Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach



Proximal humeral fractures, Deltoid-splitting approach, Nerve crush, Electromyography


Aim: The most common complication of the Lateral deltoid splitting approach (LDSA), which is used in the shoulder area, especially for posterior extension fractures and other soft tissue pathologies, is axillary nerve injury. Determining the frequency of nerve injuries that may occur after LDSA is decisive for the applicability of this approach. Therefore, in our study, we aimed to evaluate the axillary nerve integrity and shoulder functions in patients who underwent LDSA. Methods: In this prospective cohort study, 55 patients who were operated with LDSA for proximal humerus fractures between February 2015 and July 2018 were evaluated. Among these patients, 35 were selected and included in the study. Six months later Electrophysiological tests (Electroneuromyelography – ENMG) and Constant Shoulder Score (CSS) were used for evaluation of each operated and non-operated shoulder. CSS difference between the operated and non-operated sides was graded as mild (11-20 point), moderate (21-30) and severe (>30). Results: Mean age of the group was 66 (9) years. Twenty-five patients were female and 10 were male. Mean follow-up time was 4 (1) years. Mean latencies of axillary nerve were 4.6 (1.8) msn, 3.7 (0.54) msn and mean amplitudes of axillary nerve were 6.6 (2.21) mV, 8.4 (2.80) mV in the operated and non-operated shoulders, respectively. There was no statically significant difference between the operated and non-operated sides according to latency and amplitude (latency P=0.25, amplitude P=0.16). Mean CSS of the patients were 28.7. CSS of 12 patients were severe (mean: 39.08), 18 patients, moderate (mean 25.4) and 5 patients, mild (mean 16). There was no statically significant correlation between CSS and axillary nerve latency / amplitude (P= 0.62, r=0.267 / P=0.98, r=-0.339). Fracture type and CSS showed a statically significant correlation (P=0.032, r= 0.829). Conclusion: This study revealed that LDSA provides wide and versatile fracture control without compromising the deltoid muscle functions and axillary nerve, especially in fractures extending to the posterior part of the proximal humerus.


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Buecking B, Mohr J, Bockmann B, Zettl R, Ruchholtz S. Deltoid-split or deltopectoral approaches for the treatment of displaced proximal humeral fractures? Clin Orthop Relat Res. 2014;472:1576–85. doi:10.1007/s11999-013-3415-7.

Hoppenfeld S. deBoer P. Surgical exposures. Philadelphia: Lippincott, Williams and Wilkins; 2003.

Saran N, Bergeron SG, Benoit B, Reindl R, Harvey EJ, Berry GK. Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide. Injury. 2010;41:1037–40. doi:10.1016/j.injury.2010.04.014.

Gardner MJ, Voos JE, Wanich T, Helfet DL, Lorich DG. Vascular implications of minimally invasive plating of proximal humerus fractures. J Orthop Trauma. 2006;20:602–7. doi:10.1097/01.bot.0000246412.10176.14.

Gerber C, Werner CML, Vienne P. Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg - Series B. 2004;86:848–55. doi:10.1302/0301-620X.86B6.14577.

Kayaokay K, Mirzazade C, Küçük L, Coşkunol E. Comparison of open acromioplasty outcomes according to approach type; anterior and lateral. J Surg Med. 2017;1:49–51. doi:10.28982/josam.351717.

Perlmutter GS. Axillary nerve injury. In: Clin Orthop Relat Res. Lippincott Williams and Wilkins; 1999. p. 28–36. doi:10.1097/00003086-199911000-00005.

Gurushantappa PK, Kuppasad S. Anatomy of axillary nerve and its clinical importance: a cadaveric study. J Clin Diagn Res. 2015 Mar;93:13-7.

Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160–4.

Westphal T, Woischnik S, Adolf D, Feistner H, Piatek S. Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings. J Shoulder Elb Surg. 2017;26:464–71. doi:10.1016/j.jse.2016.07.027.

Singh H, Batra A, Patel D. Lateral transdeltoid approach to proximal humerus fractures. Int Surg J. 2015;2:337–40. doi:10.18203/2349-2902.isj20150400.

Robinson CM, Murray IR. The extended deltoid-splitting approach to the proximal humerus: Variations and extensions. J Bone Joint Surg. 2011;93 B:387–92. doi:10.1302/0301-620X.93B3.25818.

Wu CH, Ma CH, Yeh JJH, Yen CY, Yu SW, Tu YK. Locked plating for proximal humeral fractures: Differences between the deltopectoral and deltoid-splitting approaches. J Trauma. 2011;71:1364–70. doi:10.1097/TA.0b013e31820d165d.

Gardner MJ, Griffith MH, Dines JS, Briggs SM, Weiland AJ, Lorich DG. The extended anterolateral acromial approach allows minimally invasive access to the proximal humerus. Clin Orthop Relat Res. 2005;123–9. doi:10.1097/01.blo.0000152872.95806.09.

Khan LAK, Robinson CM, Will E, Whittaker R. Assessment of axillary nerve function and functional outcome after fixation of complex proximal humeral fractures using the extended deltoid-splitting approach. Injury. 2009;40:181–5. doi:10.1016/j.injury.2008.05.031.

Isiklar Z, Kormaz F, Gogus A, Kara A. Comparision of deltopectoral versus lateral deltoid split approach in operative treatment of proximal humeral fractures. J Bone Joint Surg Br. 2010;92:352.

Cheung S, Fitzpatrick M, Lee TQ. Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach. J Shoulder Elbow Surg. 2009;18:748–55. doi:10.1016/j.jse.2008.12.001.

Laflamme GY, Rouleau DM, Berry GK, Beaumont PH, Reindl R, Harvey EJ. Percutaneous humeral plating of fractures of the proximal humerus: Results of a prospective multicenter clinical trial. J Orthop Trauma. 2008;22:153–8. doi:10.1097/BOT.0b013e3181694f7d.

Robinson CM, Stirling PHC, Goudie EB, Macdonald DJ, Strelzow JA. Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. J Bone Joint Surg. 2019;101:2129–39. doi:10.2106/JBJS.19.00595.

Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: The effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23:113–9. doi:10.1097/BOT.0b013e31819344bf.

Jung SW, Shim SB, Kim HM, Lee JH, Lim HS. Factors that influence reduction loss in proximal humerus fracture surgery. J Orthop Trauma. 2015;29:276–82. doi:10.1097/BOT.0000000000000252.

Hardeman F, Bollars P, Donnelly M, Bellemans J, Nijs S. Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus. Injury. 2012;43:153–8. doi:10.1016/j.injury.2011.04.003.

Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427–33. doi:10.1016/j.jse.2004.01.034.

Fisher ND, Barger JM, Driesman AS, Belayneh R, Konda SR, Egol KA. Fracture severity based on classification does not predict outcome following proximal humerus fracture. Orthopedics. 2017;40:368–74. doi:10.3928/01477447-20170925-04.






Research Article

How to Cite

Unal Ömer K, Ateş MF, Dağtaş MZ, Ugutmen E. Evaluation of axillary nerve integrity and shoulder functions in patients who underwent lateral deltoid splitting approach. J Surg Med [Internet]. 2020 Aug. 1 [cited 2023 Feb. 6];4(8):645-8. Available from: https://jsurgmed.com/article/view/777069