Name:
Anterolateral Acromial Approach Through a Shoulder Strap Incision
Description:
Anterolateral Acromial Approach Through a Shoulder Strap Incision
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/29fc3443-2a19-4ecb-a74f-f9c24630de8f/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H09M24S
Embed URL:
https://stream.cadmore.media/player/29fc3443-2a19-4ecb-a74f-f9c24630de8f
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/29fc3443-2a19-4ecb-a74f-f9c24630de8f/Anterolateral acromial approach through a shoulder strap inc.mp4?sv=2019-02-02&sr=c&sig=R6adplQHPO6G345Eu1azGqF%2Bpdvhejz14LGg6mJB2Ic%3D&st=2024-11-23T11%3A58%3A47Z&se=2024-11-23T14%3A03%3A47Z&sp=r
Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ASHOK GAVASKAR: The strap incision to perform an extended deltoid split approach is especially useful in an obese patient. The patient is placed in a beach chair position with the image intensifier from the opposite side, allowing the surgeon to take a true AP and a modified axial view of the shoulder. This obese patient has a two part surgical neck fracture displaced into varus. The inverted U incision is marked on the skin with the summit at the tip of the acromion.
ASHOK GAVASKAR: The cause of the axillary nerve from the tip of the acromion is around four to six centimeters. The limbs on the U should be of adequate length to allow the use of a three hole philon plate. Further screws into the distal segment can be inserted through stab incisions. Full thickness skin flaps are raised without undermining the flap.
ASHOK GAVASKAR: Bleeding vessels should be cauterized. Further bleeding from the flap can be minimized by infiltrating the skin with local anesthetic mixed with epinephrine prior to the skin incision.
ASHOK GAVASKAR: The skin flap is raised distally to the predetermined length to allow safe fracture reduction and plate fixation. The approach provides excellent lateral access to the shoulder due to easier deltoid retraction since the skin is completely moved out of the way. The incision also heals well as it is situated along the relaxed skin tension lines of the shoulder.
ASHOK GAVASKAR: The anterolateral deltoid is identified between the anterior and medial portions of the muscle. It represents a watershed line, providing a relatively avascular plane. The proximal working window is created by splitting the muscle for a distance of around four centimeters from the tip of the acromion.
ASHOK GAVASKAR: The sub deltoid plane should be cleared of other actions to allow easy retraction and intense exposure. The axillary nerve is identified by palpation through the proximal window with the limb in slight abduction. The distal window is created after identification of the node.
ASHOK GAVASKAR: Around one centimeter of the deltoid muscle is left as a cuff to protect the node from inadvertent injury during the procedure. The right angle clamp is then used to feed a wire loop around the node to protect it throughout the entire procedure.
ASHOK GAVASKAR: The subdeltoid bursa is then incised to expose the proximal fracture lines and to perform fracture reduction and fixation. Heavy non absorbable sutures using number 5 etibond or placed in the superior, anterior and posterior regions of the rotator cuff
ASHOK GAVASKAR: and the cuff bone junction. These sutures are used to maneuver the humeral head during fracture reduction and are finally anchored to the plate to increase the stability of fixation. Additional sutures in the anterior and posterior part of the cuff can also be placed to help reduce the tuberosities to one another in 3 and 4 part fractures.
ASHOK GAVASKAR: This two part surgical neck fracture with varus displacement is reduced by pulling on the traction sutures to bring the humeral aid out of varus. The humeral shaft is simultaneously pushed medially under the humeral head. Once satisfactory reduction is confirmed, k-wires are inserted from the top of the greater tuberosity into the medial calcar to provisionally hold the reduction.
ASHOK GAVASKAR: Placement of k-wire should be as such that they do not interfere with definitive fixation. A similar two part fracture can also be reduced by using an a-wall reduction clamp. In cases with significant medial shaft displacement due to the pull of the pectoralis major muscle, a 3.5 m cortical screw can be placed as a reduction screw through the proximal oblong wall of the distill segment of the philos plate.
ASHOK GAVASKAR: This screw is used to pull the shaft under the humeral head. You should, however, be careful not to pull the shaft too laterally, which will leave the humeral head unsupported on the medial side.
ASHOK GAVASKAR: In case of 3 and 4 part fractures varus displacement of the humeral head can be reduced by using the cuff sutures and then securing the head to the shaft with k-wires. Two k-wires are typically placed, one from the tip of the greater tuberosity to the medial shaft and one from the anterior aspect of the distal shaft into the humeral head.
ASHOK GAVASKAR: The tuberosities are then produced to one another by using additional traction cuff sutures placed in the anterior and posterior part of the rotator cuff. The sutures are passed into the eyelets of the plate before inserting it, as it may become difficult to pass it later on. The plate is then slid safely under the axillary node and secured onto the proximal humerus.
ASHOK GAVASKAR: After securing it with k-wires, fracture reduction and push in of the plate are confirmed by fluoroscopy in both planes. It is major. The plate is centered on the humeral head and shaft at an appropriate height from the top of the head. After confirming the position of the calcus screws in the anterior, posterior view, the proximal portion of the plate is typically fixed first with multiple locking screws.
ASHOK GAVASKAR: Screw placement into the humeral head should be as sub-chondral as possible and should be confirmed with sounding and fluoroscopy. The divergence screws in row C of the philos plate should be carefully placed into the humoral head to avoid inter-articlar penetration.
ASHOK GAVASKAR: The infra medial calcar screws which are important in resisting virus deformation, especially in 3 and 4 part fractures, should be placed as inferiorly as possible to provide the desired effect.
ASHOK GAVASKAR: Finally, the traction cuff sutures are secured to the plate to complete fixation.
Form Title Download
Form Title Bookmark
Form Title Share
Form Title Cite
