Clin Orthop Surg.  2013 Sep;5(3):209-215. 10.4055/cios.2013.5.3.209.

Modified Combined Approach for Distal Humerus Shaft Fracture: Anterolateral and Lateral Bimodal Approach

• Lee TJ
• Kwon DG
• Na SI
• Cha SD

• KMID: 1705547
• DOI: http://doi.org/10.4055/cios.2013.5.3.209

Abstract

BACKGROUND
Due to the anatomical nature of the radial nerve, dissection and attainment of an adequate operative field in mid to distal humerus fracture is dangerous and limited. We devised a combined anterolateral and lateral approach that ensures protection of the radial nerve. This is achieved by performing bimodal dissection of the proximal humerus anteriorly and the distal humerus laterally.
METHODS
Thirty-five consecutive patients were treated using a combined anterolateral and lateral approach for a minimum follow-up period of 24 months. We analyzed time to bony union, time to return to daily work, range of motion, elbow joint function as assessed by the Mayo elbow performance index and complications.
RESULTS
Radiologic bony union was observed at 11.2 weeks (range, 8 to 20 weeks) on average. Four cases of incomplete radial nerve palsy before surgery all recovered. Time to return to work was 10.2 weeks (range, 2 to 32 weeks) on average. The average range of motion of the elbow was 3.3degrees (range, 0degrees to 10degrees) of extension and 135.9degrees (range, 125degrees to 145degrees) of flexion. There were 21 cases of excellent and 13 cases of good or better recovery, comprising over 97.1% on the Mayo elbow performance index. There were no complications of radial nerve palsy, non-union, mal-union, or infection.
CONCLUSIONS
Our a modified combined anterolateral and lateral approach is a clinically effective surgical method of achieving protection of the radial nerve and securing easy and firm internal fixation.

Keyword

Humerus; Radial nerve; Distal shaft fracture; Surgical approach; Plate fixation

MeSH Terms

Adolescent
Adult
Aged
Female
Humans
Humeral Fractures/radiography/*surgery
Male
Middle Aged
Orthopedic Fixation Devices
Orthopedic Procedures/adverse effects/instrumentation/*methods
Pain, Postoperative
Prospective Studies
Range of Motion, Articular
Return to Work
Treatment Outcome

Figure

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  Fig. 1 Cross-sectional anatomy of the distal humeral shaft. Cross-sectional level of the distal humeral shaft and anatomic course of radial nerve. Anterolateral approach regarding the proximal humerus (level 1 and 2): surgical dissection is made through the middle portion of the brachialis muscle. Lateral approach regarding the distal humeral shaft (level 3): surgical dissection is made between the triceps muscle and the lateral intermuscular septum. Note the radial nerve between the brachialis and brachioradialis muscles. Bc: biceps muscle, B: brachialis muscle, Tc: triceps muscle, Br: brachioradialis muscle.

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  Fig. 2 Skin incision marking between the coracoid process and lateral epicondyle of the humerus.

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  Fig. 3 Intraoperative photograph of distal humerus fracture. Surgical incision in the combined anterolateral and lateral approach that is marked between the lateral epicondyle of the humerus distally and the coracoid process of the scapula proximally. (A) The plate is inserted through the submuscular extraperiosteal tunnel (brachioradialis, radial nerve, and lateral portion of the split brachialis). Fracture reduction is maintained by the plate and screw. (B) The radial nerve is shown between the split brachialis muscle and brachioradialis muscle. (C) Distal location of the plate shows sufficient space for screw fixation in the distal short remnant. BR: brachioradialis muscle, sB: split brachialis muscle, asterisk: radial nerve.

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  Fig. 4 Exposure of the distal humeral shaft in the combined approach. The proximal part is approached through the middle portion of the brachialis muscle (m). The distal part is approached posteriorly to the lateral intermuscular septum. The distal humeral shaft and lateral epicondyle are exposed. The plate is inserted from the distal dissection area to the proximal dissection area though the submuscular extraperiosteal tunnel.

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  Fig. 5 A 33-year-old man sustained a fracture in an accident. (A) The initial radiograph shows multifragmentary fracture of the distal humerus. (B) The radiograph after operation shows anatomical reduction and alignment by open reduction and internal fixation with a plate and circlage wires. (C) The radiograph shows bony union of the distal humerus.

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  Fig. 6 Precontoured anatomical plate for the distal humeral shaft.

Reference

1. Ward EF, Savoie FH, Hughes JL. Fractures of the diaphyseal humerus. In : Browner BD, Jupiter JB, Levine AM, editors. Skeletal trauma: fractures, dislocations, ligamentous injuries. Philadelphia: Saunders;1992. p. 1177–1200.

2. Heim D, Herkert F, Hess P, Regazzoni P. Surgical treatment of humeral shaft fractures: the Basel experience. J Trauma. 1993; 35(2):226–232.

3. Henry AK. Extensile exposure applied to limb surgery. Edinburgh: Churchill Livingstone;1945.

4. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005; 87(12):1647–1652.

5. Paris H, Tropiano P, Clouet D'orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot. 2000; 86(4):346–359.

6. Lim KE, Yap CK, Ong SC, Aminuddin . Plate osteosynthesis of the humerus shaft fracture and its association with radial nerve injury: a retrospective study in Melaka General Hospital. Med J Malaysia. 2001; 56:Suppl C. 8–12.

7. Dabezies EJ, Banta CJ 2nd, Murphy CP, d'Ambrosia RD. Plate fixation of the humeral shaft for acute fracture, with and without radial nerve injuries. J Orthop Trauma. 1992; 6(1):10–13.

8. Holsetin A, Lewis GM. Fractures of the humerus with radial-nerve paralysis. J Bone Joint Surg Am. 1963; 45(7):1382–1388.

9. Hoppenfeld S, deBoer P. Surgical exposures in orthopedics: the anatomic approach. Philadelphia: JB Lippincott;1984.

10. Kwon DG, Moon KH, Na SI, Shin BK, Lee TJ. Combined anterolateral and lateral approaches in treatment of extra-articular fracture of the distal humerus. J Korean Fract Soc. 2012; 25(3):185–190.

11. Artico M, Telera S, Tiengo C, et al. Surgical anatomy of the radial nerve at the elbow. Surg Radiol Anat. 2009; 31(2):101–106.

12. Fleming P, Lenehan B, Sankar R, Folan-Curran J, Curtin W. One-third, two-thirds: relationship of the radial nerve to the lateral intermuscular septum in the arm. Clin Anat. 2004; 17(1):26–29.

13. Bodner G, Buchberger W, Schocke M, et al. Radial nerve palsy associated with humeral shaft fracture: evaluation with US--initial experience. Radiology. 2001; 219(3):811–816.

14. Morrey BF, An KN. Functional evaluation of the elbow. In : Morrey BF, editor. The elbow and its disorders. 4th ed. Philadelphia: WB Saunders;2009. p. 80–91.

15. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg Br. 2000; 82(3):336–339.

16. Cooney WP. Humeral fractures: operative treatment, complication, and reconstruction surgery. In : Evarts CM, editor. Surgery of the musculoskeletal system. 2nd ed. New York: Churchill Livingstone;1990. p. 1600–1633.

17. Gerwin M, Hotchkiss RN, Weiland AJ. Alternative operative exposures of the posterior aspect of the humeral diaphysis with reference to the radial nerve. J Bone Joint Surg Am. 1996; 78(11):1690–1695.

18. Jupiter JB. Complex non-union of the humeral diaphysis: treatment with a medial approach, an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am. 1990; 72(5):701–707.

19. Thompson JE. Anatomical methods of approach in operations on the long bones of extremities. Ann Surg. 1918; 68(3):309–329.

20. Swanson TV, Gustilo RB, Kyle RF, Templeman DC. Fracture of the humeral shaft. In : Gustilo RB, Kyle RF, Templeman DC, editors. Fractures and dislocations. 4th ed. St. Louis: Mosby;1993. p. 365–386.

21. Mills WJ, Hanel DP, Smith DG. Lateral approach to the humeral shaft: an alternative approach for fracture treatment. J Orthop Trauma. 1996; 10(2):81–86.

22. Pospula W, Abu Noor T. Percutaneous fixation of comminuted fractures of the humerus: initial experience at Al Razi hospital, Kuwait. Med Princ Pract. 2006; 15(6):423–426.