8.2.1 Anterior Approach to the Humerus

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  Patient is supine with the arm on a hand table.

  
  
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  A midline longitudinal incision is made.

  
  
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  Dissect along the lateral side of the biceps.

  
  
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  Using a finger, bluntly develop the plane between the biceps and brachialis muscles and retract the biceps medially.

  
  
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  Identify, and protect, the lateral antebrachial cutaneous nerve on the lateral undersurface off the biceps.

  
  
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  Using a periosteal elevator, split the brachialis longitudinally down the midline (lateral brachialis is innervated by the radial nerve, and the medial brachialis is innervated by the musculocutaneous nerve).

  
  
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  The entire anterior humeral shaft can be exposed. The placement of hardware is limited distally by the coronoid fossa. Proximally, the exposure can be extended into the deltopectoral interval by moving over to the lateral side of the proximal biceps.

  
  
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  Closure is accomplished by loosely approximating the brachialis muscle with 0 or 2–0 absorbable suture. The biceps is laid back in place. The subcutaneous tissue is closed with absorbable 2–0 suture, and the skin per surgeon preference.

8.2.2 Lateral Approach to the Distal Humerus

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  Patient is supine with the arm on a hand table.

  
  
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  Mark the lateral epicondyle.

  
  
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  The incision begins proximally on the epicondylar ridge, and curves distally at the lateral epicondyle extending along the lateral forearm.

  
  
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  For lateral condyle and capitellum fractures, the best exposure is usually through the interval between the extensor carpi radialis longus (ECRL) and the extensor digitorum communis (EDC)—the Kaplan approach. The ECRL and extensor carpi radialis brevis (ECRB), along with the lateral capsule are released from the epicondyle and ridge. If more proximal exposure is needed, be careful and identify the radial nerve at the superior edge of the brachioradialis muscle.

  
  
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  If visualization of the ulno-humeral joint and inferior capitellum is needed, or if lateral ligament repair/reconstruction is required, the plane of dissection is between the ECU and anconeus (Kocher approach). This will give wide exposure of the entire lateral side of the elbow.

  
  
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  Closure is accomplished by repairing the extensor origin to a cuff of posterior tissue using absorbable or permanent 0 or 2–0 suture. If soft tissues are poor, the origin can be repaired to the bone through drill holes or with a suture anchor. Fascia between muscle groups can be approximated with absorbable 2–0 suture. And the subcutaneous tissue and skin in normal fashion.

8.2.3 Posterior Approaches

Of the described methods of exposing the posterior humerus, the most commonly used are the triceps sparing, triceps splitting, and olecranon osteotomy. All have advantages and disadvantages. The triceps sparing maintains integrity of the extensor mechanism but has the most limited visualization of the joint surface. The triceps splitting gives better exposure but requires repair of the triceps tendon and may result in residual extensor insufficiency. Making an olecranon osteotomy provides the best exposure of the joint, including the anterior joint surface. The osteotomy creates another fracture to fix and heal, and there is frequent irritation from the hardware.