Shoulder

Approaches

 

Anterior

Anterolateral

Posterior

 

Anterior Approach / Deltopectoral

 

Indications

- shoulder stabilization

- arthroplasty

- fracture fixation

 

Approach

 

Position

- beach chair

- upper body elevated 30- 40o / reduces venous pressure and bleeding

- knees flexed / pressure point care

- headrest

- sandbag under ipsilateral shoulder / lifts shoulder forward so arm can fall back / opens GHJ

- arm draped free

 

Landmarks

- coracoid process and deltoid groove

 

Incisions

 

1. Anterior

- deltopectoral groove

- from coracoid to axilla

 

2. Axillary

- incision in anterior axillary skin fold

- requires more extensive undermining of skin edges

 

Superficial Dissection

- find cephalic vein in deltopectoral groove

- take laterally or medially (more branches to ligate)

- finger dissection in groove and up to coracoid

- insert retractor

- identify conjoint tendon

- dissection remains lateral to conjoined tendon to avoid NV bundle

- musculocutaneous nerve enters medially

- divide clavipectoral fascia

- elevate subdeltoid space

- place retractor under conjoint tendon / gentle retraction

 

Deep dissection

- subscapularis muscle underlies clavipectoral fascia

- arm put in ER to reveal SSC 

- sutures in medial aspect SSC

- subscapularis incised 1cm from insertion and separated from capsule

- leave inferior 1/4 of SSC to protect AXN

 

Anterior shoulder approach

 

Extension

 

Proximally

- superomedially over middle 1/3 clavicle 

- perform clavicular osteotomy to gain access to underlying axillary artery and brachial plexus

 

Distally

- release upper 1/2 pectoralis raphe +/- part deltoid insertion

- biceps retracted medially & brachialis split

 

Anterolateral Approach

 

Indications

- acromioplasty

- ACJ resection

- open rotator cuff repair

- ORIF GT fracture

- IM humeral nail

 

Approach

 

Position

- beach chair

 

Incision

- antero-lateral corner of the acromion

- transversely from ACJ along anterior edge acromion

- antero-laterally from AL corner acromion

 

Dissection

- find raphae between anterior and lateral deltoid

- deltoid split, must protect underlying rotator cuff

- detach anterior deltoid from anterior acromion

- control bleeding acromial branch of thoracoacromial artery

- axillary nerve 7 cm below acromion

- cannot split futher than 5 cm below acromion

- coracoacromial ligament detached from acromion

- bursectomy

- humeral head rotated to examine RC

 

Posterior approach

 

Indications

- open posterior stabilisation

- glenoid osteotomy / bone graft

- ORIF glenoid neck fracture

 

Approach

 

Shoulder Posterior Approach

 

Position

- lateral position with arm draped free

- beach chair with access to posterior shoulder

 

Landmarks

- acromion and scapula spine

 

Incision

1.  Transverse along entire scapular spine to PL corner acromion

2.  Longitudinal from postero-lateral acromion to axilla

 

Internervous plane

- between IS (suprascapular nerve) and T minor (axillary nerve)

 

Superficial dissection

- deltoid split in line of fibres

- infraspinatous and teres minor exposed

- IS tagged laterally then detached 1 cm from insertion

- joint capsule exposed

 

Dangers

 

Axillary nerve / posterior circumflex humeral artery

- emerges through quadrangular space beneath T minor

 

Suprascapular nerve

- passes around base of scapular spine

- IS must not be forcefully retracted medially to stretch the nerve around base of scapular spine