The Modified Anterolateral Approach to the Humerus : Techniques in Orthopaedics (2023)

*Saint Louis University Department of Orthopaedic Surgery, St. Louis, MO

The Residency Program, University of Florida-Jacksonville, Jacksonville, FL

The authors declare that they have nothing to disclose.

For reprint requests, or additional information and guidance on the techniques described in the article, please contact Philip J. Shaheen, MD, at [emailprotected] or by mail at Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, St. Louis, MO 63110. You may inquire whether the author(s) will agree to phone conferences and/or visits regarding these techniques.

We describe a distal modification of the anterolateral approach to the humerus that allows for adequate exposure of humeral shaft fractures with improved visualization and protection of the radial nerve. Humeral shaft fractures account for roughly 3% of the total fracture burden.1 These injuries are seen both in high energy trauma in young patients and lower energy mechanisms in all age groups. Many isolated humeral shaft fractures are treated nonoperatively with a coaptation splint followed by functional bracing such as with a Sarmiento brace with a goal of maintaining <20 degrees of anterior angulation, <30 degrees of varus/valgus angulation, and <3 cm of shortening.2,3 Predictors of failure for conservative treatment include transverse or short oblique fracture patterns and patients with large body habitus such as obese females with pendulous breasts. The indications for surgical treatment of a humeral shaft fracture include failure of conservative treatment, open fractures, those with neurovascular injuries or compartment syndrome, ipsilateral forearm fractures, or polytrauma patients. The most common surgical fixation of a humeral shaft fracture is with open reduction internal fixation. Approaches for open reduction internal fixation include direct lateral, anterolateral, and posterior depending upon the fracture location. A worrisome complication is radial nerve injury. The incidence of radial nerve injuries during humeral shaft fractures has been reported between 1% and 24%.4–7 A 2005 review by Shao et al7 found that radial nerve injuries occur most commonly with transverse and spiral morphology fractures of the middle and middle-distal shaft of the humerus, with no difference noted in the rate between open and closed fractures as well as no difference between conservatively treated fractures and those treated with early operative fixation. Seventy-one percent of radial nerve injuries spontaneously recovered and 88% recovered overall with average onset of recovery at 7 weeks and average time to full recovery at 6 months.7 With this in mind, protection of the radial nerve during fixation is critical.

Traditionally, the anterolateral approach to the humerus begins proximally at the deltopectoral interval and extends distally between the deltoid and biceps brachii. Following the lateral edge of the biceps, the incision then curves medially to end in the interval between the distal insertion of the biceps and the mobile wad. The superficial dissection is then carried out with the biceps being retracted medially, taking care not to injure the lateral antebrachial cutaneous nerve in the distal portion of the incision. Retracting the biceps reveals the brachialis, which has dual innervation by both the musculocutaneous nerve and the radial nerve, and the brachioradialis, which is innervated by the radial nerve. The radial nerve typically is found between the brachialis and brachioradialis and should be carefully identified before proceeding. To access the humeral shaft for repair of fractures, the brachialis must then be elevated off of the periosteum.

(Video) Extended anterolateral approach to the proximal humerus

This traditional anterolateral approach to the humerus places both the radial nerve and lateral antebrachial cutaneous nerves at risk particularly during the distal dissection where the radial nerve is in close contact with the bone and can be injured. With the traditional anterorolateral approach curving anterior distally, fractures which require plate fixation in the distal portion may be more prone to radial nerve injury during vigorous retraction such as with a Hohmann (Fig. 1).

We propose a modified anterolateral approach to the humerus that provides both excellent exposure of the fracture and protection of the radial nerve in the distal portion. The incision is made along a line that is drawn between the coracoid process of the scapula proximally and the lateral epicondyle of the distal humerus (Fig. 2). This contrasts with the traditional anterolateral approach that curves anteromedially in the distal portion in order to follow the lateral edge of the biceps. Once the incision is made, the superficial dissection is again carried out in a similar manner, retracting the biceps brachialis medially to access the brachialis and brachioradialis. Rather than curving medially, the modified anterolateral approach to the humerus continues toward the lateral condyle of the elbow. This in theory reduces the chance of encountering the radial nerve during dissection as it should be visualized as it travels obliquely across the distal dissection in a predictable manner (Figs. 3, 4). In addition, the lateral path of the distal incision avoids the lateral antebrachial cutaneous nerve which exits more anteriorly at the lateral portion of the distal biceps. The brachialis can then be elevated off of the periosteum of the humerus to gain access for fracture repair. During exposure, one should be cautious with placement of Hohmann type retractors in the distal one third of the humerus as the radial nerve is in intimate contact with the bone. Often times if the traditional anterolateral approach is used and the plate extends distally, these retractors are used vigorously for exposure and may lead to radial nerve injury. Therefore, in conjunction with our distal modification, we do not use Hohmann type retractors distally. We instead use Weitlaners after visualizing our dissection to reduce the risk of nerve injury.

In summary, the modified anterolateral approach to the humerus provides excellent exposure for repair of humeral shaft fractures. This exposure encounters the radial nerve in a predictable manner crossing obliquely through the distal portion of the incision and minimizes chances of iatrogenic injury.


1. Carroll EA, Schweppe M, Langfitt M, et al. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012;20:423–433.

2. Rutgers M, Ring D. Treatment of diaphyseal fractures of the humerus using a functional brace. J Orthop Trauma. 2006;20:597–601.

(Video) Extensile Anterolateral Approach to the Humerus. Medical Documentary

3. Sarmiento A, Zagorski JB, Zych GA, et al. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82:478–486.

4. Gottschalk MB, Carpenter W, Hiza E, et al. Humeral shaft fixation: incidence rates and complication as reported by the American Board of Orthopaedic Surgery Part II candidates. J Bone Joint Surg Am. 2016;98:e71.

(Video) anterolateral approach to humerus

5. Wang JP, Shen WJ, Chen WM, et al. Iatrogenic radial nerve palsy after operative management of humeral shaft fractures. J Trauma. 2009;66:800–803.

6. Claessen FM, Peters RM, Verbeek DO, et al. Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. J Shoulder Elbow Surg. 2015;24:e307–e311.

(Video) Humeral Shaft Fracture- Open Plating Strategies

7. Shao YC, Harwood P, Grotz MR, et al. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005;87:1647–1652.


humerus; anterolateral approach; humeral shaft

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.


What is anterolateral humerus shaft approach? ›

The anterolateral approach to the humerus provides excellent exposure to the humeral shaft, especially to more proximal aspects. In addition, the approach can be extended both proximally and distally, providing the surgeon a dynamic exposure to the humerus for the treatment of fractures and other pathologies.

What is the approach to proximal humerus fracture surgery? ›

The (anterior) deltopectoral approach can be used for almost any proximal humeral fracture treatment and is often the preferred approach. This approach is also highly recommended for revision surgery.

What approach is used for a distal third humerus fracture? ›

The approach uses a combination of (1) an anterior brachialis muscle splitting approach; (2) an interval exposure of the radial nerve between the brachialis and brachioradialis muscles; and (3) a direct lateral exposure of the lateral epicondyle and the supracondylar ridge, between the brachioradialis/wrist extensor ...

What is the Posteromedial approach to the humerus? ›

The posteromedial approach allows the surgeon to avoid dissection of the radial nerve, and is an interesting alternative to lateral approaches especially in cases of re-operation or nonunion.

What are the advantages of the anterolateral approach to the hip? ›

Minimally invasive anterolateral total hip replacement surgery is a specific approach to the hip that minimizes surgical trauma to soft tissues by working between muscle groups with a single small incision. There is no detachment or splitting of muscles that takes place during this procedure.

What is the anterolateral approach of the distal humerus? ›

Anterolateral Approach to the Humerus exposes the distal fourth of the humerus. Its major advantage over the brachialis-splitting anterior approach is that it can be extended both distally and proximally. It's used for: Open reduction and internal fixation of humeral shaft fractures.

What is the recovery time for humerus bone plate surgery? ›

Healing Time

The shoulder or proximal humerus treated with surgery takes about 3 months to heal completely. If too much activity is done too early the metal plate can break before bone is healed. Younger patients heal slightly faster and older patients or those with diabetes take slightly longer to heal.

How long does it take for a broken humerus to heal after surgery? ›

The broken bone will take 3 to 4 months to heal. During this time, you will need to perform exercises to regain range of motion, strength, and return to normal activities. Even if surgery is performed, recovery of full function often takes as long as 18 months.

How long does it take for a proximal humerus fracture to heal with surgery? ›

Healing: This injury normally takes 6-12 weeks to heal. Pain: Take pain killers as prescribed.

What is Mckenzie approach humerus? ›

The anterolateral (acromial) approach (Mackenzie) can be used for various treatments of proximal humeral fractures. It is especially useful for nailing and osteosynthesis of fractures of the greater tuberosity. It is also recommended for minimally invasive plate osteosynthesis (MIPO).

What is Campbell approach to distal humerus? ›

The triceps-splitting approach [11,12], also known as the Campbell approach, involves a midline incision in the triceps, and divides the triceps into equal medial and lateral halves. The incision continues to the olecranon insertion, and the triceps are peeled subperiosteally to expose the distal humerus.

What is the approach to a distal humeral fracture? ›

There are two traditional types of surgical accesses in the treatment of distalthird fractures of the humerus: a lateral approach with supine position of the patient or a posterior approach with prone or lateral position.

What is modified anterolateral approach humerus? ›

In summary, the modified anterolateral approach to the humerus provides excellent exposure for repair of humeral shaft fractures. This exposure encounters the radial nerve in a predictable manner crossing obliquely through the distal portion of the incision and minimizes chances of iatrogenic injury.

What is lateral humeral approach? ›

The lateral approach allows safe exposure of the distal two thirds of the humerus. It can be extended proximally also to expose the proximal humerus.

What are the routine views performed for a humerus procedure? ›

An X-ray technician will take pictures of the humerus:
  • from the front (anteroposterior view or AP)
  • from the side (lateral view)

What is the difference between lateral and anterolateral approach hip? ›

The major difference between the two approaches is, unlike lateral (side of the hip) approaches, the anterior approach uses an incision in the front of the hip while the patient is laying on their back. While both options for hip replacement provide some benefits, it's not without its disadvantages.

What nerve is injured in the anterolateral approach of the hip? ›

Femoral nerve palsy is an uncommon but serious complication during the anterolateral approach for total hip arthroplasty. One of the reported reasons for femoral nerve palsy is retractor-induced intraoperative damage after retractor placement on the anterior wall of the acetabulum.

What are hip precautions for anterolateral approach? ›

Anterior Approach Precautions

Do not allow surgical leg to externally rotate (turn outwards). Do not cross your legs. Use a pillow between legs when rolling. Sleep on your surgical side when side lying.

What is the anterolateral surface of the humerus? ›

Definition. The antero-lateral surface is directed lateralward above, where it is smooth, rounded, and covered by the Deltoideus; forward and lateralward below, where it is slightly concave from above downward, and gives origin to part of the Brachialis.

What is the anterolateral approach to proximal femur? ›

The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fasciae latae provides somewhat limited access to the hip joint along with the lateral proximal femur.

What is anterolateral position? ›

As for anterior lateral or anterolateral , this is equivalent to “toward the front” and “towards the edge” in standard anatomical position. Anterior features are closer to the front of the body while lateral features are closer to the edge of the body.

Do you wear a cast after humerus surgery? ›

After your surgery, your arm will be immobilized. You'll need some combination of a splint, cast or sling before you can start using it as you did before your fracture.

Do you have to wear a sling after humerus surgery? ›

With proximal humerus repair surgery, you will be placed in a sling. You need to wear the sling for 6 weeks. It should only be removed for showering and for your exercises. Until you have seen physical therapy, you should come out at least 3 times a day to move your elbow, wrist and fingers.

Is humerus surgery painful? ›

You can expect some pain and swelling around the cut (incision) the doctor made. This should get better within a few days after your surgery. But it is normal to have some pain for 2 to 3 weeks after surgery and mild pain for up to 6 weeks after surgery.

What should you not do after a broken humerus? ›


Use a face cloth, soap and water ensuring the area is dried thoroughly. Do not try to raise your arm A fractured Humerus can be very mobile.

What is the most painful bone to break? ›

The Femur is often put at the top of the most painful bones to break. Your Femur is the longest and strongest bone in your body, running from your hip to your knee. Given its importance, it's not surprising that breaking this bone is an incredibly painful experience, especially with the constant weight being put on it.

What are the complications after humerus fracture surgery? ›

Infection. Bleeding. Nerve damage. Tissue death due to poor blood supply (avascular necrosis) of the humerus.

What is the success rate of humerus fracture surgery? ›

Most humerus body fractures can be treated with a conservative approach with a success rate of more than 90% [1].

How do you shower with a broken humerus? ›

Showers are not recommended when you have a cast on your arm because you must not get the cast wet. There are products that help protect your cast while in the shower, like this waterproof cast cover, but most doctors recommend taking a bath instead to avoid getting water in your cast.

How do you lift your arm after a humerus fracture? ›

Keep the elbow of your injured arm tucked into your side and your elbow bent. Hold onto a stick/umbrella/golf club or similar. Use your unaffected arm to push your injured hand outwards. Remember to keep your elbow tucked in.

What are the three syndromes of McKenzie? ›

The McKenzie method describes three syndromes: postural (end-range stress of normal structures), dysfunction (end-range stress of shortened structures possibly due to scarring, fibrosis, or nerve root adhesion), and derangement (anatomical disruption or displacement within the spinal segment).

When not to do McKenzie exercises? ›

The McKenzie method isn't for everyone. If you've had back surgery, it's best to avoid this program. You should also avoid it if you have a serious spinal condition, such as a spinal fracture. It also doesn't hurt to check with your healthcare provider before attempting these exercises.

What are the contraindications for the McKenzie method? ›

The treatment component of the McKenzie method is contraindicated in patients with serious spinal pathology such as fracture, infection, cancer, or cauda equina syndrome.

What is the transolecranon approach? ›

This approach involves an osteotomy of the olecranon to give better access to the distal humerus. There are several described patterns of osteotomy. The most commonly used technique is a distally-based chevron osteotomy as this provides greatest access and has inherent rotational stability.

What are the O Driscoll principles for distal humerus fixation? ›

There are 8 technical objectives by which these principles are met: (1) every screw in the distal fragments should pass through a plate; (2) engage a fragment on the opposite side that is also fixed to a plate; (3) as many screws as possible should be placed in the distal fragments; (4) each screw should be as long as ...

What is conservative treatment for proximal humeral fracture? ›

Non-operative treatment of PHF usually involves a period of immobilization followed by physiotherapy. Immobilization provides support and pain relief during healing, while physiotherapy aims to restore the function and mobility of the injured arm. In our opinion, PHF should be immobilized in some external rotation.

What is Baumann's angle? ›

Bauman's angle is used to determine the degree of displacement and angulation, and the quality of fracture reduction. Carrying angle is the clinical parameter ofvarus-valgus angulation with elbow fully extended and forearm completely supinated.

Can you move your arm with a distal humerus fracture? ›

A distal humerus fracture is a break in the lower end of the upper arm bone (humerus), one of the three bones that come together to form the elbow joint. A fracture in this area can be very painful and make moving the elbow impossible.

What is the prognosis for a distal humerus fracture? ›

Outcomes. Most patients can return to their normal activities within about 6 months, although full healing can take up to 2 years. Recovering strength in your arm often takes longer than might be expected—sometimes up to 6 months or more.

What is shoulder or anterolateral procedure? ›

Anterolateral Approach to the Shoulder offers excellent exposure to the acromioclavicular joint and the coracoacromial ligament and supraspinatus tendon, and it's used for: Rotator cuff repair. Repair of the long head of the biceps. Acromioclavicular joint decompression.

What is anterior approach to distal third humerus? ›

An anterolateral approach of the distal humerus is a safe approach for treating distal third humeral shaft fractures. This extensile approach can be used to address more proximal and distal injuries and should be considered an alternative approach for distal third humeral shaft fractures.

What is the best approach for a humeral shaft fracture? ›

Open reduction and internal fixation using an anterior approach with plate fixation provides a safe alternative to posterior plating in the treatment of humeral shaft fractures.

What position should patient be in for lateral humerus? ›

Humerus: The humerus AP radiograph is obtained with the patient standing erect or supine with the humerus aligned to the long axis of the image receptor. The arm needs to be abducted slightly with the supination of the hand for a true AP View. A lateral radiograph of the humerus can be obtained in different ways.

What is the surgical approach for the shaft of the humerus fracture? ›

The anterolateral approach is the classic approach for humeral shaft fracture fixation. It allows for excellent fracture exposure and fixation. In the medial approach, the brachial vessels and the median nerve run in a relatively superficial location, making them easy to explore.

How long is recovery from humerus surgery? ›

The shoulder or proximal humerus treated with surgery takes about 3 months to heal completely. If too much activity is done too early the metal plate can break before bone is healed. Younger patients heal slightly faster and older patients or those with diabetes take slightly longer to heal.

How long do you wear a sling after humerus surgery? ›

For a fractured proximal humerus, a sling may be needed for up to two weeks. For a fractured scapula, doctors usually recommend wearing a sling until you can move the shoulder without significant pain—anywhere from two to four weeks.

What to expect after a humerus surgery? ›

Expect swelling and bruising for a few weeks following the surgery. This is due to the trauma from the fracture and from the surgery. The swelling and bruising may go below the elbow into the wrist and hand or into the front of the chest. Take a stool softener or laxative if needed.

What is the anterolateral approach to the elbow joint? ›

In anterolateral approach group, a curved incision began 5 cm above the elbow flexion crease in the supinated forearm, and followed the lateral border of the biceps distally, but curves laterally at the elbow joint level to avoid crossing a flexion crease at 90°.

What is anterolateral approach to total hip replacement? ›

The anterolateral surgical exposure for mini-incision hip replacement described in this article is one that allows THR to be done through a very small incision. This skin incision leads to an intermuscular exposure of the hip intended to cause minimal muscle damage and to facilitate rapid rehabilitation.

What is anterolateral approach to ankle joint? ›

This incision is centered at the ankle joint, parallel to the fourth metatarsal distally, and parallel to and between the tibia and fibula proximally. Dissection through the skin and subcutaneous tissues should proceed sharply with maintenance of full thickness skin flaps.

What is an anterior lateral approach? ›

The anterolateral approach (Watson-Jones) to the proximal femur, through the interval between glutei and tensor fasciae latae provides somewhat limited access to the hip joint along with the lateral proximal femur.

What not to do with fractured humerus? ›

Do not try to raise your arm A fractured Humerus can be very mobile. You may feel or hear the bone moving; this is not unusual but by allowing your arm to relax from the shoulder and hang loose may reduce or even prevent this from happening.

Can a broken humerus heal without surgery? ›

Most fractures of the proximal humerus can be treated without surgery if the bone fragments are not shifted out of position (displaced). If the fragments are shifted out of position, surgery is often performed to allow earlier mobility.

How long does it take to recover from humerus shaft fracture surgery? ›

It takes approximately 12 weeks for bony healing in most cases. Some fractures will benefit from early fixation.

Which approach is best for hip replacement? ›

The best hip replacement operation out there, is through the anterior approach. Anterior - meaning from the front of your hip. Most of the country traditionally goes from the posterior approach. The posterior approach works, but post-operative dislocations are higher than the anterior approach.

What is the difference between anterior approach hip replacement and traditional? ›

The anterior approach to hip replacement tends to provide the surgeon with a more limited view of the hip joint during surgery, making the surgery technically challenging, especially for less experienced surgeons. The posterior and direct lateral approaches provide the surgeon with a better view of the hip joint.

What is the most common approach for hip replacement? ›

The posterior approach to total hip replacement is the most commonly used method and allows the surgeon excellent visibility of the joint, more precise placement of implants and is minimally invasive.

What causes anterolateral ankle impingement? ›

Anterolateral impingement syndrome of the ankle is caused by entrapment of the hypertrophic soft tissue in the lateral gutter. The impingement process begins when an inversion sprain tears the anterior talofibular, and/or the calcaneofibular ligament.

What causes anterolateral ankle pain? ›

Anterolateral Impingement: May be caused by inversion ankle sprains causing inflammation and scar formation or reactive synovitis. May also be due to forced plantarflexion and supination which can tear anterolateral capsular tissues.

What is anterolateral ankle pain? ›

Pain at the front and outside aspect of the ankle joint (“anterolateral” region) is the main feature of anterolateral ankle impingement. This pain is often precipitated when the leg is bent forward over the ankle (dorsiflexed). There may be a history of a twisting ankle injury in the past.


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