Modified medial approach for the treatment of fractures of the lower third of the humeral shaft: An anatomical study

Background

The anatomical study of the modified medial approach for addressing fractures of the distal third of the humeral shaft aimed to elucidate the benefits of this method in providing optimal exposure for surgical intervention.

Methods

Sixteen upper limb specimens from eight cadavers, obtained from the Anatomy Teaching Department of Fujian Medical University, were dissected. Three-dimensional anatomical structures were mapped onto a two-dimensional coordinate system. Key anatomical structures relevant to the modified medial approach, including the medial cutaneous nerve, musculocutaneous nerve, ulnar nerve, basilic vein, brachial artery, superior ulnar collateral artery, and inferior ulnar collateral artery, were documented in detail.

Results

The average humeral shaft length measured (29.22 ± 2.78) cm, with its medial surface being flat and well-suited for plate fixation. The basilic vein, located superficially in the upper arm's first quadrant, measured (1.35 ± 0.35) cm from the most prominent point of the medial epicondyle of the humerus, with the deep fascia being penetrated at (12.41 ± 1.71) cm. The basilic vein serves as a key landmark for the modified medial approach. The nervi cutanei antebrachii medialis, running along the medial biceps humerus, closely accompanies the basilic vein, perforating the deep fascia above the medial epicondyle and extending anterior external and posterior medial branches. These branches are positioned (0.80 ± 0.17) cm and (0.45 ± 0.29) cm, respectively, from the basilic vein. Additionally, all nervi cutanei antebrachii medialis pass anteriorly to the basilic vein before continuing distally to the forearm. The ulnar nerve initially accompanies the basilic vein in the upper arm but diverges posteriorly without branching at (14.75 ± 1.74) cm, with the maximum separation from the basilic vein measuring (2.28 ± 0.59) cm. The brachial artery bifurcates into the superior and inferior ulnar collateral arteries along the humeral shaft. The superior collateral ulnar artery primarily supplies the ulnar nerve, positioned (14.14 ± 1.27) cm from the medial epicondyle, which ensures a sufficient blood supply for operative procedures. The musculocutaneous nerve and radial nerve branch are located in the lateral region of the brachial muscle, with minimal postoperative impact on muscle strength when splitting the brachial muscle by one-third.

Conclusions

The modified medial approach, as revealed by anatomical studies, focuses on the fracture site with a straight skin incision aligned between the most prominent point of the medial epicondyle and the midpoint of the axilla, positioned one transverse finger from the radial side. Using the basilic vein as a reference, major vessels and nerves remain undisturbed, ensuring a safe operative zone. This technique allows for significant exposure of both the anterior and external humeral shaft fracture site and the ulnar side butterfly fragment while minimizing tissue damage and facilitating rapid recovery. The approach offers notable clinical value due to its reduced invasiveness and accelerated postoperative rehabilitation.