The modified anterolateral approach to the humerus

Abstract

Introduction: The anterior and anterolateral approaches to the humerus describe splitting brachialis longitudinally, assuming its fibres run parallel to the shaft. Recent improvements in the understanding of brachialis anatomy however have demonstrated it has two distinct heads, with the bulk of its fibres running oblique relative to the humerus. Attempting to split brachialis longitudinally to the extent required for plate osteosynthesis invariably leads to transection of a significant number of muscle fibres. The authors present a less muscle destructive modification to the anterolateral approach (ALA) based on a bicipital brachialis muscle. Method: In order to preserve brachialis muscle fibres, the modified ALA elevates the superficial head from the underlying humerus and longitudinally splits the deep head to allow a fixation device to be tunnelled. Case notes of patients with a humeral shaft fracture fixed via the modified ALA were retrospectively reviewed. Results: Ninteen humeral shaft fractures were fixed via the modified ALA. No post-operative nerve palsies were reported. Of the 19 patients, 14 (73.7%) received clinical and radiological follow-up. All reported being satisfied with their outcome. One developed a superficial wound infection and one (previous diagnosis of spondyloepiphyseal dysplasia tarda) developed a non-union requiring revision surgery. Of the five patients lost to follow-up, two died, and three reported no ongoing orthopaedic issues via telephone. Conclusions: Improved anatomical understanding of brachialis has resulted in the described modification to the ALA which is less muscle destructive and follows a truer inter-nervous plane. This small series demonstrates satisfactory outcomes using this approach.

Comparison of the Posterior and Anterolateral Surgical Approaches in the Treatment of Humeral Mid-Shaft Fractures: A Retrospective Study

“…In the current study, the Constant scores and MEPS in group II (95.1 and 91.9, respectively) and group IV (94.4 and 91.1, respectively) were high, consistent with the excellent functional results reported by Chang et al [30]. In the current study, the rate of lateral antebrachial cutaneous nerve damage was 2.0%, similar to the results reported by Idoine et al [15].…”

“…The advantages of this approach include the supine positioning of the patient and the availability of distal and proximal extensions to achieve excellent exposure of the humeral shaft during surgery. Several retrospective clinical studies of patients with humeral diaphyseal fractures have reported no iatrogenic radial nerve palsy and high union rates after ORIF via the anterolateral approach [ 29 , 30 ]. Further, evidence suggests that during anterolateral surgery, patients are safer due to the supine position and the adequate exposure of the proximal and middle humeral shaft that can be achieved via this approach.…”

Anterolateral approach with two incisions versus posterior median approach in the treatment of middle- and distal-third humeral shaft fractures

“…Many authors have carried on retrospective studies and reported excellent functional outcomes via the posterior approach, with union rates of 90% to 100% [ 12 , 13 ]. Several retrospective clinical studies with humeral diaphyseal fractures have reported high union rates after ORIF via the anterolateral approach [ 20 , 21 ]. Our data showed that nonunion incidence was lower using anterolateral approach with two incisions compared to the posterior median approach.…”

Comparison of Posterior and Anterolateral Surgical Approaches in Treating Adult Humeral Shaft Fractures

“…The anterolateral approach can be used as an alternative to humeral midshaft fractures. The advantages of the anterolateral approach include the supine position and excellent imaging when the incision is extended proximally and distally [22].…”