Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Jun 13;2(6):e017.
doi: 10.5435/JAAOSGlobal-D-18-00017. eCollection 2018 Jun.

Surgical Approaches to the Proximal Humerus: A Quantitative Comparison of the Deltopectoral Approach and the Anterolateral Acromial Approach

Luke S Harmer  1 , Colin V Crickard  1 , Kevin D Phelps  1 , R Randall McKnight  1 , Katherine M Sample  1 , Erica B Andrews  1 , Nady Hamid  1 , Joseph R Hsu  1
Affiliations

Surgical Approaches to the Proximal Humerus: A Quantitative Comparison of the Deltopectoral Approach and the Anterolateral Acromial Approach

Luke S Harmer et al. J Am Acad Orthop Surg Glob Res Rev. .

Abstract

Background: Debate exists over the optimal approach for addressing fractures of the proximal humerus. The purpose of this study was to objectively quantify the surface area of the humerus exposed using the deltopectoral (DP) and anterolateral acromial (ALA) approaches and to compare visualized and palpable anatomic landmarks.

Methods: Ten arms on five fresh-frozen torsos underwent the DP and ALA approaches. The arms were positioned to simulate a supine patient and held in a fixed position. Visual and/or palpable access to relevant surgical landmarks and the myotendinous junctions were recorded. The myotendinous junctions were used as a rough approximation of consistent proximal exposure of a clinically retracted tuberosity. Landmarks were grouped into quadrants based on the location. Calibrated digital photographs of each approach were analyzed to calculate the surface area and the length of the exposed bone.

Results: The DP and ALA approaches exposed 22.9 ± 6.3 cm2 and 16.3 ± 6.4 cm2, respectively (P = 0.03). The DP and ALA approaches provided equivalent visual and palpable access to all landmarks in the superior and inferior quadrants. The ALA allowed improved visual (80% versus 70%) and palpable (100% versus 70%) access to the myotendinous junction of the infraspinatus in the posterior quadrant. The DP approach allowed better access to anterior quadrant structures, including improved ability to visualize the myotendinous junction of the subscapularis (100% versus zero), the subscapularis insertion (100% versus 80%), and the medial anatomic neck (100% versus 20%). Palpable access to the myotendinous junction of the subscapularis (100% versus 70%) and medial anatomic neck (100% versus 60%) was also improved with the DP.

Conclusions: In a cadaver model with fixed arm position, the DP provides increased exposure to the proximal humerus and more reliable access to anterior surgical landmarks, whereas the ALA allows improved access to the most posterior aspect of the shoulder.

PubMed Disclaimer

Conflict of interest statement

Dr. Hamid or an immediate family member serves as a paid consultant to Biomet. Dr. Hsu or an immediate family member serves as a member of a speakers' bureau or has made paid presentations on behalf of Smith & Nephew; serves as a paid consultant to Acumed; and serves as a board member, owner, officer, or committee member of the Limb Lengthening Research Society. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Harmer, Dr. Crickard, Dr. Phelps, Dr. McKnight, Dr. Sample, and Dr. Andrews.

Figures

Figure 1
Figure 1
Photograph showing deltopectoral approach retractor placement with ruler in place.
Figure 2
Figure 2
Photograph showing anterolateral acromial approach retractor placement with ruler in place.
Figure 3
Figure 3
Graph showing the surface area exposed in the deltopectoral and anterolateral acromial approaches.
Figure 4
Figure 4
Graph showing the ability of surgeons to see surgical landmarks through two different surgical approaches (deltopectoral [DP], anterolateral acromial [ALA]): the myotendinous junction of infraspinatus [MTIS], infraspinatus insertion onto the greater tuberosity [ISGT], myotendinous junction of the supraspinatus [MTSS], supraspinatus insertion onto the greater tuberosity [SSGT], myotendinous junction of the subscapularis [MTSubS], subscapularis insertion onto the lesser tuberosity [SubSLT], deltoid insertion at the deltoid tubercle [DeltoidTub], and medial anatomic neck of the humerus [MedNeck]).
Figure 5
Figure 5
Graph showing the ability of surgeons to touch surgical landmarks through two different surgical approaches (deltopectoral [DP], anterolateral acromial [ALA]): the myotendinous junction of the infraspinatus [MTIS], infraspinatus insertion onto the greater tuberosity [ISGT], myotendinous junction of the supraspinatus [MTSS], supraspinatus insertion onto the greater tuberosity [SSGT], myotendinous junction of the subscapularis [MTSubS], subscapularis insertion onto the lesser tuberosity [SubSLT], deltoid insertion at the deltoid tubercle [DeltoidTub], and medial anatomic neck of the humerus [MedNeck]).
See this image and copyright information in PMC

References

    1. Aaron D, Shatsky J, Paredes JCS, Jiang C, Parsons BO, Flatow EL: Proximal humeral fractures: Internal fixation. Instr Course Lect 2013;62:143-154. - PubMed
    1. Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ: Management of humeral shaft fractures. J Am Acad Orthop Surg 2012;20:423-433. - PubMed
    1. Hoppenfeld S, deBoer P, Buckley R: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 4 Philadelphia, Lippincott Williams & Wilkins, 2009.
    1. Zlotolow DA, Catalano LW, III, Barron OA, Glickel SZ: Surgical exposures of the humerus. J Am Acad Orthop Surg 2006;14:754-765. - PubMed
    1. Gardner MJ, Boraiah S, Helfet DL, Lorich DG: The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma 2008;22:132-137. - PubMed

LinkOut - more resources