Introduction Indications Open reduction and internal fixation of humeral shaft fractures Humeral tumor biopsy/resection Humeral osteotomy Surgical Plane Internervous plane proximal Deltoid muscle (axillary nerve) and pectoralis major (medial and lateral pectoral nerves) distal Medial brachialis (musculocutaneous nerve) and lateral brachialis (radial nerve) Preparation Postion Supine with arm on arm board, abducted 60 degrees Approach Incision Make a curved incision from the tip of the coracoid process distally in line with deltopectoral groove along the lateral aspect of the humerus Incision should end approximately 5 cm short of elbow flexion crease (lateral antebrachial cutaneous nerve at risk) Superficial dissection Identify the cephalic vein - can take medially or laterally Proximally, develop the interval between the deltoid and pectoralis major muscle Distally, incise the deep fascia of the arm in line with the skin incision Identify the interval between the biceps and brachialis Biceps can be retracted medially or laterally (typically is taken medially) Deep dissection Proximally, incise the periosteum lateral to the pectoralis major tendon insertion, staying lateral to the long head of the biceps tendon The anterior humeral circumflex artery is seen here and must be ligated Distally, the fibers of the brachialis are split longitudinally along the midline to expose the periosteum and humeral shaft Extension Proximal extension can be obtained by developing the anterior approach to the shoulder with full deltopectoral dissection Distal extension cannot be obtained with this approach Dangers Anterior circumflex humeral artery At risk proximally between the pectoralis major and deltoid muscle Axillary nerve Can be injured with vigorous retraction of the deltoid Radial nerve must be identified before any incision is made into the brachialis muscle or before periosteal elevation of the brachialis off the humerus occurs also at risk on the middle 1/3 of the humerus where it lays in the spiral groove on the posterior humerus