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Approach to arm

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  • 1. APPROACHES TO HUMERUS DR NAVENDU GOYAL RESIDENT DEPARTMENT OF ORTHOPAEDICS CMC , LUDHIANA
  • 2. ANTERIOR DELTOPECTORAL APPROACH INCISION : - coracoid process running along the deltopectoral groove towards the deltoid insertion. The incision length is dependent on the procedure and build of patient. Deepen into subscapularis fat, expose deltopectoral groove (the cephalic vein and the coracoid are landmarks to the interval).
  • 3. INDICATIONS 1. INTERNAL FXATION OF FRACTURES OF THE HUMERUS 2. OSTEOTOMY OF THE HUMERUS 3. BIOPSY AND RESECTION OF BONE TUMOURS 4. TREATMENT OF OSTEOMYELITIS
  • 4. • PLACE THE PATIENT SUPINE WITH ARM ON ARM BOARD ABDUCTED ABOUT 60 DEGREES • CORACOID PROCESS AND LATERAL BORDER OF BICEPS BRACHII • TIP OF CORACOID  IN LINE OF DELTOPECTORAL GROOVE  TO THE INSERTION OF DELTOID  STOPPED 5 CM ABOVE FLEXION CREASE OF ELBOW.
  • 5. INTERNERVOUS PLANES PROXIMALLY DELTOID (AXILLARY NERVE ) PECTORALIS MAJOR ( MEDIAL AND LATERAL PECTORAL N.) DISTALLY MEDIAL FIBRES OF BRACHIALIS (MUSCULOCUTANEOUS N.) LATERAL FIBRES OF BRACHIALIS ( RADIAL N. )
  • 6. Deltopetoral groove and cephalic vein exposure
  • 7. Identification of tuberosities and humeral head
  • 8. • Expose – subscapularis tendon long head of the biceps. • Distally - expose the pectoralis major. • The musculocutaneous nerve - vigorous retraction must be avoided to prevent neuropraxia .
  • 9. Distal humeral shaft • Split brachialis longitudinally along midline to expose the periosteum • Incise periosteum and strip off brachialis • Flex the elbow to make the task easier
  • 10. Possible complications • Radial nerve damage – 2 main points – a. spiral groove ( dissect the muscle subperiosteally ) b. anterior compartment of the distal 1/3rd Axillary nerve damage – as a compression injury due to vigorous compression Anterior circumflex humeral vessels ligated / subjected to diathermy
  • 11. ANTEROLATERAL APPROACH TO THE HUMERUS (HENRY’S) INCISION distally between biceps and the mobile wad deltopectoral interval proximally Lateral edge of biceps and the anterior edge of the deltoid.
  • 12. SUPERFICIAL DISSECTION Incise fascia – b/w biceps/brachialis and the mobile wad lateral cutaneous nerve of the forearm crossing distally. Radial nerve - identify b/w biceps and the mobile wad Proximally, look for the cephalic vein in deltopectoral interval.
  • 13. SUPERFICIAL DISSECTION CONTD.. Retract the biceps and brachialis medially, and the mobile wad laterally in order to identify radial nerve. Extend the dissection proximally, as needed, to the anterior border of the deltoid and along the deltopectoral interval.
  • 14. DEEP DISSECTION Distally, the anterior humerus has been exposed to the elbow joint, between the mobile wad and brachialis. Mobilize the radial nerve, as needed, to access the bone. Follow the nerve to the point where it passes through the lateral intermuscular septum
  • 15. DEEP DISSECTION CONTD.. Partially release the deltoid insertion anteriorly, if necessary, and retract laterally to access the proximal humerus. Leave as much muscle attached to bone as possible in order to preserve vascularity.
  • 16. LATERAL APPROACH TO THE HUMERAL SHAFT (INDICATIONS) 1. OPEN REDUCTION AND INTERNAL FIXATION OF FRACTURES OF THE LATERAL CONDYLE 2. SURGICAL TREATMENT OF TENNIS ELBOW POSITION : - SUPINE WITH ARM ACROSS THE CHEST
  • 17. LATERAL APPROACH TO THE HUMERAL SHAFT INCISION - deltoid insertion to the lateral epicondyle.
  • 18. SUPERFICIAL DISSECTION
  • 19. DEEP DISSECTION
  • 20. DEEP DISSECTION Find the posterior antebrachial cutaneous nerve,followed proximally to the radial n. (Distally this cutaneous nerve passes through the fascia over brachioradialis.) Develop the interval between the lateral intermuscular septum and triceps, . In the middle third of the humerus find the radial nerve within fat immediately adjacent to the triceps.
  • 21. Deep dissection Follow radial n. b/w brachialis and brachioradialis Retract the nerve to expose the humerus Release intermuscular septum
  • 22. Deep dissection contd.. Follow the radial nerve proximally, posterior to the humerus and anterior to the triceps
  • 23. PROXIMAL EXTENSION OF THE APPROACH Proximally - along the deltopectoral interval OR extended along the posterior deltoid and into the posterior compartment .
  • 24. POSTERIOR APPROACH TO THE HUMERUS (HENRY) INDICATIONS 1. ORIF – FRACTURES OF THE HUMERUS 2. OSTEOMYELITIS TREATMENT 3. BIOPSY AND EXCISION OF TUMOURS 4. TREATMENT OF FRACTURE NONUNION 5. EXPLORATION OF RADIAL NERVE 6. INSERTION OF RETROGRADE HUMERAL NAILS
  • 25. POSITION OF THE PATIENT 2 POSITIONS POSSIBLE 1. LATERAL POSITION . 2. PRONE POSITION WITH ARM ABDUCTED 90 DEGREE .
  • 26. POSTERIOR APPROACH TO THE HUMERUS (HENRY) INCISION Beginning at the tip of the olecranon. proximally in a straight line along the posterior midline of the arm rosses the radial nerve in the mid-humeral region and the axillary nerve proximally to the acromion .
  • 27. Superficial dissection
  • 28. Superficial dissection contd.. By palpation with a finger, identify the interval between the lateral and long heads of the triceps. The opening of this interval will be developed from proximal to distal, remembering that the radial nerve lies beneath the triceps as it crosses the humerus.
  • 29. Deep dissection Develop the proximal interval between the two heads by blunt dissection, retracting the lateral head laterally and the long head medially. Within the spiral groove, identify the radial nerve and profunda brachii artery. Distally, split the common triceps tendon by sharp dissection.
  • 30. Deep dissection contd.. Release the medial head of triceps proximally and incise distally Protect the ulnar nerve medially Dissect proximally and locate the axillary nerve
  • 31. Extending the approach Distal extension Splitting the triceps tendon limits distal exposure, improved by approaching the humerus from the lateral side of this muscle Proximal extension Limited proximal extension, even beyond the axillary nerve, is possible with careful mobilization and retraction of both radial and axillary nerves and their accompanying vessels.
  • 32. POSSIBLE COMPLICATIONS RADIAL NERVE – VULNERABLE N THE SPIRAL GROOVE ULNAR NERVE – LIES DEEP TO MEDIAL HEAD OF TRICEPS , VULNERABLE IF MUSCLE ELEVATED OFF THE HUMERUS PROFUNDA BRACHII ARTERY – LIES WITH RADIAL NERVE IN SPIRAL GROOVE