By Dr. Sachin. M., 2 Junior resident, Dept of Orthopaedics, SMCH, SIlchar

1. ANTERIOR
APPROACH TO
THE SHOULDER
P R E S E N T E D BY : D R . S A C H I N . M .
2 N D Y E A R P G T, D E P T O F O R T H O PA E D I C S , S M C H
M O D E R ATO R : D R . A . K . S I PA N I
P R O F & H O D, D E P T O F O R T H O PA E D I C S , S M C H

2. INTRODUCTION
• Also known as Deltopectoral approach
• Fairly extensile exposure – gives access to the anterior, medial and
lateral aspects of the shoulder
• Can extend distally to include the anterior approach to the humerus.

3. INDICATIONS
• Shoulder arthroplasty
• Proximal humerus fractures
• Reconstruction of recurrent dislocations
• Injury to long head of the biceps – repair
• Septic glenohumeral joint – drainage
• Biopsy and excision of tumerus

4. INTERNERVOUS PLANE
• Deltoid muscle – Axillary nerve
• Pectoralis major – pectoral nerves

5. POSITION OF THE PATIENT
• Beach chair position – patient lying supine with head end of the table
elevated by 30-45 degrees
• Sandbag under the spine at the medial
end of the scapula

6. LANDMARKS
• Coracoid process
– Lies 2.5 cm distal to the point of maximum concavity of the distal clavicle
– Directed anterolaterally and covered by Pectoralis major
• Deltopectoral groove
– Look for cephalic vein which runs in this groove
– Easily seen in thin patients, but difficult in obese individuals

7. INCISION
• 10 - to 15 cm linear incision is made along the deltopectoral groove
• Begins at tip of coracoid process

8. SUPERFICIAL DISSECTION
• Superficial skin vessels can
bleed significantly – cauterize
• Deltopectoral fascia is
encountered first
• Cephalic vein is the landmark to
identify the deltopectoral
interval

9. SUPERFICIAL DISSECTION
• Mobilize the cephalic vein either medially or laterally
• Deltoid fibers are retracted laterally and fibers of pectoralis major are
retracted medially

10. DEEP DISSECTION
• Conjoint tendon of short head
of biceps and coracobrachialis
arise from the coracoid process
retracted medially
• Musculocutaneous nerve enters
the biceps 5-8cm distal to the
coracoid process – conjoint
tendon to be retracted with care

11. DEEP DISSECTION
• Fascia lateral to the conjoint tendon is cut to expose the subscapularis
tendon
• External rotation of the shoulder makes the subscapularis tendon taut
and pulls it away from the axillary nerve, which travels through the
quadrangular space

12. DEEP DISSECTION
• Subscapularis tendon can be mobilized either by incising the tendon
perpendicular to its fibers or by releasing its insertion on the LT
subperiosteally or via osteotomy

13. DEEP DISSECTION
• Capsule is incised to gain access into the joint

14. ENLARGEMENT OF EXPOSURE
• Extend the skin incision proximally along the clavicle and distally along
the deltopectoral groove
• Release deltoid either from its origin from the clavicle or from its
insertion on the humerus
• Partial detachment of pectoralis major tendon from its insertion
• Use of suitable retractors – Bankart skid
• Internal and external rotation of shoulder to expose the different areas
of the joint

15. ENLARGEMENT OF EXPOSURE

16. DANGERS
• Musculocutaneous nerve – neurapraxia if conjoint tendon is retracted
vigorously
• Cephalic vein – has to be preserved, works as landmark in case of
reversion surgeries
– Can be ligated if injured
• Axillary nerve – can be injured while incising the subscapularis tendon
– Can be avoided by external rotation of the shoulder
• Anterior circumflex humeral artery – runs anteriorly around the
proximal humerus proximal to pectoralis major tendon

17. THANK YOU