How to perform a deltopectoral approach
Source
Surgeon:
Ville Vänni (trauma surgeon), Lasse Rämö (orthopedic surgeon)
To access the full video and additional content on this subject, log in or subscribe
Summary
Focus: Deltopectoral approach to facilitate open reduction and internal fixation of proximal humerus fracture.
Key elements: Patient positioning, skin incision, development of the deltopectoral space, visualization of the proximal humerus, wound closure, aftercare, and pitfalls.
Indications and Clinical Context
General
Medical experts: Ville Vänni (trauma surgeon), Lasse Rämö (orthopedic surgeon), Jenni Liikanen (orthopedic resident), Thomas Ibounig (orthopedic surgeon), Robert Björkenheim (orthopedic surgeon)
Name of procedure: Deltopectoral approach
Goal of Operation
To facilitate open reduction and internal fixation of the proximal humerus fracture.
Problem
Fracture of the proximal humerus
Diagnosis
Proximal humerus fracture (ICD-10: S42.2)
Short Pathophysiological Description
Certain proximal humerus fractures and fracture dislocations can lead to impaired function and pain unless treated operatively.
Key Anatomical Structures
Coracoid process
Acromion
Deltopectoral groove: the interval between deltoid and pectoralis major muscles
Cephalic vein
Conjoint tendon
Insertions of the deltoid and pectoral muscles
Clavipectoral fascia
Coracoacromial ligament
The greater and lesser tubercles of humerus
The long head of biceps brachii muscle (LHBB) and the intertubercular groove
Rotator cuff tendons: subscapularis (SSC), supraspinatus (SSP) and infraspinatus (ISP)
Step-by-Step Technique
Patient Positioning, Anesthesia and Preparation
The patient is in a beach chair position with the upper extremity draped so that it can be freely moved. Also, make sure that the C-arm can move freely for adequate imaging during fracture fixation. Make sure that patient head is securely supported in the head rest to prevent airway problems or head movements during the surgery.
General anesthesia is applicable, with or without plexus blockade for post-operative pain relief.
Skin Incision
Inspect and palpate the landmarks: acromion, clavicle, coracoid process, deltopectoral groove and the humeral shaft.
Make a longitudinal skin incision (10–15 cm in length) starting from the level of the coracoid process and advance distally towards the distal attachment of deltoid muscle.
Log in or subscribe to access full content and see all the images.
Develop a Deltopectoral Space and Visualize the Clavipectoral Fascia
Use a blunt Adson retractor to retract the skin and subcutaneous fat. Take care of the hemostasis while advancing.
Locate the deltopectoral groove and identify the cephalic vein. Release the cephalic vein carefully from adjacent tissues and mobilize it either laterally or medially, depending on the course of its tributaries (usually laterally).
Create a deltopectoral space via blunt dissection. Palpate the coracoid process and bluntly dissect to form a space lateral to it. Identify the clavipectoral fascia.
Visualize the Proximal Part of the Humerus
Place the retractor(s) in the created deltopectoral space, between the deltoid and pectoralis muscles. Cut the clavipectoral fascia (i.e. using a scalpel, scissors or diathermy) lateral to the conjoint tendon.
Make sure that you stay lateral to coracoid process and the conjoint tendon to avoid harming structures just medial to the conjoint tendon: the brachial plexus and the axillary artery.Identify the tendons of rotator cuff (the supraspinatus, infraspinatus and subscapularis tendon) and the long head of biceps brachii. It is recommended to place stay-sutures in the rotator cuff tendons, which facilitates control of the tuberosities while operating and aids in fracture reduction. When these sutures are attached to the plate, they also add stability to the fixation.
For better visualization, it is possible to cut the coracoacromial ligament along the lateral border of the coracoid process. If you cut the ligament, it is not necessary to suture it during wound closure.
In addition, to gain even more visibility – especially in multifragmentary fractures – you can open the rotator cuff interval between the supraspinatus and subscapularis tendon. Advance with scissor alongside the lateral border of biceps tendon until the cranial edge of the glenoideum. With this maneuver you will now get good visualization of the shoulder joint and enable better fracture reduction. Tenotomy of LHBB is often done in conjunction with this maneuver. It is not necessary to re-attach the LHBB but it can be attached with an anchor in the sulcus region or for example with FiberWire or other non-absorbable suture material sutures to the plate.
Treating the Humeral Pathology
These steps depend on the type of fracture you are treating. See our external resources for more.
As a general tip to plate fixation in proximal humerus fractures: the plate is positioned just laterally to the sulcus of the long head of biceps brachii.
Wound Closure
Use a 1 or 0 absorbable thread (i.e. Vicryl™) to close the deltopectoral groove with interrupted X-sutures.
Use a 2-0 absorbable thread (i.e. Vicryl™) for suturing the subcutaneous layer.
You can use either sutures or skin staples for closing the skin.
To access the full video and additional content on this subject, log in or subscribe
Piftalls and Complications
Pitfalls
Incorrect Site of Incision
An incision made too laterally may result damaging the anterior part of the deltoid muscle. Whereas, an incision made too medially may cause potentially life threatening injuries to vessels (axillary artery) and damage nerves (brachial plexus). An incorrect incision site may also prevent optimal surgical exposure. Identifying key landmarks, as well as adequately visualizing and recognizing key structures, is required to prevent such errors.
Careless Tissue Handling and Placement of Retractors
During surgery, careless tissue handling and/or placement of retractors can lead to nerve injury. The axillary and musculocutaneous nerves are especially prone to damage. The brachial plexus is especially sensitive to traction. Avoid excessive traction of the upper limb during surgery.
Disorientation During Surgery
Stay lateral to the coracoid process when creating deltopectoral space. Medial to the coracoid process are the neurovascular structures you want to avoid.
Axillary Nerve Injury
The axillary nerve runs posterior to the neck of humerus, on the inner surface of the deltoid muscle. Make sure to place retractors along the bone surface when creating the deltopectoral space in the proximal part of the humerus to avoid unnecessary manipulation of the nerve. Iatrogenic injury to the axillary nerve may cause deltoid muscle atrophy and potential functional impairment.
Brachial Plexus Injury
The brachial plexus lies just medial to the conjoint tendon. It can be damaged via careless tissue handling but also excess traction of the upper limb during surgery can cause iatrogenic damage to the plexus. Avoid especially excessive external rotation of the upper limb.
Musculocutaneous Nerve Injury
The musculocutaneous nerve runs from the medial side of the coracoid process and comes into contact with the posterior side of conjoint tendon about 2–3 cm distally from the coracoid process. Careless tissue handling and soft tissue dissection may damage the nerve. Potentially causing impairment in the function of the muscles it provides motor branches to: coracobrachialis, biceps brachii and brachialis and also sensory loss in the lateral forearm.
Cephalic Vein Injury
Be wary when visualizing the deltopectoral fascia as operating carelessly through the subcutaneous fat tissue may result in damage to the cephalic vein. However, if damaged, the cephalic vein can be ligated.
Anterior Humeral Circumflex Artery
The anterior humeral circumflex artery has its origin in the axillary artery, so, when damaged, it will bleed intensively. The branches of the anterior humeral circumflex artery come to the area of the proximal humerus from the medial side, under the conjoint tendon, and must be carefully coagulated.
Aftercare
General Guidelines
For most patients early post operative mobilization and resuming daily activities are recommendable, while return to heavy manual labor may take up to several weeks.
FAQ
What is the goal of the deltopectoral approach?
The goal is to facilitate open reduction and internal fixation of the proximal humerus fracture.
What position is used for the patient?
The patient is placed in a beach chair position with the upper extremity draped so that it can be freely moved.
Which landmarks are inspected and palpated before the skin incision?
The landmarks are the acromion, clavicle, coracoid process, deltopectoral groove and the humeral shaft.
Where is the plate positioned in proximal humerus fracture fixation?
The plate is positioned just laterally to the sulcus of the long head of biceps brachii.
To access the full video and additional content on this subject, log in or subscribe