**2.3 Surgical exposure**

A deltopectoral incision is made beginning at the level superior to the coracoid and passing to a point directly anterior to the deltoid insertion. (Figure 7) The fat stripe over the cephalic vein is identified and carefully incised avoiding injury to the vein. With the edema encountered in acute fractures, blunt dissection can be carried through the deltopectoral interval dissecting the cephalic vein laterally with the deltoid down to the level of the fracture site itself. Fracture hematoma is evacuated and the anatomy of the fracture is now examined. The conjoined tendon is retracted medially and the deltoid is retracted laterally. The deltoid origin and insertion are preserved. Landmarks which assist in identification of critical structures include the coracoid which has been named "the lighthouse of the glenoid" and the biceps tendon which has been called "the highway to the glenoid". The coracoacromial ligament is identified at the lateral edge of the coracoid and can be followed to the subacromial space. The base of the coracoid can be palpated and helps guide the surgeon to the glenoid. The biceps tendon can be identified in the pectoralis insertion on the humeral shaft and followed into the fracture site. The fracture line between the lesser and greater tuberosities is typically immediately posterior to this tendon. The axillary nerve must be identified and protected throughout the procedure. The nerve is palpated anteriorly along the inferior border of the subscapularis and laterally along the undersurface of the deltoid muscle. Continuity of this nerve can be verified using the Tug Test (Flatow & Bigliani 1992) and is reassuring that the nerve has not been lacerated by fracture fragments.

A deltopectoral incision is made beginning at the level superior to the coracoid and passing to a point directly anterior to the deltoid insertion. (Figure 7) The fat stripe over the cephalic vein is identified and carefully incised avoiding injury to the vein. With the edema encountered in acute fractures, blunt dissection can be carried through the deltopectoral interval dissecting the cephalic vein laterally with the deltoid down to the level of the fracture site itself. Fracture hematoma is evacuated and the anatomy of the fracture is now examined. The conjoined tendon is retracted medially and the deltoid is retracted laterally. The deltoid origin and insertion are preserved. Landmarks which assist in identification of critical structures include the coracoid which has been named "the lighthouse of the glenoid" and the biceps tendon which has been called "the highway to the glenoid". The coracoacromial ligament is identified at the lateral edge of the coracoid and can be followed to the subacromial space. The base of the coracoid can be palpated and helps guide the surgeon to the glenoid. The biceps tendon can be identified in the pectoralis insertion on the humeral shaft and followed into the fracture site. The fracture line between the lesser and greater tuberosities is typically immediately posterior to this tendon. The axillary nerve must be identified and protected throughout the procedure. The nerve is palpated anteriorly along the inferior border of the subscapularis and laterally along the undersurface of the deltoid muscle. Continuity of this nerve can be verified using the Tug Test (Flatow & Bigliani 1992) and is reassuring that the nerve has not been lacerated by fracture fragments.

Fig. 6.

**2.3 Surgical exposure** 

Fig. 7.
