Proximal Humerus: Surgical Approaches

Proximal humeral fractures can be addressed with different approaches, depending on the type of fracture, surgical technique, bone quality, patient’s needs, and surgeon’s preference. The standard deltopectoral approach is extremely versatile and makes it possible to achieve fracture reduction and fixation and to implant a prosthesis if necessary. By extending the traditional approach, some proximal humerus fractures requiring a more posterior route can be treated. The lateral approaches through the deltoid fibers are utilized to fix the humeral head and metadiaphyseal fractures and to treat concomitant rotator cuff tears. These approaches require the longitudinal splitting of the deltoid muscle. The axillary nerve must be protected when establishing these approaches. Posterior approaches to the shoulder often require the osteotomy of the acromion or the detachment of the deltoid. The osteotomy of the acromion at the level of the origin of the spine of the scapula provides a better access to the superior aspect of the shoulder. These routes are rather invasive and create some difficulties in reconstructing the anatomy. The axillary approach provides a good exposure of the shoulder for anterior stabilization and capsular release. It is relatively noninvasive. However, it is rarely used because it requires the isolation of major neurovascular structures.