Anterior approach to the humerus

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)

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 cu

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)

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

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

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)