Operative Technique

A, The skin incision begins at the coracoid process, extends to the middle of the axilla, curves distally on the medial aspect of the arm, and terminates at its upper third. Surgical exposure of the proximal end of the humerus by this axillary approach results in minimal visibility of the operative scar.

B, The lateral skin margin is retracted laterally. With the shoulder in medial rotation, the upper humeral shaft is exposed. The surgeon must avoid injury to the cephalic vein and anterior humeral circumflex vessels. The proximal humeral physis should not be disturbed.

C, The level of osteotomy is distal to the insertion of the pectoralis major and proximal to the insertion of the deltoid.

D to F, This increases range of shoulder abduction and also facilitates exposure of the humeral shaft. We recommend internal fixation with a four- or five-hole plate. First, the surgeon performs an incomplete osteotomy of the humeral diaphysis three fourths of the way through the anteromedial aspect. Second, the humeral segment is fixed to the plate with two screws (D). The osteotomy is completed with an electric saw, and the arm is rotated laterally to the desired degree and temporarily fixed with bone-holding forceps (E). Next, passive range of shoulder rotation is tested. The ideal position of the shoulder is complete lateral rotation in 90 degrees of abduction. Then, with the shoulder in adduction, the hand should touch the anterior aspect of the abdomen without elevating the scapula. The surgeon should avoid the pitfall of overcorrection because it will produce lateral rotation–abduction contracture of the shoulder. Finally, once the desired degree of lateral rotation is obtained, internal fixation of the osteotomy is completed by insertion of the distal two or three screws (F). The wound is closed as usual. The shoulder is immobilized in a shoulder spica cast. To save operating room time, the shoulder spica cast may be manufactured before surgery, bivalved, and fitted at the completion of surgery.