Introduction The shoulder strap approach involves an anterolateral deltoid split with use of an inverted U incision, providing excellent lateral exposure for locked plate fixation of complex proximal humeral fractures.
Step 1: Positioning of the Patient and the Image Intensifier Proper positioning of the image intensifier is important for uninterrupted fluoroscopy.
Step 2: Skin Incision The tip of the acromion is a useful landmark and serves as the proximal extent of the incision.
Step 3: Raise the Distally Based Fasciocutaneous Flap Raise a broad-based full-thickness fasciocutaneous flap.
Step 4: Creation of the Proximal Working Window Split the deltoid anteriorly to minimize the chances of denervation.
Step 5: Identification and Protection of the Axillary Nerve Leave a cuff of deltoid muscle to protect the axillary nerve.
Step 6: Placement of Traction Cuff Sutures The cuff sutures are helpful in reduction of the proximal fracture segments and improve stability of three and four-part fractures.
Step 7: Reduction of the Head and Tuberosity Fragments Avoid varus reduction and reestablish the relationship between the humeral head and the greater tuberosity.
Step 8: Plate Placement Proper plate positioning is important to maximize the possibility of using all proximal screw options and to minimize chances of impingement.
Step 9: Fracture Fixation As is necessary with all locked internal fixators, reduce the fracture before fixing the plate; the order of fixation may vary with the type of fracture.
Results In our study of fifty patients with a displaced three or four-part fracture treated with this approach, all flaps healed well without any necrosis and no infections were seen.
Pitfalls & Challenges
The shoulder strap approach involves an anterolateral deltoid split with use of an inverted U incision, providing excellent lateral exposure for locked plate fixation of complex proximal humeral fractures.
Locked plate fixation is a …
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