Anterolateral approach to the proximal humerus

The anterolateral (acromial) approach (Mackenzie) can be used for open reduction if closed reduction is unsuccessful.

Usually, there is no need for the adult extensile approach and the approach is limited to management of interposed soft-tissue and fracture reduction.

The incision is placed between the anterior and middle part of the deltoid, as illustrated.

Depending on the fracture morphology and planned osteosynthesis, the skin incision may be extended distally but the axillary nerve should be protected.

The course of the axillary nerve must be appreciated.

This approach utilizes a relatively avascular plane, away from the anterior and posterior circumflex humeral arteries.

Anatomical landmarks for the anterolateral approach are:

• Anterolateral edge of the acromion (A)
• Lateral side of the proximal humeral shaft (B)

Both landmarks can easily be palpated.

The axillary nerve runs dorsolaterally around the humeral metaphysis on average 5 cm distal to the tip of the acromion in children of 6 years and older.

Make a skin incision from the anterior border of the acromion parallel to the axis of the humerus.

Split the deltoid muscle between the anterior and medial fibers, to create an avascular plane.

For maximum exposure, split the deltoid proximally to the margin of the acromion.

Palpate the axillary nerve on the deep surface of the deltoid muscle, distal to the incision.

Hemorrhagic subdeltoid bursal tissue may require excision to expose the humeral head.

Irrigate the wound.

Close the deltoid interval, subcutaneous tissues, and skin.