A minimally invasive approach for plate fixation of the proximal humerus

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.