Surgical Approaches to Shoulder and Arm

Anterior ( Deltopectoral) approach

• Indications:– Open Capsulorraphy– Shoulder arthroplasty– Proximal humerus fractures.

Beach chair position

• Mayfield headrest or comercially available beach chair attachment.

• Upper torso elevated 30-60 degrees.

• Operated side positioned off the table.

• Arm holders.

Extended deltopectoral incision

• Arthroplasty / Fracture

• 10-15 cm incision just lateral to the coracoid process to the deltoid insertion.

Limited anterior incision

• Open capsulorraphy• Coracoid bone block

transfers.• 5 cm vertical incision

from the coracoid to the inferior axillary crease.

Superficial dissection

• Deltopectoral interval.• Cephalic vein is a key landmark• More easily dissected from PM and is

retracted with the deltoid.• Deltoid laterally, PM medially

• Incision made in the clavipectoral fascia lateral to the conjoint tendon.

• Identify the subscapularis and conjoint tendon.

• Capsule may or may not be released.

POSTERIOR APPROACH TO THE SHOULDER

INDICATIONS

• Posterior capsulorrhaphy• Posterior glenoid fractures• Posterior glenoid osteotomy

POSITIONING• Lateral Decubitus Position• Can follow arthroscopy in

this position• The nonoperative side

must be well protected– Use an axillary roll– Pad the elbow, fibular head,

and ankles– Secure the head

• Position and drape the operative arm so it is free

INCISION• A 6- to 8-cm vertical

incision is made directly over the glenohumeral joint and extended towards the axillary fold.

• Typically 2 cm medial to the posterolateral edge of the acromion and can incorporate a posterior arthroscopic portal.

SUPERFICIAL DISSECTION

• The deltoid is identified on the scapular spine

• The deltoid may be split in line with its fibers

• Deltoid can be retracted superiorly after detachment of the medial 2 cm of the deltoid origin

DEEP DISSECTION

• Interval between the infraspinatus and teres minor is identified

• The infraspinatus is identified by -– Horizontal direction of

muscle fibers– Bipennate nature– Fatty raphe that divides

the muscle belly

• Interval between the infraspinatus and teres minor is developed by blunt dissection.

• Taking down the infraspinatus from its humeral insertion.

• Splitting the two heads of the infraspinatus and using this interval

• Do not dissect below the teres minor muscle because of risk to the axillary nerve and posterior humeral circumflex artery.

• Fat may be present at the inferior border of the teres minor to help identify that you have gone too low

• When performing a glenoid osteotomy, the suprascapular nerve should be identified by dissection and palpation 0.5 to 2 cm medial to the glenoid neck.

SUPEROLATERAL APPROACH

Indications

• Rotator cuff tears and acromion fractures.

• Beach chair position.

Incision

• 5-cm oblique incision is made immediately proximal to the anterolateral corner of the acromion.

• Extended distally to the level of the inferior aspect of the coracoid.

Superficial dissection

• Deep deltoid fascia is identified along with the anterolateral corner of the acromion.

• The deltoid is detached and split-– Subperiosteally elevate

the deltoid from the anterolateral acromion and acromioclavicular joint.

– High-strength sutures are placed in the deltoid to aid in retraction and for later repair.

Deep dissection

• Identify the coracoacromial ligament, subacromial bursa, and supraspinatus tendon.

• The supraspinatus tendon and overlying bursa are exposed and explored by rotating the arm.

• The humeral head may be seen if a rotator cuff tear is present.

Deltoid Splitting Approach

• Rotator cuff repair and shoulder arthroplasty.

• Beach chair position.• Longitudinal incision up

to 5 cm is made from the midportion of the lateral acromion distally.

• Subdeltoid bursa and supraspinatus insertion on the greater tuberosity can be exposed

Anterior Approach to Humerus

• Supine with use of an arm board.

• 8- to 12-cm incision is made along the lateral border of the biceps.

Superficial Dissection

• Brachialis splitting/ Brachialis- biceps interval.

Posterior Approach

• Humerus fractures and radial nerve exploration.

• 10- to 15-cm midline longitudinal incision is made directly posteriorly.

• Incision in the fascia in line with the skin incision.

• Identify and separate the lateral and long head of the triceps.

• interval is more obvious proximally as the tendons merge distally

Deep dissection

• Medial (deep) head is exposed and split.

• Radial nerve passes from medial to lateral in the upper/middle portion of the field and should be identified and protected.