This document summarizes the anatomy of the shoulder and approaches for shoulder surgery. It describes: 1) The bones, muscles, ligaments and joints of the shoulder including the humerus, glenoid fossa, rotator cuff muscles, labrum and key landmarks. 2) Six surgical approaches to the shoulder - anterior, anterolateral, lateral, minimal access, posterior and anterior arthroscopic. 3) The anterior approach in detail, including patient positioning, incision along the deltopectoral groove, identification of landmarks like the coracoid process, and layer-by-layer dissection of muscles like the deltoid, pectoralis major and subscap

1. SEMINAR ON APPLIED ANATOMY AND SURGICAL
APPROACHES TO SHOULDER
Moderator :- Dr.B.B.Dayanand
Presentor :- Dr. Hari krishna Bachu

2. Surgical anatomy of shoulder
Anatomy

3. Shoulder
• It is a ball and socket joint that moves in all
three planes and has.
• Most mobile and least stable joint.

4. • Humeral head
• Tuberosities:
– Greater (lateral)
– Lesser (medial)
– Bicipital Groove
• Glenohumeral Joint
– Instability/laxity
– Labrum
– Capsule

5. Muscles of the Shoulder Joint
• The four rotator cuff
muscles cover the humeral
head and hold the head
against the glenoid fossa.

6. 1 2
3
4
1. Subscapularis
2. Supraspinatus
3. Infraspinatus
4. Teres Minor

7. • Glenoid labrum-fibrocartilage ring attached to
the rim of the glenoid fossa, which deepens the
cavity.

8. Shoulder Landmarks
• Greater Tubercle/Tuberosity- large projection
lateral to the head. Supraspinatus,
infraspinatus and teres minor attach here.

9. • Lesser Tubercle/Tuberosity- smaller projection
on the anterior surface, subscapularis attaches
here.

10. Deltoid.
•Origin. Anterior border of lateral
third of clavicle. Outer border of
acromion and inferior lip of crest of
scapular spine.
•Insertion. Deltoid tubercle of
humerus.
•Action. Abduction of shoulder.
Anterior fibers act as flexors of
shoulder; posterior fibers act as
extensors of shoulder.
•Nerve supply. Axillary nerve.

11. Pectoralis Major.
•Origin. From two heads
• Clavicular head: from medial half of clavicle.
Sternocostal head: from manubrium and body of
sternum, upper 6 costal cartilages, and
aponeurosis of external oblique.
• Insertion. Lateral lip of bicipital groove of
humerus.
•Action. Adduction of arm.
•Nerve supply. Medial and lateral pectoral nerves.
(A separate branch of the lateral pectoral groove
supplies the clavicular fibers.)

12. Coracobrachialis.
• Origin. Tip of coracoid process.
• Insertion. Middle of medial border of humerus.
•Action. Weak flexor of arm and weak adductor of arm.
• Nerve supply. Musculocutaneous nerve.
Biceps Brachii.
• Origin. Short head from tip of coracoid process. Long
head from supraglenoid tubercle of scapula.
•Insertion. Bicipital tuberosity of radius.
•Action. Flexor of elbow. Supinator of forearm. Weak
flexor of shoulder.
• Nerve supply. Musculocutaneous nerve.

13. •Pectoralis Minor.
• Origin. Outer borders of third,
fourth, fifth, and sixth ribs.
•
•Insertion. Coracoid process of
scapula.
• Action. Lowers lateral angle of
scapula. Protracts scapula.
•Nerve supply. Medial pectoral nerve

14. • Articulations
– Sternoclavicular
– Acromioclavicular
– Scapulothoracic
– Glenohumeral

15. Coracoacromial Ligament
• coracoacromial ligament is
triangular and connects the
horizontal portion of the coracoid
process to the tip of the acromion.
•
The coracoid process, the
acromion, and the coracoacromial
ligament form the coracoacromial
arch

16. Conoid and Trapezoid Ligaments
The conoid ligament:
resembles an inverted cone,
extends upward from the upper surface of the knuckle of the
coracoid process to the undersurface of the clavicle.
The trapezoid ligament:
runs from the upper surface of the coracoid process and
extends superiorly and laterally to the trapezoid ridge on the
undersurface of the clavicle.
These two structures are the main accessory ligaments of the
acromioclavicular joint.
They are extremely difficult to repair in cases of
acromioclavicular dislocation.

17. Vasuclar supply

18. Lymphatic drainage

19. Surgical approaches to shoulder
Six surgical approaches
1. anterior,
2. anterolateral,
3. lateral,
4. minimal access approach to the proximal
humerus,
5. posterior, and
6. Anterior arthroscopic

20. Anterior Approach
The anterior surgical approach offers good wide
exposure of the shoulder joint,
allowing repairs to be made of its anterior,
inferior, and superior coverings.
the anterior approach permits the following:
•Reconstruction of recurrent dislocations,
•Drainage of sepsis ,biopsy and excision of
tumors
•Repair or stabilization of the tendon of the
long head of the biceps
•Shoulder arthroplasties, which usually are
inserted through modified anterior incisions

21. Position of the Patient
• supine position on the operating table.
• Wedge a sandbag under the spine and medial
border of the scapula to push the affected side
forward while allowing the arm to fall backward,
opening up the front of the joint.

22. Applied Surgical Anatomy of the Anterior Approach
Landmarks and Incision
Landmarks
•The coracoid process of the scapula is an accessible bony protuberance that lies at
the upper end of the deltopectoral groove and is the landmark for incisions based on
that groove.
• critical landmark for injections and arthroscopic examinations of the shoulder joint.
Hook shaped.
• The tip of the coracoid process projects forward, laterally, and inferiorly toward the
glenoid cavity.
• it is palpated best by posterior and medial pressure.
• tenderness over this site is not diagnostic of local pathology.
•Ligaments attached to the coracoid process

23. Deltopectoral Groove
The cephalic vein, runs in the groove, sometimed is visible
Incisions
The anterior aspect of the shoulder can be approached
through either of two skin incisions
Anterior and axillary
Anterior Incision
Make a 10- to 15-cm straight incision, following the line
of the deltopectoral groove. The incision should begin
just above the coracoid

24. Axillary Incision
• the patient supine,
abduct the shoulder 90° and rotate it externally.
• Mark the anterior axillary skin fold with a sterile pen.
•Make a vertical incision 8 to 10 cm long, starting at the
midpoint of the anterior axillary fold and extending
posteriorly into the axilla.
•The skin flaps should be undermined extensively with a
finger, especially superiorly in the area of the deltopectoral
groove, using the cephalic vein as a guide to ensure correct
position in the vertical plane.
•Retract the skin flaps upward and laterally so that the
incision comes to lie over the deltopectoral groove

25. the groove between the fascia overlying
the pectoralis major and the fascia
overlying the deltoid. The cephalic vein
will be of help in locating the groove

26. •Superficial Surgical Dissection
•superficial surgical dissection of the anterior approach to the shoulder joint: the
deltoid muscle laterally,
•the pectoralis major muscle medially, and
•the cephalic vein.
•Deltoid Muscle
•The anterior fibers of the deltoid muscle run parallel to each other, without fibrous
septa between them.
• Sutures must be placed through the full thickness of the muscle, including its fascial
coverings, to effect a strong reattachment.
•The attachment should be protected from active stress for 4 weeks to heai
adequately
•The anterior portion of the deltoid can be denervated only if the entire anterior part
of the muscle is stripped and retracted vigorously in a lateral direction.
•Pectoralis Major Muscle
•Cephalic Vein
•The cephalic vein drains into the axillary vein after passing through the clavipectoral
fascia.

27. Surgical Dissection
•The short head of the biceps and the coracobrachialis (which is
supplied by the musculocutaneous nerve) must be displaced
medially before access can be gained to the anterior aspect of the
shoulder joint.
•the two muscles can be detached with the tip of the coracoid
process. To release them, detach the tip of the coracoid process with
an osteotome. The bone can be replaced later either with a screw or
with sutures
•If a screw is used, the coracoid process must be drilled and tapped
before the osteotomy is carried out.
•Otherwise, the small piece of coracoid may split during drilling, and
anatomic reduction can be obtained only with extreme difficulty

28. The axillary artery is surrounded by the cords of the brachial
plexus, which lie behind the pectoralis minor muscle.
Abduction of the arm causes these neurovascular structures
to become tight and brings them close to the tip of the
coracoid and the operative site.
Retract the coracoid medially
Divide the fascia that fans out from the conjoined tendons
of the coracobrachialis and the short head of the biceps on
the lateral side of the coracobrachialis—because the
musculocutaneous nerve enters the coracobrachialis on its
medial side.
downward retraction can cause a neurapraxia of the
musculocutaneous nerve. If the coracoid process is left intact,
the attached coracoid muscles protect the nerve from
traction injury.

30. Beneath the conjoined tendons of the
coracobrachialis and the short head of the
biceps lie the transversely running fibers of
the subscapularis muscle, which forms
anterior covering of the shoulder joint
capsule
As the muscle crosses the glenoid cavity, a
bursa separates it from the joint capsule;
that bursa communicate with the shoulder
joint.

31. A) The subscapularis muscle lies in the deep part of the wound. It is to be incised perpendicular to its
fibers, close to its tendon. The axillary nerve passes anteroposteriorly through the quadrangular space.
B) External rotation of the arm during incision into the subscapularis tendon will draw the point of incision
away from the axillary nerve.

32.  multiple anterior dislocations, adhesions often exist
between the muscle and the joint capsule, making it
difficult, to find the layer between the two. .
• Apply external rotation to the arm to stretch the
subscapularis, increases the distance between the
subscapularis and the axillary nerve as it disappears
below the lower border of the muscle
• landmarks on the inferior border of the subscapularis are
a series of small vessels that run transversely The vessels
run as a triad: a small artery with its two surrounding
venae comitantes,
• The superior border of the subscapularis muscle is
indistinct and blends in with the fibers of the
supraspinatus muscle

33. •Deep Surgical Dissection
•The coracobrachialis and the short head of the biceps brachii share a
common origin from the tip of the coracoid process. common nerve
supply, the musculocutaneous nerve. These muscles form an
intermediate layer during the surgical approach
•Coracobrachialis Muscle
•The coracobrachialis muscle is largely vestigial and has little
function.
•The coracobrachialis used to have three heads of origin. The
musculocutaneous nerve passes between two of the original heads,
which now are fused during development.
•Biceps Brachii Muscle
•The joint capsule of the shoulder is incomplete inferiorly, so the
tendon can escape under the transverse ligament.
•it runs in the bicipital groove of the humerus.

34. Pectoralis Minor Muscle
•second part of the axillary artery and the cords of the brachial
plexus lie directly behind the muscle and below the coracoid
process
Subscapularis Muscle
•Forms the deep layer of the dissectio
•inserts partly into the capsule of the joint.
•The subscapularis limits external rotation, helping to prevent
anterior dislocations Because the two subscapular nerves enter
the subscapularis medially, incising it 2.5 cm from its insertion
does not denervate the muscle
•Superiorly, the muscle is connected to the supraspinatus.
•The plane of cleavage between the two muscles, which
represents a true internervous plane between the suprascapular
and subscapular nervesThe tendon of the long head of the
biceps corresponds to the interval between the muscles and can
be used as a surgical guideline to that interval.

35. Shoulder Joint Capsule
Anteriorly, attached to scapula via the border of the
glenoid labrum
Posteriorly and inferiorly, attached to the border of the
labrum.
The fibrous capsule inserts into the humerus around the
articular margins of the neck, except inferiorly, where the
insertion is 1 cm below the articular margin.
The capsule bridges the gap across the bicipital groove,
forming a structure known as the transverse ligament.
The long head of the biceps enters the joint beneath this
ligament

36. Synovial Lining of the Shoulder Joint
•The synovial membrane, which is attached around the
glenoid labrum, lines the capsule of the joint.
• The membrane usually communicates with the
subscapularis bursa and with the infraspinatus bursa.
•It envelopes the tendon of the long head of the biceps
within the shoulder joint.
•The synovium forms a tubular sleeve that permits the
tendon to glide back and forth during abduction and
adduction of the arm.
•Therefore, the tendon is anatomically intracapsular, but
extrasynovial

37. Glenoid Labrum
The glenoid labrum is a triangular,
fibrocartilaginous structure that rings the glenoid
cavity .The joint capsule attaches to it superiorly,
inferiorly, and posteriorly.

38. To Enlarge the Approach
Local Measures
The exposure can be enlarged in the following four ways:
1. extend the skin incision superiorly by curving it laterally along the
lower border of the clavicle. Detach the deltoid from its origin on
the outer surface of the clavicle for 2 to 4 cm to permit better
lateral retraction of the muscle (Fig. 1-15).
2. Lengthen the skin incision inferiorly along the deltopectoral
groove to separate the pectoralis major from the deltoid further
inferiorly and to improve the exposure without having to detach
the deltoid origin.
3. Use a suitable retractor (such as the Bankart skid) for the humeral
head. A humeral head retractor is the key to excellent exposure
of the inside of the glenoid fossa
4. Rotate the shoulder internally and externally to bring different
elements of the anterior shoulder coverings into view.

39. Extensile Measures
•Proximal Extension
•extend the skin incision superomedially, crossing the middle third of
the clavicle.
• dissect the middle third of the clavicle subperiosteally and perform
osteotomy of the bone,
•Cut the subclavius muscle, which runs transversely under the
clavicle. Retract the trapezius superiorly and the pectoralis major
and pectoralis minor inferiorly to reveal the underlying axillary
artery and the surrounding brachial plexus .
•Distal Extension
•The approach can be extended into an anterolateral approach
to the humerus.
•Extend the skin incision down the deltopectoral groove, then
curve it inferiorly, following the lateral border of the biceps.
Deep dissection consists of moving the biceps brachii medially to
reveal the underlying brachialis

40. Dangers
•Nerves
•The musculocutaneous nerve enters the body of the
coracobrachialis about 5 to 8 cm distal to the muscle's
origin at the coracoid process. Because the nerve enters
the muscle from its medial side, all dissection must remain
on the lateral side of the muscle.great care should be
taken not to retract the muscle inferiorly, to avoid
stretching the nerve and causing paralysis of the elbow
flexors.
•Vessels
• The cephalic vein should be preserved
• A traumatized cephalic vein should be ligated to prevent
the slight danger of thromboembolism

41. Anterolateral Approach
The anterolateral approach to the shoulder offers excellent
exposure of the acromioclavicular joint and the underlying
coracoacromial ligament and supraspinatus tendon.
•Anterior decompression of the shoulder
•Repair of the rotator cuff
•Repair or stabilization of the long head of a biceps tendon
•Excision of osteophytes from the acromioclavicular joint
•extensive degenerative disease of the rotator cuff.

42. Position of the Patient
•Place the patient in the supine position on the operating
table, with a sandbag under the spine and medial border of
the scapula to push the affected side forward.
•Elevate the head of the table 45°.

43. Superficial Surgical Dissection
Superficial surgical dissection involves splitting the fibers of the deltoid
muscle. Proximal extension of the approach to expose the supraspinatus
involves splitting the fibers of the trapezius muscle
•Deltoid Muscle
•The lateral deltoid consists of oblique fibers arising in a multipennate
fashion from tough tendinous bands that originate from the acromion.
•This multipennate arrangement provides the deltoid muscle with
maximum strength, although it limits the degree to which it can
contract.
•it is relatively easy to split the muscle in a longitudinal fashion. The
tough tendinous bands also prevent excessive damage to the muscle
when it is split during surgery

44. Landmarks and Incision
Landmarks:
Coracoid Process
Palpate the coracoid process 1 in. from the anterior end of the clavicle just inferior to
the deepest point of the clavicular concavity.
Acromion
Palpate the acromion at the shoulder summit.
Incision:
Make a transverse incision that begins at the anterolateral corner of the acromion and
ends just lateral to the coracoid process
Internervous Plane
No internervous plane is available for use. The deltoid muscle is detached at a point
well proximal to its nerve supply, which, therefore, is not in danger.

45. Supraspinatus Muscle
•multipennate muscle,
•passes laterally beneath the
coracoacromial ligament.
• The muscle is the frequent site
of degenerative changes and
frank tears.
•Degeneration in its tendon
invokes an inflammatory
response in the overlying
subacromial bursa, and most
cases of subacromial bursitis
probably reflect pathology in the
muscle.

46. Superficial Surgical Dissection
Split the deltoid muscle in the line of its fibers from the acromion
downward for 5 cm. Insert a suture at the inferior apex of the split to
help prevent it from extending accidentally, with consequent axillary
nerve damage.

47. Deep Surgical Dissection
•The lateral aspect of the upper humerus and its
attached rotator cuff lie directly under the deltoid
muscle and the subacromial bursa
•In fractures of the neck of the humerus, the bare
ends of bone usually appear at this point without
further dissection.
•Small tears of the supraspinatus muscle also can be
reached through this approach.

48. •Dangers
•Nerves
•The axillary nerve leaves the posterior wall of the axilla by
penetrating the quadrangular space. Then it winds around the
humerus with the posterior circumflex humeral arteries .
•The nerve enters the deltoid muscle posteriorly from its deep
surface, about 7 cm below the tip of the acromion. From that
point, its fibers spread anteriorly.
•the dissection cannot be extended farther in an inferior
direction without denervating that portion of the deltoid
muscle that is located anterior to the muscle split.

49. Extensile Measures
Proximal Extension
•Extend the incision superiorly and medially across the
acromion and parallel to the upper margin of the spine of
the scapula, about 1 cm above it along the lateral two
thirds of the scapular spine
• Incise the trapezius muscle parallel to the spine of
the scapula and about 1 cm above it. Retract the
muscle superiorly to reveal the supraspinatus and
its fascial covering

50. To expose the entire supraspinatus muscle, cut the acromion
and split the trapezius muscle to reveal the underlying
supraspinatus muscle belly and tendon

51. Posterior Approach
The posterior approach offers access to the posterior and inferior
aspects of the shoulder joint.
It rarely is needed, but can be used in the following instances:
•Repairs in cases of recurrent posterior dislocation or subluxation
of the shoulder.
•Glenoid osteotomy.
•Biopsy and excision of tumors
•Removal of loose bodies in the posterior recess of the shoulder
•Drainage of sepsis (the approach allows dependent drainage with
the patient in the normal position in bed)
•Treatment of fractures of the scapula neck, particularly those in
association with fractured clavicles (floating shoulder)
•Treatment of posterior fracture dislocations of the proximal
humerus.

52. Applied Surgical Anatomy of the Posterior
Approach
Landmark
The spine of the scapula
Superficial Surgical Dissection
•In the posterior approach, only those fibers of the deltoid muscle that arise from the
spine of the scapula are detached.
Deep Surgical Dissection
•The deep dissection in this approach lies between the infraspinatus and teres minor
muscles
•Infraspinatus Muscle
•The fibers of the infraspinatus muscle are multipennate;
•numerous fibrous intramuscular septa give attachment to them.
•The infraspinatus forms its tendon just before crossing the back of the shoulder
joint; a small bursa lies between the muscle and the posterior aspect of the
scapular neck to help the tendon glide freely over the bone.
•Teres Minor Muscle
•The teres minor runs side by side with the infraspinatus. Its fibers run parallel
with one another, in contrast to the multipennate fibers of the infraspinatus; this
difference may help in identification of the interval between the two muscles.

53. Dangers
Axillary Nerve
The axillary nerve is a branch of the posterior cord of the brachial plexus. It runs down
along the posterior wall of the axilla on the surface of the subscapularis, far from the
incision made in that muscle during the anterior approach to the shoulder
Radial Nerve
branch of the posterior cord of the brachial plexus,
leaves the axilla by passing backward through a triangular space that is defined
superiorly by the lower border of the teres major, laterally by the shaft of the
humerus, and medially by the long head of the triceps
Circumflex Scapular Vessels
Yet another triangular space exists when the inner sleeve of shoulder muscles is
viewed from the back. Its boundaries are as follows: superiorly, the lower border of
the teres minor.

55. Arthroscopic Approaches to the Shoulder
General Principles of Arthroscopy
•The most commonly used arthroscope is angulated
30° at its tip so that the view obtained shows the
structures that are 30° from the long axis of the
arthroscope and not the structures that are directly in
front of the scope
•The use of an angled scope allows the surgeon to
see “around the corner” and thereby greatly
increases the view obtained within any joint.

56. Visualization of structures using
an arthroscope

57. Rotating the scope will provide a series
of views at angles of 30°

58. •Because the scope is angled 30° from its axis, it is not
possible to zoom in on an object merely by advancing the
scope.
•Rotating the arthroscope will reveal a series of views
angled at 30° from the axis of the scope
•Angling the scope will change the direction of the
view.one will not be able to visualize those structures
directly in front of the arthroscope unless you angle it.
•It is possible to change the view by moving the joint while
leaving the arthroscope in the same position. This
maneuver is vital for full inspection of any joint

59. Arthroscopy of the shoulder is indicated in
•Arthroscopic subacromial decompression for
chronic rotator cuff tendonitis
•Treatment of partial thickness tears of the
rotator cuff
•Treatment of tears of the glenoid labrum
•Treatment of degenerative disease of the
acromioclavicular joint
•Removal of loose bodies
•Treatment of osteochondritis dissecans
•Synovectomy

60. Position of the patient
“beach chair” position

61. Incisions
Posterior
Make an 8-mm stab incision 2 cm inferior and 1 cm medial to the posterolateral tip of the
acromion
Anterior
Make an 8-mm stab incision halfway between the tip of the coracoid process and the anterior
aspect of the acromion

62. Internervous Plane
Posterior
The internervous plane lies between the
teres minor muscle (supplied by the
axillary nerve) and the infraspinatus
muscle (supplied by the suprascapular
nerve)
Anterior
The internervous plane lies between the
pectoralis major muscle (supplied by the
medial and lateral pectoral nerves) and
the deltoid (supplied by the axillary
nerve).

63. Posterior insertion of the arthroscope. Place your finger on
the coracoid process. Insert the trochar and arthroscopic
sheath through the posterior skin incision, aiming the tip of
the arthroscope toward your finger.

64. Anterior insertion of the arthroscope. Insert an arthroscope
through the posterior portal to allow you to visualize the anterior
capsule of the shoulder joint. Next, insert a long hypodermic
needle through the anterior skin incision and enter the joint
under direct vision of the scope

65. Order of Scoping
Insert a 30° arthroscope through the posterior incision.
•Identify the biceps tendon and its origin as it runs from
superior to inferior.
•Next, rotate the arthroscope superiorly to allow
visualization of the supraspinatus .The supraspinatus lies
posterior to the biceps tendon.
•To visualize infraspinatus and teres minor you will need
to rotate not only the arthroscope but also the humeral
head .
•Next, note the anterior triangle of the shoulder, formed
by the biceps tendon, the superior edge of the
subscapularis, and the glenoid .This triangle marks the safe
spot for entry through the anterior portal.

66. •Pass the arthroscope to the upper anterior margin of the
glenoid and rotate the scope inferiorly to allow
examination of the anterior glenohumeral complex. You
may need to apply a distraction force to the shoulder at
that time, or alternatively use a 70° rather than a 30°
telescope.
•Pass the arthroscope anteriorly into the anterior triangle
and rotate the scope so as to allow you to look inferiorly
into a space underlying the subscapularis. This space is a
frequent site for loose bodies.
•Next, redirect the arthroscope inferiorly and rotate the
telescope posteriorly to allow access to the posterior
recess of the shoulder . Visualization of the humeral head
and glenoid are easily accomplished through the posterior
portal. Careful manipulation of the shoulder is required to
visualize the whole of the articular surface.

68. Dangers
Nerves
Posterior
•The axillary nerve leaves the posterior wall of the axilla by
penetrating the quadrangular space. It winds around the
humerus running on the deep surface of the deltoid
muscle, about 7 cm below the tip of the acromion.If the
posterior portal is correctly located with regard to the
posterolateral tip of the acromion, this portal should lie
about 3 cm superior to the nerve.
•The suprascapular nerve,runs around the base of the
spine of the scapula as it runs from the supraspinatus
fossa to the infraspinatus fossa .
• The correctly positioned portal is approximately 2 cm
lateral to the nerve.

69. Anterior
•The axillary nerve may be in danger as it traverses along
the deep surface of the deltoid from superiorly placed
incisions.
•The musculocutaneous nerve, the nerve supply of the
flexor muscles of the upper arm, enters those muscles
some 2 cm to 8 cm distal to the tip of the coracoid
process. The nerve, therefore, is unlikely to be damaged by
a portal made superior and lateral to the level of the
coracoid process
•Vessels
• The cephalic vein runs superficially between the deltoid
and pectoralis major muscle. It can only be damaged from
incisions made too laterally.

70. Thank you