authors have concluded that elevating the anterior insertion of the deltoid or the lateral edge of the pectoralis is often required when plating the proximal humerus through a deltopectoral approach. Philos proximal humerus interlocking system approach. Univers ii techniques surgical approach, part 1 with dr. As the most likely location for iatrogenic injury during revision shoulder arthroplasty and the placement of cerclage wires around the humerus, the position of the radial nerve entry into the proximal spiral groove relative to anatomic landmarks pertinent to the deltopectoral approach has not been previously described. Open reduction and internal fixation orif via the deltopectoral approach is the gold standard for operatively treated proximal humeral fractures when joint preservation is desired. Extended anterolateral approach cambridge orthopaedics.
Anatomical variation in formation of brachial plexus. Comparison of lateral deltoid splitting and deltopectoral. Humeral exposure of the anterior deltopectoral approach with ruler and area measurement outline. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. This approach provides only limited access to the posterolateral aspect of the shoulder and the view of a retracted greater. The pectoralis fascia is incised lateral to the tendon of the short. Extend the skin incision down the deltopectoral groove. Lcp posterolateral distal humerus plates, with support and lcp medial distal humerus plate duration. Advantage of minimally invasive lateral approach relative to.
There are two options when choosing the surgical approach for locking plate fixation to treat proximal humerus fractures phf. The deltopectoral approach is sometimes associated with soft tissue injury and impaired blood supply to the proximal humerus. Alternatively, the plate can also be advanced into the middle of the muscle insertion. A minimally invasive approach for plate fixation of the. Supine extensile approach to the anterolateral humerus. The shoulder anterior deltopectoral approach is indication in. From the shoulder injury clinic, royal infirmary of edinburgh, little. In this case the patient had severe proximal humeral fracture which was operated by proximal humeral locking plate. A modified deltoid splitting approach with axillary nerve. An anterosuperior approach for proximal humeral fractures. The deltopectoral approach is useful for open reduction and internal fixation of a proximal humeral fracture.
The anterior deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the preferred approach. 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. Learn about the humerus anterior approach brachial split, an online 3dvideobased course, accredited by the royal college of surgeons of england. May 17, 2014 the standard deltopectoral approach is extremely versatile and makes it possible to achieve fracture reduction and fixation and to implant a prosthesis if necessary. Shoulder lateral deltoid splitting approach approaches.
Expose the proximal humerus and confirm the anatomical landmarks subscapularis tendon, lesser tuberosity, bicipital groove with the bicipital tendon and the greater tuberosity. Displaced and unstable fractures of the proximal humerus are notoriously difficult to manage. A cadaveric study on the anatomy of the deltoid insertion and. Curve it inferiorly, following the lateral border of the biceps. The anterosuperior approach for reverse shoulder arthroplasty. Background the deltopectoral approach is a welldescribed surgical approach to the proximal humerus and glenohumeral joint. 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. Position plate the positioning of the philos long requires a partially lateral section of the deltoid muscle. Nonoperative management is associated with good outcomes in the majority of proximal humerus fractures in adults. This approach develops the internervous plane between the deltoid axillary nerve and the pectoralis major medial and lateral pectoral nerves.
By extending the traditional approach, some proximal humerus fractures requiring a more posterior route can be treated. Mrs upper extremity surgical protocol mrs distal humerus the mrs distal humerus and ulna system is designed for a universal fit with the mrs proximal humerus system and solar ulna components. The transdeltoid or the deltoid splitting approach obviates some of the disadvantages of the deltopectoral approach and provides convenient access to the lateral surface of the proximal humerus. Deltopectoral vs deltoid split approach for proximal humerus. The cephalic vein is the landmark for this interval.
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