The document discusses different approaches to the shoulder joint for surgical procedures, including the anterior, posterior, and lateral approaches. It describes the indications, patient positioning, incision sites, surgical planes, and structures at risk for each approach. It also covers the rotator cuff muscles, labrum, biceps tendon, and concavity compression theory of shoulder joint stability. The concavity compression theory demonstrates that the humeral head is stabilized in the glenoid cavity by compressive forces, and this effect is increased by an intact labrum.

1. APPROACHES TO SHOULDER JOINT
&
STABILITY OF SHOULDER JOINT
PRESENTATION BY - DR. PRADEEPKUMAR. T
MODRATOR- DR. VINEET THOMAS ABRAHAM

2. ANTERIOR APPROACH
LATERAL APPROACH
POSTERIOR APPROACH

3. ANTERIOR APPROACH
INDICATION :-

4. POSITION OF PATIENT
Coracoid
Process,
Clavicle & Deltopectoral
groove

5. ANTERIOR INSICION :-10-15cm
straight incision along the D/P groove.

6. AXILLARY INSICION :-
Supine and abduct the shoulder
to 90 degree.
Vertical insicion 8-10cm
long starting at mid
point of ant axillary fold
extending posteriorly in
to axilla.

7. TRUE INTERNERVOUS PLANE
Deltoid (axillary) and Pec Major
(pectoral nerve)

8. ANTERIOR SUPERFICIAL DISSECTION
Develop the groove b/w the fascia overlying
pectoralis Major and deltoid

9. ANTERIOR DEEP DISSECTION
Subscapularis muscle lies in the deep part part of the
wound and incised perpendicular to its fibres and
close to its tendon .
External rotation to avoid damage to axillary nerve

12. DANGER ZONES
• Musculocutaneous Nerve
• Axillary Nerve
• Coracoid process
• Cephalic Vien

13. ADVANTAGES :-
The approach is through an internervous plane
b/w deltoid and pectoralis major Incision can be
expanded proximally or distally
DISADVANTAGES :-
The approach is clearly the best and it
has no significant disadvantages

14. POSTERIOR APPROACH OF SHOULDER
JOINT
INDICATIONS :-Repairs in cases of recurrent
posterior dislocation or
subluxation of the shoulder
Glenoid osteotomy
Biopsy and excision of tumors
Removal of loose bodies in

15. Drainage of sepsis
Fractures of the scapula neck,
particularly those in association
with fractured clavicles
Posterior fracture dislocations of
the proximal humerus

16. POSITION OF THE PATIENT :-
LANDMARKS :- Acromion and spine of scapula

17. INCISION :-Linear over the entire length of scpular
line extending to post corner of acromion

18. INTERNERVOUS PLANE :-

19. SUPERFICIAL DISSECTION
Identify the origin of the deltoid muscle, the
spine of the scapula, and the attachment from
its origin detaching the muscle from the
lateral to the medial point

20. DEEP SURGICAL DISSECTIONS

22. STRUCTURES AT RISK
• Axillar nerve
• Suprascapular nerve
• Post circumflex humeral artery

23. LATERAL APPROACH OF PROXIMAL
HUMERUS
INDICATIONS :- Open reduction and internal
fixation of the displaced
fractures of the greater tuberosity
of the humerus.
Open and internal fixation of humeral
neck fractures.
Removal of calcific deposits from the
subacromial bursa
Repair of supraspinatus tendon .
Repair of rotator cuff.

24. POSITION OF PATIENT :-
Supine position with effected arm on edge of
table
LANDMARKS :- Acromion

25. INCISION :-
5cm longitudinal incision from tip of
acromion to lateral aspect of arm
INTERNERVOUS PLANE :- No internervous plane

26. SUPERFICIAL SURGICAL EXPOSURE
Split the deltoid muscle in the line of fibres
from the acromion downwards for 5cm and
apply a stay sutures at inferior apex.

27. DEEP SURGICAL EXPOSURES

28. STRUCTURES AT RISK
AXILLARY NERVE
EXTENSILE MEASURES :-
Proximal Extension -incision superiorly and
medially across the acromion

29. ROTATOR CUFF MUSCLES
• Supraspinatus
– attach to greater tubercle from above (Abduct)
• Infraspinatus
– attach to greater tubercle posteriorly (Ext. Rot.)
• Teres Minor
– attach to greater tubercle posteriorly (Ext. Rot.)
• Subscapularis
– attach to lesser tubercle anterior (Int. Rot.)

30. ROTATOR CUFF MUSCLES
• Not very large
• Must possess strength & muscular endurance
• Conducting repetitious overhead activities
(throwing, swimming, & pitching) with poor
technique, muscle fatigue, or inadequate warm-
up & conditioning leads to failure of rotator cuff
muscle group in dynamically stabilizing humeral
head in glenoid cavity
• Leads to further rotator cuff problems such as
tendinitis & rotator cuff impingement within
subacromial space

31. SUPRASPINATUS
• ABDUCTION
• STABILIZATION OF THE HUMERAL HEAD IN
GLENOID FOSSA

32. INFRASPINATUS
• EXTERNAL ROTATION
• HORIZONTAL ABDUCTION
• EXTENSION
• STABILIZATION OF
HUMERAL HEAD IN
GLENOID FOSSA

33. TERES MINOR
• EXTERNAL ROTATION
• HORIZONTAL ABDUCTION
• EXTENSION
• STABILIZATION OF
HUMERAL HEAD IN
GLENOID FOSSA

34. SUBSCAPULARIS
• INTERNAL ROTATION
• ADDUCTION
• EXTENSION
• STABILIZATION OF
HUMERAL HEAD IN
GLENOID FOSSA

35. LABRUM
The Labrum deepens the cavity (the glenoid
cavity) and effectively increases the surface of
the shoulder joint.
A ring of fibrocartilage that runs around the
cavity of the scapula (wingbone) in which the
head of the humerus (the bone in the upper
arm) fits

36. BICEPS TENDON
Many theories have been proposed regarding
the function of the LHB tendon; however, its
exact purpose is poorly understood. It has been
described as an important stabilizer of the
glenohumeral joint, a depressor of the humeral
head, and as a vestigial structure. The LHB
tendon can be a significant source of pain in
patients with rotator cuff tears.

37. CONCAVITY COMPRESSION THEORY
A compressive load of 50 N was applied to the
humeral head in a direction perpendicular to the
glenoid surface.
Increasing tangential forces were then applied
until the head dislocated over the glenoid lip.
The tangential force at dislocation was examined
for eight different directions, 45° apart around
the glenoid.
Concavity-compression stability was then
examined for an increased compressive load of
100 N.

38. CONCAVITY COMPRESSION THEORY
Finally, the protocol with 50 and 100 N of
compressive load was repeated after the glenoid
labrum was excised.
Concavity-compression of the
humeral head into the glenoid is a
most efficient stabilizing mechanism.
With the labrum intact the humeral
head resisted tangential forces of up
to 60% of the compressive load.

39. The degree of compression stabilization varied
around the circumference of the glenoid with the
greatest magnitude superiorly and inferiorly.
This may be attributed to the greater glenoid depth
in these directions.
Resection of the glenoid labrum reduced the
effectiveness of compression stabilization by
approximately 20%
CONCAVITY COMPRESSION THEORY

40. CONCAVITY COMPRESSION THEORY
Concavity-compression may be an important
mechanism for providing stability in the mid-
range of glenohumeral motion where the
capsule and ligaments are lax. The effectiveness
is enhanced by the presence of an intact glenoid
labrum.