Anterior Approach to Humeral Shaft (Henry)

What it exposes. The anterior (Henry) approach gives direct access to the middle and distal third of the humeral shaft for ORIF of fractures, nonunion repair and tumour excision. First described by Henry in 1945, it is the most commonly used corridor for humeral shaft fractures needing fixation. Why anterior (and not posterior). Supine positioning is familiar, anaesthesia-friendly and allows simultaneous procedures in the polytrauma patient; the brachialis-splitting interval spares the triceps and the extensor mechanism; and the plate sits anterolaterally on the tension side (optimal biomechanics). The posterior approach is reserved for a mid-shaft fracture at the spiral groove where the radial nerve must be directly visualised and protected, or for nerve exploration — it brings the nerve into the field but needs prone or lateral positioning and carries extensor-mechanism morbidity. Position & landmarks. Supine, arm on a radiolucent side table, shoulder at the table edge for circumferential access; no tourniquet (a pneumatic tourniquet risks brachial plexus compression). Fluoroscopy (C-arm) is essential. The incision runs along the lateral border of biceps, from 2 to 3cm distal to the anterior axillary fold (coracoid level) to 5cm proximal to the antecubital crease (15 to 20cm). Do not extend proximal to the coracoid (axillary nerve risk) or distally across the elbow crease (lateral antebrachial cutaneous nerve injury, unsightly scar). When to operate. Functional bracing remains first-line for closed, isolated fractures with acceptable alignment, but several situations demand fixation.

Approach selection. The fracture level and the radial nerve status drive the choice between anterior and posterior.

Work down through the layers along the lateral border of biceps, retract biceps medially to carry the neurovascular bundle out of the field, then split the dual-innervated brachialis in its midline and expose the shaft subperiosteally — protecting the radial nerve at every step.

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Structures at risk, by layer

Intra-operative nerve injury (secondary/iatrogenic, about 4-6 percent). Mechanisms include excessive lateral retraction or traction during reduction, subperiosteal dissection straying around the tethered posterolateral humerus, drill or screw penetration of the far cortex, and entrapment beneath the plate or by a suture. Prevention rests on subperiosteal dissection only, proximal-to-distal exposure, and identifying the nerve at the lateral intermuscular septum for Holstein-Lewis patterns before reduction. Recognise it intra-operatively as loss of wrist and finger extension, or post-operatively as a wrist drop with weak EPL, EDC, EIP, APL and EPB while elbow extension and dorsal web-space sensation are preserved. Post-operative nerve palsy — make the critical distinction. A secondary palsy with intact pre-operative function raises concern for iatrogenic injury (traction, suture or plate entrapment, thermal injury). If the nerve was directly handled, lay at the fracture site, or its integrity is in doubt, early re-exploration is reasonable — identify it at the lateral intermuscular septum and perform neurolysis if in continuity, or primary repair or graft if lacerated. Most secondary palsies are neurapraxic and recover, so observation with nerve studies is also defensible when the nerve was not handled. A primary fracture palsy (present at injury, unchanged post-operatively) is observed: about 71 percent recover spontaneously (Shao 2005), nerve studies are obtained if there is no recovery by around 9 weeks (Entezari 2021), and exploration is considered at 4 to 6 months. If no recovery occurs, tendon transfers follow at around 9 to 12 months (PT to ECRB for wrist extension; FCR or FDS to EDC for finger extension; PL to a rerouted EPL for thumb extension). Extensile options. Extend proximally along the deltopectoral interval for proximal-third access (above the deltoid insertion the deltopectoral approach is preferred). Extend distally toward the elbow, staying clear of the crease. When a mid-shaft fracture at the spiral groove demands direct nerve visualisation, switch to the posterior approach — the modified exposure of Gerwin reflects both triceps heads medially after distal nerve identification and exposes a mean 26.2cm of diaphysis (versus 15.4cm for a standard triceps-splitting approach). Closure. Brachialis reapproximation with interrupted absorbable sutures is optional (the muscle heals spontaneously). Close the deep fascia and subcutaneous layer with absorbable sutures and the skin with a running subcuticular or interrupted suture. Apply a coaptation splint for 7 to 10 days, then a sling; wound check at 1 to 2 weeks, early shoulder and elbow pendulum/passive ROM at 2 weeks, active ROM at 6 weeks, and radiographic follow-up at 2, 6 and 12 weeks.

• ORIF of middle and distal-third shaft fractures — the principal operation. Reduce with direct manipulation, longitudinal traction and rotation control, holding fragments with pointed or Weber clamps and verifying with fluoroscopy.
• Plate fixation (gold standard). A 4.5mm narrow LCP or LC-DCP is placed on the anterolateral humerus (the tension side) with 6 to 8 cortices proximal and distal (AO principles). Use compression or lag-through-plate screws for simple transverse or short-oblique patterns; locking screws for osteoporotic, comminuted or metaphyseal extension; and bridge plating for comminuted fractures (span the comminution, do not reconstruct every fragment).
• Nonunion and malunion — revision ORIF with bone grafting (iliac crest autograft), a larger plate, and smoking cessation; BMP-2 may be considered for high-risk atrophic nonunion.
• Pathological fracture — prophylactic fixation for metastatic lesions.
• Polytrauma — early stabilisation in the multiply-injured patient.
• Intramedullary nailing retains a role in segmental, pathological and osteoporotic fractures, but pooled randomised data favour plating (Bhandari 2006).