Surgical Discussion

Patient positioning:  Semi beach chair

Anatomical surgical approach:  Deltopectoral merging into an aggregate anterior approach

The patient was positioned in a semi-beach chair configuration, and the right arm was secured in a spider pneumatic arm holder. Extended deltopectoral incision transitioning into an anterolateral approach distally. During surgery, we dissected through the deltopectoral interval, identifying the lateral border of the biceps and the transition of the deltoid insertion into the proximal brachialis musculature. Through blunt dissection bezween muscle bellies, we visualized the multiple butterfly fragments without detaching significant muscle mass. We utilized three fragment-specific 3.5 mm bicortical lag screws to secure the butterfly fragments. Given the anatomical relationship of one large spiral fragment to the deltoid insertion, we opted against releasing it. Instead, a posterior blunt dissection posterior to deltoid created a window from the proximolateral humeral head, continuing posterior and deep to deltoid, and emerging anterolaterally between the medial and lateral heads of the brachialis. A limited release of the lateral head of the brachialis was necessary to accommodate the placement of a 268 mm Philos plate, which was contoured and positioned along this subdeltoid posterio position. Multi-planar fluoroscopy was employed to confirm the provisional positioning of the plate prior to fixation with two bicortical 3.5 mm screws at both proximal and distal aspects. Á total of six proximal monocortical screws in the humeral head, along with two bicortical locking screws in the proximal diaphysis and three bicortical distal locking screws in the distal humeral diaphysis, resulted in a robust bridge plate construct. There was no visualisation of the radial nerve in either the proximal or distal approach windows locations.

Postoperative protocol:   Free ROM

Orthopaedic implants used:   268mm Philos - Helix Bend. Note the imaged Phios plate is from a previous case, and does not represnt the over 90deg of twist required in the current case