Surgical approach

1. Surgical Approaches to Shoulder
and Arm

3. Anterior ( Deltopectoral) approach
• Indications:
– Open Capsulorraphy
– Shoulder arthroplasty
– Proximal humerus fractures.

4. 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.

5. Extended deltopectoral incision
• Arthroplasty / Fracture
• 10-15 cm incision just
lateral to the coracoid
process to the deltoid
insertion.

6. Limited anterior incision
• Open capsulorraphy
• Coracoid bone block
transfers.
• 5 cm vertical incision
from the coracoid to
the inferior axillary
crease.

7. 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

9. • Incision made in the
clavipectoral fascia
lateral to the conjoint
tendon.
• Identify the
subscapularis and
conjoint tendon.
• Capsule may or may not
be released.

11. POSTERIOR APPROACH TO THE
SHOULDER

12. INDICATIONS
• Posterior capsulorrhaphy
• Posterior glenoid fractures
• Posterior glenoid osteotomy

13. 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

14. 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.

15. 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

16. 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

17. • 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

18. • 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.

19. SUPEROLATERAL APPROACH

20. Indications
• Rotator cuff tears and acromion fractures.
• Beach chair position.

21. 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.

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

23. • 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.

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

25. • 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.

26. Deltoid Splitting Approach

27. • 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.

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

30. Anterior Approach to Humerus

31. • Supine with use of an
arm board.
• 8- to 12-cm incision is
made along the lateral
border of the biceps.

32. Superficial Dissection
• Brachialis splitting/
Brachialis- biceps
interval.

33. Posterior Approach

34. • Humerus fractures and
radial nerve
exploration.
• 10- to 15-cm midline
longitudinal incision is
made directly
posteriorly.

35. • 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

36. 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.