ORIF Humeral Shaft – Anterior Approach
23 year old motorcyclist with totally crushed foot, pelvic injury, pulmonary contusion, head injury, and humeral shaft fracture. Indication to fix humerus – multi-trauma. Fracture was kind of distal, so we could have used the posterior or anterior approach, but with the patient having a bad chest we did it anteriorly. O’Brien calls this the anterolateral approach of Henry, which is in conflict with what Hoppenfeld calls it (the anterior approach). He does make the point that the anterior approach is more difficult for distal humeral shaft fractures because the brachialis is less mobile here, as it is closer to its insertion on the ulna and therefore cannot be lifted off the humerus as readily.
Positioning: Supine with arm-board.
The incision lies along the line from the coracoid to the lateral epicondyle. Biceps is encountered and the lateral aspect is located. This fascia is incised and the biceps is lifted off brachialis. The musculocutaneous nerve is found lying on brachialis medially. It is important to be aware that the radial nerve is piercing the area laterally, lying in a furrow between the brachialis muscle medially and the brachioradialis and extensor carpi radialis longus muscles laterally. This is about 5 cm above the lateral epicondyle.
The brachialis is split in line with the fibers, using tenotomy scissors. This tends to make the muscle bleed a fair amount. Be careful when splitting the brachialis that you can stray medially and get into the vessels.
Get down onto bone and expose. Should get 8 cortices above and below the fracture.
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