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The anterior deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the preferred approach. Further neurovascular structures, eg, the brachial plexus, are only at risk if there is a rigorous retraction.
Anatomical landmarks for the anterior deltopectoral approach are: A Coracoid process B Proximal humeral shaft on the level of the axilla.
Make a cm long skin incision between the coracoid process and the proximal humeral shaft. For an arthroplasty, a rather vertical incision may be preferred dashed line. The sulcus is slightly more pronounced and in cases of revision surgery less scared. Retract the cephalic vein laterally or medially, and open along the groove.
Shoulder Anterior (Deltopectoral) Approach – Approaches – Orthobullets
If retracted laterally, the anatomical drainage of blood from the deltoid muscle is respected but it is at risk of damage by retractors during surgery. In any case, the cephalic vein should be preserved in order to reduce the surgical edema of the limb. Failure to find the deltopectoral groove can lead to difficulty in dissection of the deltoid and possibly to denervation of the anterior portion of the deltoid.
Bluntly dissect between and under the deltoid and pectoralis muscles down to expose the clavipectoral fascia. Identify the coracoid process and the conjoined tendon. Incise the clavipectoral fascia lateral to the conjoined tendon and inferior the coracoacromial ligament.
Retract the deltoid muscle laterally using a delta modified Hohmann retractor and the conjoint tendon medially using a Langenbeck retractor.
AO Surgery Reference
The musculocutaneous nerve enters the coracobrachialis muscle as close as 2. Retractors placed under the conjoined tendon can cause neuropraxia; therefore vigorous retraction must be avoided. Expose the proximal humerus and confirm the anatomical landmarks subscapularis tendon, lesser tuberosity, bicipital groove with the bicipital tendon and the greater tuberosity.
Evaluate the fracture morphology. Hemorrhagic bursa tissue has to be resected if needed. Satisfactory reduction of anatomical neck fractures eg, C1.
Access is improved by doing an osteotomy of the coracoid process to allow reflection of the deltopextoral and biceps muscles. Drill the coracoid first for later fixation.
Take care regarding the musculocutaneous nerve and underlying brachial plexus. The subscapularis tendon is identified and divided vertically lateral to the musculotendinous junction.
Remember the axillary nerve just distal to the subscapularis and medial to the proximal humerus. Reflect the subscapularis from the underlying joint capsule and enter the joint through a vertical capsulotomy, medial to the lateral stump of subscapularis.
The arthrotomy is repaired by suture closure of the capsule and deltopechoral the subscapularis. The coracoid is repaired with a screw or sutures placed through the drill hole.
Shoulder Anterior (Deltopectoral) Approach
Placement of a drainage underneath the deltoid abrodaje might be considered. Close the deltopectoral groove, the subcutaneous tissues and the skin. Indication The anterior deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the preferred approach. This approach is also highly recommend for revision surgery.