Locked Plate Fixation of Proximal Humeral Fractures Through an Extended Deltoid Split Approach with Use of a Shoulder Strap Incision

INTRODUCTION: The shoulder strap approach involves an anterolateral deltoid split with use of an inverted U incision, providing excellent lateral exposure for locked plate fixation of complex proximal humeral fractures. STEP 1: POSITIONING OF THE PATIENT AND THE IMAGE INTENSIFIER: Proper positioning of the image intensifier is important for uninterrupted fluoroscopy. STEP 2: SKIN INCISION: The tip of the acromion is a useful landmark and serves as the proximal extent of the incision. STEP 3: RAISE THE DISTALLY BASED FASCIOCUTANEOUS FLAP: Raise a broad-based full-thickness fasciocutaneous flap. STEP 4: CREATION OF THE PROXIMAL WORKING WINDOW: Split the deltoid anteriorly to minimize the chances of denervation. STEP 5: IDENTIFICATION AND PROTECTION OF THE AXILLARY NERVE: Leave a cuff of deltoid muscle to protect the axillary nerve. STEP 6: PLACEMENT OF TRACTION CUFF SUTURES: The cuff sutures are helpful in reduction of the proximal fracture segments and improve stability of three and four-part fractures. STEP 7: REDUCTION OF THE HEAD AND TUBEROSITY FRAGMENTS: Avoid varus reduction and reestablish the relationship between the humeral head and the greater tuberosity. STEP 8: PLATE PLACEMENT: Proper plate positioning is important to maximize the possibility of using all proximal screw options and to minimize chances of impingement. STEP 9: FRACTURE FIXATION: As is necessary with all locked internal fixators, reduce the fracture before fixing the plate; the order of fixation may vary with the type of fracture. RESULTS: In our study of fifty patients with a displaced three or four-part fracture treated with this approach, all flaps healed well without any necrosis and no infections were seen. Indications Contraindications Pitfalls & Challenges