This document describes three posterior surgical approaches to the humerus: 1) The posterior approach to the proximal humerus, which exposes the bone between the lateral head of the triceps and deltoid muscles. Key structures include the axillary nerve and posterior circumflex humeral artery proximally and the radial nerve distally. 2) The posterolateral approach to the distal humeral shaft, which is a modified lateral approach between the brachioradialis and triceps muscles. 3) The posterior approach for the middle two-thirds of the humerus described by Henry, which splits the triceps muscle to access tumors.

1. POSTERIOR APPROACH TO
HUMERUS
DR. BIPUL BORTHAKUR (PROF.)
DEPT OF ORTHOPAEDICS, SMCH

2. INTRODUCTION
• 3 BASIC APPROACHES POSTERIORLY
– POSTERIOR APPROACH TO THE PROXIMAL
HUMNERUS
– POSTERIO-LATERAL APPROACH TO DISTAL
HUMERAL SHAFT
– POSTERIOR APPROACH FOR MIDDLE TWO-THIRD

3. POSTERIOR APPROACH TO THE
PROXIMAL HUMERUS
AXILLARY NERVE AND
POSTERIOR CIRCUMFLEX
HUMERAL ARTERY
RADIAL NERVE AND
PROFUNDA BRACHII ARTERY
LATERAL HEAD OF TRICEPS
MEDIAL HEAD OF
TRICEPS
LONG HEAD OF TRICEPS

4. • EXPOSES THE BONE THROUGH THE INTERVAL
BETWEEN
– LATERAL HEAD OF TRICEPS
– DELTOID
• 8cm BONE CAN BE EXPOSED APPROX.

5. • EXTENT OF THE APPROACH
1. PROXIMALLY-
 AXILLARY NERVE
 POSTERIOR CIRCUMFLEX HUMERAL ARTERY
2. DISTALLY-
 ORIGIN OF TRICEPS FROM LATERAL BORDER OF
SPIRAL GROOVE
 UNDERLYING RADIAL NERVE

6. TECHNIQUE
• POSITION – LATERAL WITH EXTRIMITY
DRAPED FREE AND POSITIONED ACROSS THE
CHEST

7. INCISION
• PROXIMALLY – 5cm DISTAL TO POSTERIOR
ASPECT OF ACROMION
• DISTALLY – LEVEL OF DELTOID TUBEROSITY
• STRAIGHT INCISION OVER INTERVAL BETWEEN
DELTOID AND TRICEPS

8. • INTERVAL DEVELOPED BLUNTLY BETWEEN
LATERAL HEAD OF TRICEPS AND DELTOID
• PERIOSTEUM EXPOSED AND INCISED
LONGITUDINALLY

9. RETRACTION
• MEDIALLY-
– PERIOSTEUM
– LATERAL HEAD OF TRICEPS
• LATERALLY-
– PERIOSTEUM
– DELTOID

10. EXTENDED EXPOSURE
• PROXIMALLY-
– SUBPERIOSTEAL DISSECTION UPTO ORIGIN OF
LATERAL HEAD OF TRICEPS
– STRUCTURE TO BE PROTECTED
• AXILLARY NERVE
• POSTERIOR CIRCUMFLEX ARTERY

11. • DISTALLY-
– INSERTION OF DELTOID PARTIALLY RTELEASED
– STRUCTURE TO BE PROTECTED
• RADIAL NERVE

12. AXILLARY NERVE & POST.
CIRCUMFLEX ARTERY
RADIAL NERVE AND PROFUNDA
BRACHII ARTERY
LONG HEAD OF TRICEPS
LATERAL HEAD OF TRICEPS
DELTOID
HUMERUS
DELTOID TUBEROSITY

13. POSTEROLATERAL APPROACH TO
DISTAL HUMERAL SHAFT
• MODIFIED LATERAL APPROACH
• INTERVAL BETWEEN BRACHIORADIALIS AND
TRICEPS
• DOESN’T INVOLVE SPLITTING OF TRICEPS

15. TECHNIQUE
• POSITION – PRONE OR LATERAL
PRONE POSITION
LATERAL POSITION

16. • INCISION-
– LONGITUDINAL
– 15-18cm LONG
– POSTEROLATERAL ASPECT OF ARM

18. • EXTENT
– DISTALLY MIDWAY BETWEEN
• LATERAL EPICONDYLE
• TIP OF OLECRANON
• 4cm DISTAL TO ELBOW JOINT
– PROXIMALLY
• 4cm POSTERIOR TO LATERAL INTERMUSCULAR SEPTUM

19. • DISSECTION
– FROM MID-POINT OF THE WOUND
– LATERALLY TILL LATERAL INTERMUSCULAR
SEPTUM
– TRICEPS FASCIA INCISED LONGITUDINALLY
– FASCIA INCISED AT LATERAL EDGE OF ANCONEUS
– UPTO 4cm DISTAL TO LATERAL EPICONDYLE

20. S

21. • RETRACTION
– ANCONEUS & FASCIA RETRACTED IN CONTINUITY
WITH TRICEPS
– POST. ANTEBRACHIAL CUT. NERVE IDENTIFIED &
PROTECTED
– RADIAL NERVE RETRACTED ANTERIORLY
– TRICEPS RETRACTED MEDIALLY

23. • CLOSURE
– TRICEPS ALLOWED TO FALL INTO IT’S BED
– FASCIA CLOSED LOOSELY WITH INTERRUPTED
SUTURES

24. POSTERIOR APPROACH FOR MIDDLE
TWO-THIRDS
• HENRY DESCRIBED
• SPLITS THE TRICEPS
• FOR EXCISION OF TUMORS

26. THANK YOU
“vihāya kāmānyaḥ sarvānpumāṃścarati niḥspṛhaḥ
nirmamo nirahaṅkāraḥ sa śāntimadhigacchati”
“That man attains peace who, abandoning all desires,
moves about without longing,
without the sense of mine and without egoism.”