Options for Surgical Exposure & Soft Tissue Coverage in Upper Extremity Trauma, An Issue of Hand Clinics (eBook)

Amit Gupta (Autor)

eBook Download: EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-32376-5 (ISBN)

Infos

Options for Surgical Exposure & Soft Tissue Coverage in Upper Extremity Trauma, An Issue of Hand Clinics,

---

This issues provides a comprehensive description of standard and alternative exposures of shoulder, arm, elbow, forearm and hand along with the relevant anatomy, and pearls and pitfalls of the described exposures and case examples illustrating the relevant points. The focus of the second section is on soft tissue coverage of the upper extremity.

Textauszug

Exposures of the Shoulder and Upper Humerus

Harry Hoyen, MDa∗[e-mail] and Rick Papendrea, MDb,     aDepartment of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 Metrohealth Drive, Cleveland, OH 44109, USA; bDepartment of Orthopaedic Surgery, Medical College of Wisconsin, Papendrea Orthopaedic Associates of Wisconsin, S.C. 1111 Delafield Street, Suite 120, Waukesha, WI 53188, USA

∗Corresponding author.

Extensile and adequate exposures of the shoulder and upper humerus are important in trauma surgery. The standard deltopectoral approach can be extended distally to expose the whole humerus if necessary. Often, wide exposures of the upper humerus are necessary to reduce complex fractures and apply the plate on the lateral aspect of the humerus. A thorough knowledge of the anatomy as well as strategies of nerve mobilization is necessary for achieving adequate exposures in this area. This article details the many exposure methods for the shoulder, upper humerus, and their extensile extensions.

Keywords

Anterior exposure

Anterolateral exposure

Posterior exposure

Extensile Judet exposure

Deltopectoral

Axillary nerve

Radial nerve

Key points

• The standard exposure to the shoulder and upper humerus is through a deltopectoral approach.

• Strategies for mobilization of the deltoid and exposure of the axillary nerve are important for wider exposure of the proximal humerus.

• Extensile approaches enable exposure of the whole humerus.

Introduction

The surgical approaches to the shoulder and upper humerus are essential for the trauma and reconstructive surgeon. The ability to perform a facile exposure to the upper arm will pay dividends in arthroplasty and fracture stabilization procedures. Owing to the intricate relationship between the vital neurovascular structures, muscle envelope, and necessary osseous exposure; minimally invasive procedures are not utilized or as necessary as with the lower limb.

The basic principles for exposure depend on the primary placement of the fixation. Although this article does not discuss in great detail primary arthroplasty procedures, in complex trauma, hemiarthroplasty, and reverse arthroplasty for proximal humerus fractures may be necessary. Thus, the choice of exposure in fractures that require an intraoperative decision between arthroplasty and fixation is vitally important.

In general terms, fixation is located along the lateral part of the upper humerus, with distal fixation in the posterior region. In the shoulder region, the approach is through a traditional anterior exposure or anterolateral approach. Fig. 1 shows the different approaches to the shoulder.

Fig. 1 Anterior skin landmarks with depiction of lateral plate fixation. (1) Actual interval between the deltoid and pectoralis muscles. (2) Interval between the anterior and middle portions of the deltoid. (3) Incision for the deltopectoral approach.

Although this article has some overlap with the fixation technique article for the humerus (see the discussion by Capo, Criner, and Shamian, also in this issue), this can be used as a guide to determine which fracture patterns are amendable to each exposure type. The tips for exposure are described with the advantages and disadvantages highlighted. The majority of these approaches are through predictable internervous planes.

Anterior shoulder exposure

Deltopectoral

The traditional anterior shoulder exposure or the workhorse for arthroplasty and fixation has been the deltopectoral exposure. The incision is center of the deltoid–pectoral interval, which is typically over the coracoid. The swelling in the shoulder after trauma can make it difficult to identify the medial aspect of the deltoid, thus keeping the exposure toward the more palpable coracoid (Fig. 2).

Fig. 2 With a displaced proximal humerus shaft fracture, the displacement of the deltoid can make incision planning more difficult.

Whether it is the anterior exposure to the glenohumeral joint for arthroplasty or the lateral aspect of the proximal humerus, the deltoid shrouds the exposure (Figs. 3 and 4). There are several strategies for mobilizing the deltoid. The distal aspect of the deltoid and the anterior aspect of its tendinous insertion can be mobilized to permit lateral retraction of the deltoid. There are multiple perforating vessels at the anterior deltoid insertion that require bovie electrocautery. The deltoid insertion is quite encompassing around the posterior aspect of the humerus and the anterior fibers and periosteum can be elevated without concern of proximal migration of the muscle. This enables the entire anterior muscle tendon unit to be mobilized laterally.

Fig. 3 The skin incision: superficial deltopectoral interval.

Fig. 4 (A, B) Deltoid and pectoralis muscles envelop the proximal humerus. (C) Even though the exposure, the plate is applied to the lateral humerus with fixation.

The clavipectoral fascia is cleared to identify the rotator cuff interval and subacromial space. There is a definitive, palpable separation between the supraspinatus and subscapularis. If the surgeon cannot identify the rotator interval, the biceps tendon in the bicipital groove can be followed proximal to the distal edge of the anterior supraspinatus fibers. These fibers are very stout, but slightly posterior and medial dissection will lead to the interval (Fig. 5A).

Fig. 5 (A) Lesser tuberosity osteotomy preparation. The biceps is removed from the bicepital groove and the medial border is further identified. (B) Before making the main cut, score the inferior aspect of the tuberosity with the chisel; use a sharp, disposable chisel. Then rotate arm to make a nice 2- to 4-mm-thick piece of lesser tuberosity. (C, D) Ensure that the osteotomy chisel is angled inferiorly and superiorly to create a clean cut. (E) Three #2 or #5 nonabsorbable sutures are used. The sutures can go from hole to hole in the superior to inferior or lateral to medial direction. (F) The medial to lateral sutures are used to cerclage the tuberosity and the superior to inferior lateral suture is used as a lateral based figure of 8 tension band.

As the biceps exits the groove distally, the inferior border of the subscapularis can be palpated. This will lead to proximal humerus calcar and the axillary nerve as it courses beneath the inferior capsule. Although the calcar cannot be directly visualized, the reduction cannot be palpated through this exposure. The axillary nerve can be palpated underneath the conjoined tendon. It is in very close proximity and courses just beneath the glenohumeral joint capsule.

The axillary nerve can also be found laterally as it is arborizing within the deltoid. Another important fracture landmark is that the nerve is often found at the distal spike of the greater tuberosity fragment. It is helpful to mobilize the nerve from this spike and the humerus. This is important for later fracture reduction, because this distal spike can often be anatomically reduced. This move will provide reestablishment of the greater tuberosity height. The humeral head needs to be elevated and reduced to this position, rather than reducing the tuberosities to the humeral head.

A difficult part of the reduction of the surgical neck portion of the proximal humerus fracture is that external rotation is necessary for fracture reduction but the plate application is more difficult owing to the deltoid. The screw fixation is applied first distally as the tendon can be retracted. Anterior wire fixation with the plate in situ or along the anterior cortex can permit enough fixation such that the arm can be internally rotated for the proximal locking screw placement.

Anterior exposure to the glenohumeral joint for arthroplasty or glenoid fixation involves a lesser tuberosity osteotomy or subscapularis tenotomy. The capsule can remain with the subscapularis or can be separately mobilized depending on the procedure. The reapproximation of the subscapularis begins with reapproximation of the rotator interval and then proceeds with tendon-to-tendon sutures or with sutures from the bone to the tendon. The lesser tuberosity osteotomy1 begins adjacent to the biceps groove and extends to the edge of the articular surface (Fig. 5A-F).

Lateral or anterolateral approach

This approach was developed as a method of more direct visualization of the greater tuberosity fragments and to mitigate the deltoid retraction issues. Whereas the deltopectoral exposure is truly an internervous dissection between the entire axillary nerve and the branches of the middle trunk, this approach is between axillary nerve branches to the middle and anterior deltoid. It can be...

Produkt-Details

• Erscheint lt. Verlag: 9.1.2015
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Unfallchirurgie / Orthopädie
• ISBN-10: 0-323-32376-6 / 0323323766
• ISBN-13: 978-0-323-32376-5 / 9780323323765