Deltopectoral interval approach to the proximal humerus

The (anterior) deltopectoral approach can be used for most proximal humeral fractures as it allows access to all relevant structures.

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

$Deltopectoral approach for proximal humeral fractures: access to structures; no adult extensile approach needed, limited to soft-tissue and fracture reduction.$

The course of the following neurovascular structures should be appreciated:

Cephalic vein
Anterior circumflex humeral artery
Ascending branch of the anterior circumflex humeral artery
Posterior circumflex humeral artery
Musculocutaneous nerve
Axillary nerve

Additional neurovascular structures, eg, the brachial plexus, are only at risk if there is excessive traction.

Key neurovascular structures include the cephalic vein, anterior and posterior circumflex humeral arteries, musculocutaneous nerve, and axillary nerve. Brachial plexus risk occurs with excessive traction.

Anatomical landmarks for the anterior deltopectoral approach are:

Coracoid process (A)
Proximal humeral shaft (B; at the level of the axilla)

Both landmarks can easily be palpated.

Anatomical landmarks for the anterior deltopectoral approach: coracoid process (A) and proximal humeral shaft (B) at the axilla; both are easily palpable.

Make a skin incision between the coracoid process and the proximal humeral shaft. This can be straight or curved depending on surgeon’s preference.

Incision between coracoid process and proximal humeral shaft; straight or curved per surgeon's preference.

Expose the deltopectoral groove with the cephalic vein. These structures can be identified by:

The course of the muscle fibers
The cephalic vein itself
Fat tissue surrounding the vein

If in doubt, look for the deltopectoral groove at the proximal and/or distal end of the skin incision.

Expose the deltopectoral groove and cephalic vein, identifiable by muscle fibers, the vein, and surrounding fat. If unsure, find the groove at the incision's ends.

Retract the cephalic vein laterally or medially, and open the fascial layer along the groove. If retracted laterally, the anatomical drainage of blood from the deltoid muscle is respected but it is at risk of damage by retractors during surgery. In any case, the cephalic vein should be preserved to reduce surgical edema of the limb.

Failure to identify the deltopectoral groove can lead to difficulty in dissection of the deltoid and possibly to denervation of the anterior portion of the deltoid.

Use blunt dissection between and under the deltoid and pectoralis muscles to expose the clavipectoral fascia.

Retract cephalic vein laterally/medially; open fascia. Lateral retraction risks damage; preserve vein to reduce edema. Identify groove to avoid dissection complications. Blunt dissection to expose clavipectoral fascia.

Identify the coracoid process and the conjoint tendon.

Incise the clavipectoral fascia lateral to the conjoined tendon and inferior the coracoacromial ligament.

Identify the coracoid process and conjoint tendon. Incise clavipectoral fascia lateral to the tendon and inferior to the coracoacromial ligament.

Retract the deltoid muscle laterally using a delta (modified Hohmann) retractor and the conjoined tendon medially using a Langenbeck retractor.

Expose the proximal humerus and confirm the anatomical landmarks (subscapularis tendon, lesser tuberosity, bicipital groove with the biceps tendon and the greater tuberosity). Evaluate the fracture morphology. Hemorrhagic bursa tissue may be resected if necessary.

Distally, expose the pectoralis major.

Pitfall: Be aware of retractor positioning to prevent iatrogenic damage of the axillary nerve.

$Retract deltoid laterally and conjoined tendon medially. Expose proximal humerus; confirm landmarks and evaluate fracture. Resection of hemorrhagic bursa if needed. Avoid axillary nerve damage with retractors.$

Pitfall: The musculocutaneous nerve exits the coracobrachialis muscle as close as 2.5 cm distal to the tip of the coracoid. Retractors placed under the conjoined tendon can cause neurapraxia; therefore, vigorous retraction must be avoided.