Anatomical study for the treatment of proximal humeral fracture through the medial approach

Abstract

Background The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy. Method Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation. Results The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14–68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67–66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously. Conclusion The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.

Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis

“…Several studies reported that the medial approach for proximal humerus fractures involved a risk of iatrogenic neurovascular injury, especially to the musculocutaneous nerve and posterior humeral circumflex artery. 35,36 The anterior brachial circumflex artery, an important blood supply to the humeral head, runs laterally along the inferior border of the subscapularis tendon directly. This can be at risk during the DP approach, especially if the anatomy is distorted by the fracture.…”

Physiological Offset Parameters of the Adult Shoulder Joint—A MRI Study of 800 Patients

“…Humeral offset (HO) and glenoidal offset (GO) parameters are important morphological parameters in diagnostics and in therapy for shoulder pathologies. Humeral head preserving surgery remains the current state-of-the-art surgery for younger patients in the case of a fracture [ 1 , 2 ]. Likewise, arthroplasty of the shoulder joint is increasingly gaining importance in the treatment of degenerative and traumatic shoulder pathologies, especially in older patients [ 3 , 4 , 5 , 6 ].…”