This document describes the anterior approach to the shoulder. It begins with an introduction stating that this approach, also known as the deltopectoral approach, provides access to the anterior, medial, and lateral aspects of the shoulder. It then discusses indications for the approach, landmarks, patient positioning, incision details, layer-by-layer dissection, potential dangers, and techniques for exposure enlargement. The overall purpose is to provide an overview of how to perform the anterior approach to the shoulder.

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