Gardner Michael J, Griffith Matthew H, Dines Joshua S, Lorich Dean G
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York 10021, USA.
Bull Hosp Jt Dis. 2004;62(1-2):18-23.
Plate fixation for unstable fractures of the proximal humerus has seen mixed results as evidenced by the trials of new methods of fixation. The deltopectoral surgical approach is most frequently used and requires significant muscle retraction and soft tissue stripping to expose the lateral humeral neck. This may contribute to avascular necrosis and fixation failure. Lateral approaches have been limited to 5 cm distal to the acromion because of the course of the anterior branch of the axillary nerve. A recent anatomic study has demonstrated the predictability of the position of the axillary nerve as it crosses the anterior deltoid raphe, which allows it to be isolated and protected, and dissection can be extended distally. In addition, no accessory motor branches to the anterior head of the deltoid cross the raphe, so extending an incision through the raphe after protecting the main motor branch of the axillary does not place the innervation to the anterior deltoid at risk. This surgical approach allows exposure of the proximal humerus and indirect reduction of the fracture, with subsequent locking plate fixation, adhering to the principles of biological fixation.
近端肱骨不稳定骨折的钢板固定效果不一，新的固定方法试验证明了这一点。三角肌胸大肌手术入路最为常用，需要显著的肌肉牵拉和软组织剥离来暴露肱骨外侧颈。这可能导致缺血性坏死和固定失败。由于腋神经前支的走行，外侧入路一直局限于肩峰远端5厘米处。最近的一项解剖学研究表明，腋神经穿过三角肌前中缝时位置具有可预测性，这使得它能够被分离和保护，并且解剖可以向远端延伸。此外，没有支配三角肌前束的副运动支穿过中缝，因此在保护腋神经主运动支后通过中缝延长切口不会使三角肌前束的神经支配处于危险之中。这种手术入路允许暴露近端肱骨并间接复位骨折，随后进行锁定钢板固定，遵循生物固定原则。
