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. More videos of surgical techniques of the shoulder can be found. The deltopectoral approach is an anterior approach to the shoulder that utilizes. Surgical approaches to distal humerus fractures dr.
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. Deltoidsplit or deltopectoral approaches for the treatment. There are two options when choosing the surgical approach for locking plate fixation to treat proximal humerus fractures phf. Overview this approach can be a fairly extensile exposure, allowing access to the anterior, medial, and lateral aspects of the shoulder. Comparison of lateral deltoid splitting and deltopectoral. Humeral exposure of the anterior deltopectoral approach with ruler and area measurement outline. The deltopectoral approach is the workhorseexposurefortheproximal humerus. Review article metaanalysis comparing deltoidsplitting. Position plate the positioning of the philos long requires a partially lateral section of the deltoid muscle. In rare occasions, this sulcus is absent and the two muscles merge.
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. This approach has recently been popularized for the copeland resurfacing and delta reversegeometry prostheses. This approach provides only limited access to the posterolateral aspect of the shoulder and the view of a retracted greater. Pdf management of proximal humerus fractures in adults.
In this prospective randomized study, we aimed to investigate whether the deltoidsplit approach is superior to the deltopectoral approach with regard to 1. Dec 11, 20 proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. Steven klepps, md, joshua auerbach, md, oren calhon, ms, jason lin, ms, edmond cleeman, md, evan flatow, md. Deltopectoral approach to the shoulder lennard funk manchester. Surgical approaches in shoulder arthroplasty intechopen. The anterosuperior approach for reverse shoulder arthroplasty. Metaanalysis comparing deltoidsplitting approach with. The use of a modified anterolateral deltoid splitting approach with axillary nerve bundle mobilization in the treatment of proximal humeral fractures yielded excellent outcomes.
Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal humeral fractures. Pdf the deltopectoral approach for reverse shoulder. Distal humeral component distal end accepts bearing insert, axle bushing and axle pin and provides an. Learn about the humerus deltopectoral approach, an online 3dvideobased course, accredited by the royal college of surgeons of england. Failure to find the deltopectoral groove can lead to difficulty in dissection of the deltoid and. Alternatively, the plate can also be advanced into the middle of the muscle insertion. 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 extended deltoidsplitting approach to the proximal. The anterior deltopectoral approach to the proximal humerus slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Humeral neck exposure substep structure actions specification 3a skin incise extend the incision proximally, lateral to the coracoid process. The vdo demonstrated the deltopectoral approach in shoulder surgery. Philos proximal humerus interlocking system approach. By extending the traditional approach, some proximal humerus fractures requiring a more posterior route can be treated. An anterosuperior approach for proximal humeral fractures. May 03, 2009 open reduction and internal fixation of displaced pediatric lateral condyle fractures of the humerus duration. Open reduction and internal fixation proximal humeral fractures hemiarthroplasty for trauma usually dont need to extend below axillary nerve see antero superior, mckenzie 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. In these cases, it is possible to combine the anterosuperior approach. Management of proximal humerus fractures in adults europe.
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. A lateral approach to the distal humerus following. The cephalic vein is the landmark for this interval. The most common location of proximal fractures is at the surgical neck of the humerus. The deltopectoral approach for exposure of the anterior and lateral shoulder region has been most commonly used for plating of the proximal humerus. Deltopectoral vs deltoid split approach for proximal humerus. 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.
The deltopectoral approach is commonly used for surgical treatment of proximal humerus fractures. Jan 28, 2016 it was only necessary to develop the proximal portion because dissection to the forearm was unnecessary for the approach. Univers ii techniques surgical approach, part 1 with dr. Deltopectoral vs deltoid split approach for proximal. Extended anterolateral approach cambridge orthopaedics. The deltopectoral approach is useful for open reduction and internal fixation of a proximal humeral fracture. Displaced and unstable fractures of the proximal humerus are notoriously difficult to manage. The deltopectoral approach for reverse shoulder arthroplasty. Because of increasing incidence of high velocity trauma. Among proximal fractures, 80% are onepart, 10% are twopart, and the remaining 10% are three and fourpart. Extensive dissection anteriorly may further compromise humeral head blood supply see, anterior circumflex humeral artery, humeral head blood supply. With the deltopectoral approach, the humeral osteotomy should be. Anterior approach to the humerus orthopaedicsone articles. Expose the proximal humerus and confirm the anatomical landmarks subscapularis tendon, lesser tuberosity, bicipital groove with the bicipital tendon and the greater tuberosity.
Surgical anatomy of the radial nerve in the deltopectoral. Figures 18a, 18b approximate the location of the anatomic neck. The deltopectoral approach is sometimes associated with soft tissue injury and impaired blood supply to the proximal humerus. Pdf anatomical variation in formation of brachial plexus. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. 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. This approach develops the internervous plane between the deltoid axillary nerve and the pectoralis major medial and lateral pectoral nerves. 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. 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.
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. There is currently insufficient evidence to suggest superiority of one treatment option over the others. 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. Despite the advantages described above, the most outstanding advantage of the minimally invasive approach is. Nonoperative management is associated with good outcomes in the majority of proximal humerus fractures in adults. 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. Remember the axillary nerve just distal to the subscapularis and medial to the proximal humerus. This approach is a useful alternative to the deltopectoral or the deltoid splitting approaches in the treatment of proximal humeral fractures. 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. The anterolateral acromial approach for fractures of the proximal. Deltopectoral approach proximal humeral fracture demo by. The system design is based on clinical input from an international panel of experienced surgeons, data from literature, and both practical and.
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. 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. 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. Lcp posterolateral distal humerus plates, with support and lcp medial distal humerus plate duration. Shoulder lateral deltoid splitting approach approaches. 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 humerus 9.
Indications include an unacceptable deformity, need for stability and early mobilization, and osteoporotic bone. In 15 cases 83% it emerged directly from the posterior compartment into the subcutaneous tissue and perforated the posterior brachial. In this case the patient had severe proximal humeral fracture which was operated by proximal humeral locking plate. 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. The cephalic vein is identified proximally and usually retracted laterally while exposing the deltopectoral plane. 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. 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.
Standard deltopectoral approach was used and dissection was carried down to the fracture site. Request pdf the anterolateral acromial approach for fractures of the. Deltopectoral interval and the cephalic vein and in. Shoulder hemiarthroplasty for proximal humeral fractures. A minimally invasive approach for plate fixation of the. A cadaveric study on the anatomy of the deltoid insertion and. Jan 12, 2014 surgical approaches to distal humerus fractures dr. In vivo, manual rotation of the humerus following each exposure. Proximal humerus plating system is designed to provide intraoperative flexibility and efficiency to the surgical team. Any surgical intervention should have clear aims and indications and the appropriate technique should be selected for each individual patient. Approach the approach must normally be lengthened because of the plate. All procedures were performed by 2 fellowshiptrained shoulder surgeons who perform a high volume of shoulder arthroplasty.
For displaced fractures that meet surgical indications, the traditional deltopectoral approach is the most common approach for plate fixation of proximal humeral fractures. As the most commonly used approach in the shoulder, deltopectoral approach is used for reduction and internal fixation of proximal humerus fractures, to. Ligation of circumflex vessels move the richardson retractor more distally along the conjoined tendon to better expose the anterior humeral circumflex vessels aka three sisters. 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. Lateral deltoid splitting approach, by exploring the axillary nerve, is a useful surgical technique which provides an expansive and multidimensional control without risking the deltoid muscle function and. Curve it inferiorly, following the lateral border of the biceps. Deltopectoral interval and the cephalic vein and in are identified. A cadaveric study on the anatomy of the deltoid insertion and its relationship to the deltopectoral approach to the proximal humerus. The use of precontoured proximal humerus locked plates has yielded excellent results, with enhanced fixation in osteoporotic bone. This video demonstrates the surgical technique for a deltopectoral approach of the shoulder.
Proximally directed force on the elbow while the arm is in extension. The approach can be extended into an anterolateral approach to the humerus. 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.
The fracture site was identified and fragments were mobilized and the humeral head fragments removed. A 66yearold sustained a left proximal humerus fracture. Approach ligation of the anterior humeral circumflex vessels figure 18a. The anterolateral approach to the humerus provides excellent exposure to the humeral shaft, especially to more proximal aspects. Bimodal anterolateral and lateral approach for distal humerus shaft fracture clinics in orthopedic surgery vol. Supine extensile approach to the anterolateral humerus. The anteriorportion iscontiguousto the clavicularheadof the pectoralis major, only separated by the deltopectoral sulcus hosting the cephalic vein. 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. Combining screws in the hybrid configuration used in the present study did not. Once this was done, the stem was prepared up to a size 10. 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.
Open reduction and internal fixation with a locking plate. In rare occasions, this sulcus is absent and the two muscles merge together. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. 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.
As incidence increases worldwide, further increased incidence for proximal humeral fractures can be expected as a result of an aging society. One of the structures at risk during this approach. Oct 11, 2019 the authors preferred technique is an open reduction through the deltopectoral approach using a precontoured proximal humerus locking plate for fixation. Proximal humeral fractures can be addressed with different approaches, depending on the type of fracture, surgical technique, bone quality, patients needs, and. Deltopectoral approach it is more commonly used approach. Learn about the humerus anterior approach brachial split, an online 3dvideobased course, accredited by the royal college of surgeons of england. Debate exists over the optimal approach for addressing fractures of the proximal humerus. The pectoralis fascia is incised lateral to the tendon of the short. A modified deltoid splitting approach with axillary nerve. From the shoulder injury clinic, royal infirmary of edinburgh, little. 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.
Advantage of minimally invasive lateral approach relative. Management of proximal humerus fractures in adults f6publishing. 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. A number of studies have revealed very good functional results in conservatively managed minimally displaced, stable fractures of the proximal humerus 10,18,24. Anatomical variation in formation of brachial plexus.
The anterior deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the preferred approach. Such fractures were classified by neer as group i fractures, and were estimated to comprise over 85% of all proximal humerus fractures. 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. Deltoidsplit or deltopectoral approaches for the treatment of displaced proximal. Incidence of proximal fractures increases with age, with about 75% of cases occurring among people over the age of 60.
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