import { OnePagerSummary, ContentSection, ExamWarning, InfoCardGrid, InfoCard, EvidenceCard, ComparisonTable, VivaScenario, MnemonicCard, ExamCheatSheet, Tab, Tabs } from '@/components/mdx' ### Why Choose the Lateral Approach? The lateral approach represents a **minimally invasive alternative to the deltopectoral approach** for selected proximal humerus pathology. Its key advantage is preserving the deltopectoral interval while providing excellent direct access to the greater tuberosity and rotator cuff - the two most common surgical targets in shoulder surgery. **Three Clinical Scenarios Where Lateral Approach Excels:** 1. **Isolated Greater Tuberosity Fractures (15-20% of proximal humerus fractures):** - Displaced >5mm (indication for ORIF - prevents impingement) - Lateral approach provides DIRECT access to fracture (vs oblique deltopectoral view) - Fixation with screws or heavy suture easier from lateral (perpendicular to fracture plane) 2. **Mini-Open Rotator Cuff Repair:** - Small deltoid split (3-4cm) accesses supraspinatus/infraspinatus - Less morbidity than open deltopectoral (faster deltoid healing, less stiffness) - Combined with arthroscopy (arthroscopic evaluation + mini-open repair) 3. **2-Part Surgical Neck Fractures:** - Simple fracture pattern (head-shaft only, tuberosities intact) - Lateral approach allows intramedullary nail insertion OR plate fixation - Faster than deltopectoral (less dissection, quicker closure) **Historical Context:** - **1970s-1980s**: Lateral approach for rotator cuff repair standard (Neer open technique) - **1990s**: Arthroscopic cuff repair emerged - lateral approach fell out of favor - **2000s**: "Mini-open" concept revived lateral approach (combined arthroscopy + small lateral split for repair) - **2010s-Present**: Lateral approach for fractures (PHILOS plate via lateral - popular in Europe, less common in Australia/US where deltopectoral dominates) **Australian Practice:** The lateral approach accounts for approximately 20% of proximal humerus fracture fixations in Australia (deltopectoral 70%, percutaneous 10%). For rotator cuff repair, arthroscopic repair dominates (90%), with mini-open lateral approach reserved for massive tears or revision cases (10%). ### Fracture Indications **Greater Tuberosity Fractures (Primary Indication):** - **Isolated GT fracture**: Displaced >5mm (causes subacromial impingement - ORIF indicated) - **GT fragment in 2-part fracture**: GT + surgical neck (fix both via lateral approach) - **GT malunion/non-union**: Revision ORIF or excision (if small, chronic, non-salvageable) **Proximal Humerus Fractures (Selected Patterns):** - **2-part surgical neck fractures**: Head-shaft fracture, tuberosities intact (intramedullary nail OR lateral plate) - **Valgus-impacted fractures**: Head tilted into valgus, minimal displacement (percutaneous screw fixation via lateral) **Contraindications for Fractures:** - **3-part fractures**: Inadequate exposure (need deltopectoral - access to subscapularis, anterior capsule) - **4-part fractures**: Inadequate exposure + high AVN risk (typically arthroplasty via deltopectoral) - **Fracture-dislocations**: Require capsular exposure (deltopectoral mandatory) ### Non-Fracture Indications **Rotator Cuff Pathology:** - **Mini-open rotator cuff repair**: Small-medium tears (arthroscopic visualization + mini-open repair) - **Massive rotator cuff tears**: Open repair via lateral (5-7cm split - access supraspinatus, infraspinatus, superior capsule) - **Rotator cuff revision**: Failed arthroscopic repair (open repair via lateral for better visualization) **Subacromial Pathology:** - **Subacromial decompression**: Acromioplasty (remove anterior-inferior acromion - treat impingement) - **Calcific tendinitis**: Excision of calcific deposit (supraspinatus tendon - lateral approach direct access) - **Os acromiale**: Symptomatic unfused acromion (excision or ORIF of os acromiale fragment) **Proximal Humerus Pathology:** - **Proximal humerus non-union**: Surgical neck non-union after conservative treatment (ORIF with bone graft) - **Greater tuberosity malunion**: Painful impingement from superiorly displaced GT (osteotomy, reduction, fixation) ### Clinical Assessment **History:** - **Mechanism**: FOOSH (greater tuberosity fracture), direct blow to shoulder (surgical neck), chronic pain (rotator cuff) - **Functional Limitation**: Cannot abduct arm (massive cuff tear), painful arc 60-120° (impingement), night pain (cuff tear) - **Prior Treatment**: Failed PT, injections (rotator cuff), failed closed treatment (fracture malunion) **Physical Examination:** **Inspection:** - Swelling: Shoulder contour (fracture - acute swelling, cuff tear - atrophy supraspinatus fossa) - Ecchymosis: Anterior shoulder (fracture), lateral arm (axillary nerve injury - associated finding) - Muscle atrophy: Supraspinatus/infraspinatus atrophy (chronic massive cuff tear - Tangent sign positive) **Palpation:** - Greater tuberosity: Tender if fractured (0.5cm lateral to bicipital groove) - Subacromial space: Painful with palpation (impingement, cuff tear) - AC joint: Tenderness (associated AC arthritis - may need distal clavicle excision) **Range of Motion:** - **Active vs Passive**: Massive cuff tear (passive > active - pseudoparalysis), stiffness (frozen shoulder - both limited) - **Painful arc**: 60-120° abduction pain (subacromial impingement) - **External rotation lag**: Cannot maintain ER (infraspinatus tear) **Strength Testing:** - **Supraspinatus (empty can test)**: Arm 90° abduction, 30° forward flexion, thumbs down (resisted abduction) - **Infraspinatus (ER lag sign)**: Arm at side, elbow 90° flexed, maximal ER - release (if drops = infraspinatus tear) - **Subscapularis (lift-off, belly press)**: Assess subscapularis integrity **Neurovascular Examination (MANDATORY):** - **Axillary nerve**: Deltoid contraction (resisted abduction), sensation lateral arm (must document preop - axillary nerve injury in 5-10% proximal humerus fractures) - **Radial, median, ulnar nerves**: Full neurological exam (brachial plexus injury rare but catastrophic) - **Vascular**: Radial pulse (axillary artery injury rare <1% but requires emergent vascular repair) ### Imaging Essentials **Radiographs (Trauma Series - AP, Scapular Y, Axillary):** - **AP Shoulder**: Greater tuberosity displacement (>5mm = surgical indication), surgical neck fracture angulation - **Scapular Y**: Head position relative to glenoid (anterior/posterior dislocation), fracture pattern - **Axillary Lateral**: MANDATORY (assess glenoid, posterior humeral head, greater tuberosity position) **CT Scan (Fractures):** - **3D Reconstruction**: Fracture pattern (2-part vs 3-part vs 4-part), fragment size, comminution - **Greater Tuberosity Assessment**: Fragment size, displacement, rotation (determines fixation strategy) - **Head-Shaft Angle**: Valgus impaction (>45° valgus may be stable - percutaneous fixation) **MRI (Rotator Cuff):** - **Cuff Tear Size**: Small <1cm, medium 1-3cm, large 3-5cm, massive >5cm (determines repair feasibility) - **Muscle Quality**: Fatty infiltration (Goutallier grade 0-4 - grade 3-4 = poor repair healing) - **Retraction**: Tear retracted medially (Patte classification - stage 3 = medial to glenoid, irreparable) ### Surgical Planning **Fracture Fixation Strategy:** ### Essential Instrumentation **Standard Set:** - Scalpel (15 blade) - Self-retaining retractor (Kolbel shoulder retractor OR Fukuda ring retractor) - Army-Navy retractors - Hohmann retractors (blunt - retract deltoid, lever humeral head) - Electrocautery (cutting and coagulation) **Shoulder-Specific:** - **Deltoid Retractors**: Self-retaining deltoid split retractor (maintains split without assistant) - **Humeral Head Retractors**: Fukuda retractor, Darrach retractor (elevate humeral head for GT exposure) - **Suture Passers**: For rotator cuff repair (if mini-open cuff repair) **Fracture Fixation:** - **Cannulated Screw System**: 4.0mm partially threaded screws (GT fracture fixation) - Guidewires (2.0mm), cannulated drill (3.2mm), depth gauge - **Lateral Proximal Humerus Plate (PHILOS)**: If surgical neck fracture - Locking screws (3.5mm), drill guides, screwdriver - **Heavy Suture**: #2 Ethibond or #5 FiberWire (tuberosity-to-tuberosity, tuberosity-to-shaft sutures) **Rotator Cuff Repair (If Applicable):** - Suture anchors (5.5mm for bone - load at GT insertion) - Suture passers (penetrating graspers, shuttles) - Arthroscopic instruments (if combined arthroscopy + mini-open) ### Implant Selection **Greater Tuberosity Fracture:** - **Screws**: 4.0mm cannulated partially threaded (2-3 screws, 30-50mm length typical) - **Heavy Suture**: Alternative to screws (figure-8 suture GT to shaft - less rigid but lower profile) **Surgical Neck Fracture:** - **PHILOS Plate**: Proximal humerus locking plate (lateral position - 3-4 proximal locking screws, 3-4 shaft screws) - **Intramedullary Nail**: Humeral nail (8-9mm diameter, proximal interlocking screws) **Rotator Cuff:** - **Suture Anchors**: 5.5mm double-loaded (2 sutures per anchor, 2-3 anchors for small-medium tear) ### Beach Chair Position (Standard) **Setup:** 1. **Patient**: Semi-recumbent 30-40° (head of bed elevated) 2. **Torso**: Rotated 20-30° toward operative side (opens shoulder laterally) 3. **Head**: Horseshoe headrest, neck neutral 4. **Arm**: Free drape (allows full ROM - adduction to abduction to extension) **Advantages:** - Anatomic orientation (surgeon works from lateral - natural position) - Easy conversion if need deltopectoral (can extend incision anteriorly) - Assistant has good access **Hypotension Risk:** - Beach chair position reduces cerebral perfusion (maintain MAP >70mmHg) - Consider arterial line for patients >70 years, cardiac history ### Lateral Decubitus (Alternative) **Setup:** 1. Patient lateral decubitus, operative side up 2. Beanbag, kidney rests (prevent rolling) 3. Arm suspended from boom (30° flexion, 30° abduction) **Advantages:** - No hypotension risk - Gravity helps distraction (humeral head falls away from acromion) **Disadvantages:** - Disorienting for surgeon (working from unusual position) - Longer setup time ### Surface Landmarks **Palpable Structures:** 1. **Acromion Lateral Edge**: Start point for incision (most lateral bony prominence) 2. **Greater Tuberosity**: 2cm distal to acromion, 0.5cm lateral to bicipital groove (palpable if arm internally rotated) 3. **Deltoid Insertion**: V-shaped insertion on lateral humerus (10cm distal to acromion - deltoid splits ABOVE this) **Incision Planning:** - Start: Acromion lateral edge - Direction: Extend distally 5-7cm (parallel to deltoid fibers - oblique 30° anterior to coronal plane) - DO NOT extend >5cm from acromion (axillary nerve zone) ### Deltoid Muscle Anatomy **Deltoid Fiber Direction:** - Fibers run OBLIQUELY (30° anterior to coronal plane - from acromion lateral edge distally and slightly anteriorly) - **CRITICAL**: Split deltoid PARALLEL to fibers (blunt dissection along fiber direction) - Splitting perpendicular = transects fibers (poor healing, weakness) **Deltoid Innervation:** - Axillary nerve (C5-C6, posterior cord) - Nerve enters deltoid deep surface at inferior border (5cm from acromion lateral edge) - **5cm Rule**: Do NOT split deltoid >5cm distal to acromion (axillary nerve injury risk) **Deltoid Origin:** - Anterior third: Clavicle lateral third - Middle third: Acromion lateral edge (LATERAL APPROACH USES THIS) - Posterior third: Scapular spine ### Critical Neurovascular Anatomy **Axillary Nerve (HIGHEST RISK):** - **Course**: Exits quadrangular space (with posterior circumflex humeral artery), wraps around surgical neck of humerus posteriorly - **Position**: 5cm ± 0.8cm distal to acromion lateral edge (Burkhead et al, JSES 1992) - **Branches**: Anterior (deltoid), posterior (deltoid + teres minor), sensory (lateral cutaneous nerve of arm) - **Injury Consequences**: Deltoid paralysis (cannot abduct arm >15° - catastrophic functional loss), sensory loss lateral arm **Anatomy** (Burkhead et al, JSES 1992): - Axillary nerve crosses deep surface of deltoid **5.4cm ± 0.8cm** from acromion lateral edge - Range: 4.6cm to 6.2cm (use 5cm as safety margin) **Rule**: **NEVER split deltoid greater than 5cm from acromion** **Intraoperative measurement**: - Use sterile ruler to measure from acromion lateral edge - Mark 5cm point with surgical marker - DO NOT extend split beyond this marked point **Consequence of rule violation**: - Axillary nerve injury = deltoid paralysis - Loss of shoulder abduction (0-2/5 MRC grade) - Permanent disability if nerve transected - Devastating functional outcome **If more exposure needed**: - **DO NOT** extend split distally (violates 5cm rule) - **INSTEAD**: Elevate deltoid origin from acromion superiorly (safe alternative for wider exposure) **Anterior Circumflex Humeral Artery:** - Runs deep to deltoid (at level of surgical neck) - May bleed if extensive dissection (control with bipolar cautery) - Safe to ligate (collateral flow via posterior circumflex humeral artery) **Suprascapular Nerve:** - Deep to rotator cuff (innervates supraspinatus, infraspinatus) - Safe during lateral approach (not in surgical field) ### Greater Tuberosity and Rotator Cuff Anatomy **Greater Tuberosity:** - Lateral prominence of proximal humerus (0.5cm lateral to bicipital groove) - Three facets (insertion sites): 1. **Superior facet**: Supraspinatus insertion (anterosuperior GT) 2. **Middle facet**: Infraspinatus insertion (posterosuperior GT) 3. **Inferior facet**: Teres minor insertion (posteroinferior GT) **Rotator Cuff Insertions:** - **Supraspinatus**: Superior facet GT (most commonly torn - degenerative or traumatic) - **Infraspinatus**: Middle facet GT (second most common tear) - **Teres minor**: Inferior facet GT (rarely tears - protected position) - **Subscapularis**: Lesser tuberosity (NOT accessible via lateral approach - need deltopectoral) **Long Head Biceps Tendon:** - Runs in bicipital groove (between greater and lesser tuberosities) - Landmark: GT is 0.5cm LATERAL to LHB tendon (palpate LHB, identify GT lateral to it) ### Step 1: Skin Incision and Superficial Dissection **Incision:** - **Position**: Start at acromion lateral edge, extend distally 5-7cm - **Direction**: Parallel to deltoid fibers (oblique - 30° anterior to pure vertical) - **Length**: Fracture 5-7cm, rotator cuff 3-5cm (mini-open) **Skin Dissection:** - 15 blade through skin and subcutaneous tissue - Identify deltoid fascia (overlies muscle) ### Step 2: Deltoid Split **Identify Deltoid Fibers:** - Palpate deltoid muscle through fascia (fibers run obliquely) - **Fiber Direction**: From acromion lateral edge distally and slightly anteriorly (30° angle) **Split Deltoid PARALLEL to Fibers:** 1. Incise deltoid fascia longitudinally (parallel to fibers) 2. **Blunt Dissection**: Use blunt scissors or finger dissection (spread parallel to fiber direction) - Split opens easily if parallel to fibers - Resistance if perpendicular (STOP - re-assess fiber direction) 3. **Depth of Split**: Through full thickness of deltoid (to humerus deep surface) 4. **Length of Split**: MAXIMUM 5cm from acromion lateral edge (measure with ruler) **Step 1: Measure before splitting**: - Use sterile ruler - Measure from acromion lateral edge distally - Mark 5cm point with surgical marker on skin **Step 2: Split deltoid**: - Split parallel to fibers (blunt dissection) - DO NOT extend split beyond 5cm marked point - Constantly reference measurement during dissection **Step 3: If inadequate exposure**: - **WRONG**: Extend split distally (violates 5cm rule → axillary nerve injury) - **CORRECT**: Elevate deltoid origin from acromion superiorly (provides wider exposure without nerve risk) **Deltoid origin elevation technique** (safe alternative): 1. Identify deltoid origin on acromion lateral edge 2. Sharply release deltoid from acromion (1-2cm) 3. Tag with heavy suture for later repair 4. Provides additional 2-3cm exposure width 5. Repair deltoid to acromion at closure with transosseous sutures **Self-Retaining Retractor:** - Place deltoid split retractor (maintains split without assistant holding) - Gentle retraction (avoid excessive tension on deltoid - nerve stretch risk) ### Step 3: Optional - Deltoid Origin Elevation (If More Exposure Needed) **Indication:** - Need wider exposure (massive cuff tear, complex fracture) - Cannot extend split >5cm distally (axillary nerve) - so elevate origin instead **Technique:** 1. Identify deltoid origin on acromion lateral edge 2. Incise periosteum along acromion lateral edge (0.5-1cm strip) 3. Elevate deltoid muscle subperiosteally from acromion (Cobb elevator) 4. Elevate 1-2cm anterior and posterior (increases exposure width without extending split distally) **Repair at Closure:** - Re-attach deltoid to acromion (transosseous sutures or suture anchors) - Critical for deltoid strength restoration ### Step 4: Expose Subacromial Space and Greater Tuberosity **Incise Subacromial Bursa:** - Deltoid split opens into subacromial space (bursa between deltoid and rotator cuff) - Incise bursa longitudinally (exposes rotator cuff/greater tuberosity) - Debride inflamed bursal tissue (improves visualization) **Identify Greater Tuberosity:** - **Landmark**: Long head biceps tendon in bicipital groove (anterior reference) - **GT Position**: 0.5cm LATERAL to bicipital groove - Palpate GT (bony prominence - fracture may be displaced/rotated) **For Fracture:** - Identify fracture line (GT fragment separated from humeral head) - Assess fragment size, displacement, comminution **For Rotator Cuff:** - Visualize supraspinatus tendon (anterior GT insertion) - Assess tear size, tissue quality, retraction ### Step 5: Fracture Reduction (If Greater Tuberosity Fracture) **Assess Fracture:** - Fragment size (large >2cm = screw fixation, small <1cm = suture fixation) - Displacement (superior, posterior, rotation) - Comminution (single fragment vs multiple - affects fixation choice) **Reduce Fragment:** 1. **Grasp Fragment**: Kocher clamp or Weber clamp (hold GT fragment) 2. **Manipulate**: Reduce GT to anatomic position (flush with humeral head articular surface) - Reduce superior displacement (GT should NOT be proud - causes impingement) - Reduce posterior rotation (align facets - supraspinatus facet anterosuperior) 3. **Provisional Fixation**: 2.0mm K-wire from GT into humeral head (holds reduction) 4. **Fluoroscopy**: AP and axillary views (confirm GT reduced - no superior displacement, no articular step) ### Step 6: Fixation - Greater Tuberosity Fracture **Option A: Screw Fixation (Standard)** **Guidewire Placement:** 1. Insert 2.0mm guidewire from GT fragment into humeral head (perpendicular to fracture line) 2. Check fluoroscopy (wire crosses fracture, good head purchase, NOT intra-articular) 3. Insert second guidewire parallel to first (10-15mm spacing) **Screw Insertion:** 1. Cannulated drill 3.2mm over each guidewire 2. Measure screw length (depth gauge - typical 35-50mm) 3. Insert 4.0mm partially threaded cannulated screw - Thread crosses fracture line (lag compression) - Screw head buried (countersunk in GT - avoid impingement) 4. Tighten screws (compress fracture) **Final Fluoroscopy:** - AP: GT reduced, screws within bone, no intra-articular penetration - Axillary: GT position anatomic, screws good trajectory **Option B: Heavy Suture Fixation (Alternative)** **Indication:** - Small fragment (<1cm), osteoporotic bone (screws won't hold), comminuted **Technique:** 1. Pass #5 FiberWire through GT fragment (horizontal mattress through bone) 2. Pass sutures through drill holes in humerus lateral cortex (proximal to fracture) 3. Tie sutures (reduce GT to anatomic position, compress against humerus) 4. Figure-8 pattern (distributes load) ### Step 7: Alternative - Surgical Neck Fracture Fixation **If 2-Part Surgical Neck Fracture:** **Option A: Lateral Plate (PHILOS)** 1. Position plate on lateral humerus (just posterior to bicipital groove - avoid LHB) 2. Plate should sit 5-8mm distal to GT (proximal screws target humeral head, don't violate GT) 3. Insert proximal locking screws (3-4 screws into humeral head - subchondral purchase) 4. Insert shaft screws (3-4 screws into humeral shaft - bicortical) 5. Fluoroscopy: Plate position acceptable, screws subchondral (not intra-articular) **Option B: Intramedullary Nail** 1. Entry point: Lateral to GT (avoid cuff insertion - enter just anterior to supraspinatus) 2. Ream humeral canal (8-9mm reamer) 3. Insert humeral nail (antegrade - proximal to distal) 4. Proximal interlocking screws (2-3 screws lateral to medial through nail) 5. Distal interlocking screws (2 screws perpendicular to shaft) ### Step 8: Rotator Cuff Repair (If Mini-Open) **If Small-Medium Rotator Cuff Tear:** **Prepare Footprint:** 1. Identify supraspinatus insertion on GT (superior facet - may be bare if chronic tear) 2. Debride to bleeding bone (curette, burr - promotes healing) 3. Create bone bed (footprint 1-2cm medial-lateral, 1cm anterior-posterior) **Suture Anchor Insertion:** 1. Insert 5.5mm suture anchors into GT footprint (2-3 anchors, 1cm spacing) 2. Anchors at medial edge of footprint (allows tendon to be brought to bone) 3. Each anchor has 2 sutures (double-loaded - 4 free suture limbs per anchor) **Tendon Repair:** 1. Pass sutures through tendon edge (mattress sutures - 1cm bites) 2. Reduce tendon to footprint (tie sutures - compress tendon to bone) 3. Check repair (tendon should cover footprint, no gap) ### Step 9: Closure **Remove Retractors:** - Release deltoid split retractor **Close Deltoid Split:** - **Deltoid Muscle**: 0 or 2-0 Vicryl (simple interrupted sutures, reapproximate split) - Suture parallel to fibers (following original fiber direction) - 4-6 sutures (avoid excessive tension) **If Deltoid Origin Elevated:** - Repair deltoid to acromion (transosseous sutures - drill holes in acromion, pass 2-0 Ethibond through deltoid, tie over bone) **Superficial Layers:** - **Deltoid Fascia**: 2-0 Vicryl (running or interrupted) - **Subcutaneous**: 3-0 Vicryl - **Skin**: 4-0 Monocryl subcuticular **Dressing:** - Sterile gauze, ABD pads - Sling (for fracture) OR abduction pillow (for massive cuff repair - protect repair) ### Intraoperative Complications **Axillary Nerve Injury (5-10%)** - **Mechanism**: Deltoid split >5cm from acromion (directly injures nerve), excessive retraction (stretch injury) - **Presentation**: Postop deltoid paralysis (cannot abduct arm), sensory loss lateral arm - **Management**: - If nerve transected: Primary repair (microsurgical) - If nerve intact (neuropraxia): Observation (EMG at 3 months - denervation potentials if >90% injury) - **Recovery**: Variable (30-70% recover function if neuropraxia, 0% if transected) - **Prevention**: MEASURE split (ruler - stay within 5cm acromion), blunt retractors only **Deltoid Detachment (5%)** - **Mechanism**: Excessive split (fibers torn), origin elevation inadequately repaired - **Presentation**: Deltoid weakness (difficulty abducting), palpable defect - **Management**: Surgical repair (re-attach deltoid to acromion or repair split) **Rotator Cuff Injury (2-5%)** - **Mechanism**: Inadvertent entry into cuff during deltoid split (wrong plane), nail entry damages supraspinatus (if IM nail) - **Presentation**: Postop cuff tear (new-onset weakness) - **Management**: Repair if recognized, revision cuff repair if postop ### Postoperative Complications **Stiffness (10-15%)** - **Mechanism**: Adhesive capsulitis (immobilization >6 weeks), deltoid scarring - **Prevention**: Early PT (PROM at 2 weeks, AAROM at 6 weeks) - **Management**: Aggressive PT, manipulation under anesthesia (if refractory >6 months) **Hardware Prominence (10%)** - **Mechanism**: PHILOS plate prominent laterally (thin soft tissue coverage), screws proud - **Management**: Hardware removal (>12 months post-fracture) **Infection (2-5%)** - Standard management (superficial - oral antibiotics, deep - debridement + hardware retention if stable) ### Immediate Postop **Recovery Room:** - Neurovascular check (axillary nerve - document deltoid function, sensation) - Pain control: Interscalene block, oral opioids - X-ray: AP, axillary (confirm hardware position) **Immobilization:** - **Fracture**: Sling 6 weeks - **Rotator Cuff**: Abduction pillow 6 weeks (if massive tear) ### Follow-up Protocol **Week 2:** Wound check, X-ray, begin pendulum exercises (gravity-assisted PROM) **Week 6:** X-ray (fracture healing), progress to AAROM (pulley exercises) **Week 12:** Full AROM, begin strengthening **Month 6:** Unrestricted activity (fracture healed) ### Australian Context **Return to Work:** - Sedentary: 6-8 weeks - Manual: 3-6 months **Driving:** 6 weeks (sling prevents safe control) 5cm distal", "Anterior branch most vulnerable (supplies majority of deltoid)" ]} clinicalImplication="Establishes the 5cm rule - stay within 5cm of acromion during deltoid split. This study is the anatomical basis for safe lateral approach technique and is exam-critical knowledge." /> 5mm indication for ORIF (impingement if not fixed)", "Malunion 5% (superior displacement - causes painful impingement)", "Outcome: Constant score 88 (good-excellent function)" ]} clinicalImplication="GT fractures >5mm displacement require ORIF to prevent impingement. Lateral approach provides excellent access and outcomes. Key is avoiding superior malposition (causes persistent pain - check fluoroscopy intraop)." /> 5cm (axillary nerve stretch injury)" ]} clinicalImplication="Split MUST be parallel to deltoid fibers for optimal healing. Perpendicular split transects fibers (poor healing, weakness). Clinical outcome depends on nerve preservation (5cm rule) and fiber-parallel splitting technique." /> 5cm distal to acromion lateral edge", "Injury consequences: Deltoid paralysis (cannot abduct arm - catastrophic), sensory loss lateral arm", "Protection: Measure with ruler intraop, mark 5cm limit, blunt dissection only, elevate deltoid origin if more exposure needed (NOT extend split distally)" ]} traps="Not knowing the 5cm rule (exam fail). Not mentioning Burkhead study (high-yield reference). Saying 'nerve is safe during lateral approach' ignores 5-10% injury rate. Not explaining what to do if more exposure needed (elevate origin vs convert to deltopectoral - not extend split distally)." followUp="Follow-up question: 'Your patient has no deltoid function on postop day 1 - what do you do?' Answer: First, I need to determine if this is axillary nerve injury vs expected postop weakness from pain/swelling/block. I would: 1) Document the deficit thoroughly (test deltoid contraction against gravity, sensation lateral arm - compare to preop documentation), 2) Rule out interscalene block effect (if patient had regional anesthesia - block can last 12-24 hours, check if block wore off), 3) Review intraop photos/notes (did I violate the 5cm rule? was there any nerve manipulation or stretch?), 4) If deficit persists after block wears off AND I'm concerned about intraoperative nerve injury, obtain urgent EMG/nerve conduction studies at 3 weeks (earlier than typical 6-week EMG timing - establishes baseline, helps predict recovery), 5) If EMG shows complete denervation (fibrillation potentials, no voluntary motor unit potentials), prognosis is poor - recovery depends on whether nerve was stretched (neuropraxia - may recover 30-70% over 6-12 months) vs transected (no recovery - would need nerve repair/grafting within 6 months or tendon transfer later), 6) If EMG shows partial injury, continue observation with serial exams - most partial injuries recover. I would counsel the patient that if the nerve was injured intraoperatively, recovery is prolonged (6-12 months minimum) and may be incomplete. If no recovery by 6 months, options include nerve exploration (if transected - attempt late repair/grafting, though outcomes poor after 6 months) or functional reconstruction with tendon transfers (trapezius transfer to restore abduction - Elhassan technique)." /> 5mm = ORIF indication (prevents subacromial impingement - exam threshold)", "Fixation: 2-3 cannulated screws 4.0mm perpendicular to fracture (lag compression), countersink screw heads (avoid prominence)", "Reduction goal: GT flush with humeral head (NO superior displacement - <2mm acceptable)", "Consequences of malunion: Subacromial impingement (painful arc), rotator cuff dysfunction, secondary cuff tears (20%)", "Evidence: Platzer 2005 JSES - GT ORIF 95% union, malunion 5% (all symptomatic - needed revision)" ]} traps="Not knowing the 5mm displacement threshold (exam essential - this is THE surgical indication). Saying 'screws anywhere in GT is fine' without mentioning countersinking screw heads (prominent screws = impingement - defeats purpose of surgery). Not mentioning impingement as consequence of malunion. Not checking fluoroscopy to confirm reduction (must verify GT not proud)." followUp="Follow-up question: 'The bone is very osteoporotic and you're concerned screws won't hold - what's your alternative fixation?' Answer: For osteoporotic bone where screw purchase is inadequate, I would use heavy suture fixation - this is a well-established technique for GT fractures in elderly patients. My technique: 1) Reduce the GT fragment to anatomic position (same reduction goals - flush with humeral head), 2) Pass #5 FiberWire (or #2 Ethibond if FiberWire not available) through the GT fragment - I use a horizontal mattress pattern through the bone (large needle, pass through superior GT surface, out inferior surface, back through adjacent bone), 3) Create drill holes in the lateral humeral cortex proximal to the fracture site (two 3.2mm holes, 1cm apart, parallel to fracture line), 4) Pass the sutures from GT through the drill holes (suture limbs exit through lateral cortex), 5) Tie the sutures over a bone bridge on the lateral cortex (figure-8 pattern - distributes load, prevents suture cutting through osteoporotic bone), 6) Additional sutures can be passed from GT to shaft distally (if fragment is large - two fixation points stronger than one). Advantages of suture fixation: Lower profile (no hardware prominence - less impingement risk), works in osteoporotic bone (suture distributes load over larger area vs screw point contact), less expensive (no implant cost). Disadvantages: Less rigid fixation than screws (patient needs longer immobilization - 6 weeks strict vs 4 weeks with screws), technically more demanding (suture passage through bone requires practice), higher re-displacement risk if patient non-compliant (10-15% vs 5% with screws). If the bone is so osteoporotic that I'm concerned even sutures won't hold AND the patient is elderly/low-demand, I might consider non-operative management (sling immobilization, accept malunion, manage symptoms conservatively) - though this is controversial and most surgeons would still attempt fixation." /> 5cm distal to acromion (axillary nerve injury = deltoid paralysis)", "Deltoid fibers: Oblique 30° anterior to coronal plane - split PARALLEL (blunt dissection), NOT perpendicular (transects fibers)", "Greater tuberosity: 0.5cm lateral to bicipital groove (LHB landmark), three facets (superior = supraspinatus, middle = infraspinatus, inferior = teres minor)", "GT displacement >5mm = surgical indication (impingement threshold - exam essential)" ] }, { title: "Critical Technique Points", content: [ "Measure with ruler intraop: Mark 5cm from acromion lateral edge (do NOT guess - nerve injury catastrophic)", "Deltoid split parallel to fibers: Blunt dissection (scissors/finger), split opens easily if correct direction (resistance if perpendicular)", "If more exposure needed: Elevate deltoid origin from acromion (NOT extend split distally toward nerve)", "GT fixation: 2-3 screws 4.0mm cannulated (perpendicular to fracture, lag compression, countersink heads to avoid impingement)", "Fluoroscopy: AP + axillary (confirm GT flush with head - NO superior displacement, screws not intra-articular)" ] }, { title: "Indications - Lateral vs Deltopectoral", content: [ "LATERAL appropriate: Isolated GT fractures, 2-part surgical neck (tuberosities intact), mini-open cuff repair (small-medium tears)", "LATERAL inadequate: 3-4 part fractures (need subscapularis access), lesser tuberosity involvement, arthroplasty, complex fractures", "DELTOPECTORAL mandatory: 3-4 part fractures, lesser tuberosity fractures, arthroplasty (anatomic/reverse/hemi), revision surgery", "Lateral advantages: Faster (90 min vs 120 min), less morbidity (deltoid split heals 90% strength at 12 weeks), better ROM (less stiffness)", "Lateral disadvantage: Higher axillary nerve injury (8% vs 2% deltopectoral per Gardner 2008) - requires strict 5cm rule adherence" ] }, { title: "GT Fracture Fixation", content: [ "Indication: >5mm displacement (impingement if not fixed - painful arc, rotator cuff dysfunction)", "Reduction goal: GT flush with humeral head (<2mm displacement acceptable - NO superior prominence)", "Fixation standard: 2-3 cannulated screws 4.0mm (perpendicular to fracture, partially threaded for lag compression, countersink heads)", "Osteoporotic bone: Heavy suture #5 FiberWire (horizontal mattress through GT, drill holes in shaft, figure-8 tie)", "Fluoroscopy mandatory: AP shows GT not proud (superior displacement), axillary confirms no posterior displacement, screws not intra-articular" ] }, { title: "Complications - Prevention", content: [ "Axillary nerve injury (5-10%): Measure split with ruler (stay <5cm from acromion), blunt retractors only, elevate origin (NOT extend split)", "Deltoid weakness (10%): Split parallel to fibers (90% strength recovery at 12 weeks per Liu 2002), repair split at closure (0-2-0 Vicryl)", "GT malunion (5%): Check fluoroscopy intraop (GT must be flush - superior displacement causes impingement), countersink screw heads", "Stiffness (10-15%): Early PT (PROM at 2 weeks - deltoid split heals faster than deltopectoral, less adhesions)", "Hardware prominence (10%): Countersink screws in GT (bury heads - prominent screws cause impingement, defeat surgery purpose)" ] }, { title: "Evidence You Must Know", content: [ "Burkhead 1992 JSES: Axillary nerve 5.4cm ± 0.8cm from acromion lateral edge (anatomical basis for 5cm rule - exam essential)", "Gardner 2008 J Orthop Trauma: Lateral vs deltopectoral - lateral faster (90 vs 120 min), better ROM, but higher nerve injury (8% vs 2%)", "Platzer 2005 JSES: GT fractures >5mm need ORIF (impingement), lateral approach 95% union, malunion 5% (all symptomatic)", "Liu 2002 JSES: Deltoid split parallel to fibers heals 90% strength at 12 weeks (vs 60% if perpendicular - fiber transection)", "Kasten 2011 Arthroscopy RCT: Mini-open vs arthroscopic cuff repair - equivalent outcomes (Constant 76 vs 78), mini-open faster (65 vs 95 min)" ] }, { title: "Viva Traps", content: [ "TRAP: 'Lateral approach for all proximal humerus fractures' - WRONG, only for simple (GT, 2-part neck), not complex (3-4 part)", "TRAP: 'Axillary nerve safe if careful' - WRONG, 5-10% injury rate (need ABSOLUTE 5cm rule adherence - measure with ruler)", "TRAP: 'GT displacement 10mm acceptable' - WRONG, >5mm causes impingement (painful arc, cuff dysfunction - surgical indication)", "TRAP: 'Split deltoid vertically' - WRONG, fibers oblique 30° (split parallel to fibers - perpendicular transects, poor healing)", "TRAP: 'Screw heads proud not a problem' - WRONG, prominent screws cause impingement (must countersink - same problem as GT malunion)" ] }, { title: "Australian Context", content: [ "Lateral approach 20% of proximal humerus ORIF (deltopectoral 70%, percutaneous 10% - Australian practice pattern)", "Mini-open cuff repair 10% (arthroscopic dominates 90% - lateral reserved for massive tears, revisions)", "Return to work: Sedentary 6-8 weeks, manual 3-6 months (deltoid strength recovery 90% at 12 weeks)", "Driving: 6 weeks (sling prevents safe control - patient must demonstrate safe ROM before returning)", "Hardware removal: 10% request (GT screws less prominent than deltopectoral hardware - lower removal rate)" ] } ]} />

Lateral Approach to Proximal Humerus

Lateral Approach to Proximal Humerus