This document describes several surgical approaches to the shoulder and elbow. For the shoulder, it discusses the anterior, anterolateral, lateral, posterior, posterior inverted U, and transacromial approaches. For the elbow, it covers the posterior, anterior, medial, anterolateral, lateral J-shaped, posterolateral, and Boyd approaches. Each approach is described in terms of indications, patient positioning, incision details, exposure of relevant structures, and potential dangers.

1. SURGICAL
APPROACHES TO
SHOULDER &
ELBOW
Dr. Sijan Bhattachan
2nd year resident
NAMS

2. Approaches to shoulder
• Anterior Approach
• Anterolateral Approach
• Lateral Approach
• Posterior Approach
• Posterior Inverted U Approach

3. Anterior approach to
shoulder
• Offers good wide exposure of shoulder joint,
allowing repairs to be made of its anterior,inferior
and superior coverings.

4. Indications
• Fixation of fractures of proximal humerus
• Shoulder arthroplasties
• Reconstruction of recurrent dislocations
• Drainage of sepsis
• Biopsy and excision of tumors
• Repair or stabilisation of the tendon of the long head of
biceps

5. Position
• Supine
• Sandbag under the spine and medial border of scapula
• Elevate the head of table 30-45 degrees to reduce venous
pressure and thereby decrease bleeding.

6. Incision
• Anterior; 10-15 cm straight incision,beginning just
above the coracoid and following the line of
deltopectoral groove.
• Axillary;
-Abduct shoulder 90 degree and rotate it externally
-Vertical incision 8-10 cm long, starting at the midpoint
of anterior axillary fold and extending posteriorly into
the axilla.

8. Internervous plane
• Between the Deltoid muscle
(Axillary nerve) and the Pectoralis
major muscle (Medial & Lateral
Pectoral nerves)

9. Superficial dissection
• Deltopectoral groove; Cephalic vein
• Retract pectoralis major medially and deltoid
laterally

11. Deep dissection
• Short head of biceps and the coracobrachialis must be displaced
medially.
• Two muscles can be detached with the tip of coracoid process for
more exposure.
• Beneath the conjoined tendons, lies the transversely running fibers
of subscapularis muscle
• Series of small vessels that run transversely on the inferior border of
subscapularis
• Divide subscapularis from its insertion
• Incise capsule longitudinally to enter the joint

16. Dangers
• Musculocutaneous nerve
-Enters the body of
coracobrachialis about 5-8 cm
distal to the muscle’s origin at
the coracoid process
• Cephalic vein
• Axillary nerve

17. Anterolateral approach to
ACJ and subacromial space
• Offers excellent exposure of the ACJ and the
underlying coracoacromial ligament and
supraspinatus tendon

18. Indications
• Repair of rotator cuff
• Anterior decompression of shoulder
• Repair or stabilisation of the long head of biceps
tendon
• Excision of osteophytes from the ACJ

19. Position
• Supine

20. Incision
• Transverse incision that begins at the anterolateral
corner of the acromian and ends just lateral to the
coracoid process

21. Internervous plane
• No internervous plane
• Deltoid muscle is detached at a point well proximal
to its nerve supply

22. Superficial dissection
For subacromial decompression
• Detach the fibers of deltoid that arise from ACJ and
continue this detachment by sharp dissection
laterally to expose 1 cm of the anterior aspect of
acromian
• Acromial branch of coracoacromial artery;
coagulate

23. For rotator cuff repair
• Split deltoid muscle in the line of its fibers starting at
ACJ
• Extend the split 5 cm down from ACJ; stay surfers
at apex

27. Deep dissection
• Detach coracoacromial ligament from acromian.
• Also detach medial end of coracoacromial ligament
just proximal to the coracoid process and excise
ligament
• Supraspinatus tendon with its overlying subacromial
bursa is now revealed

29. Dangers
• Axillary nerve
-Runs transversely across the deep surface of the
deltoid muscle about 7 cm below the tip of acromian.
• Acromial branch of coracoacromial artery
-Runs immediately under the deltoid muscle

30. Lateral approach to
Proximal humerus
• Limited access to the head and surgical neck of
humerus; not extensile.

31. Indications
• ORIF of displaced fractures of greater tuberosity of
humerus
• ORIF of humeral neck fractures
• Removal of calcific deposits from the subacromial
bursa
• Repair of rotator cuff

32. Position
• Supine

33. Incision
• 5 cm longitudinal
incision from the tip
of acromian down
the lateral aspect
of the arm

34. • No true internervous plane
• Involves splitting of deltoid muscle

35. Superficial dissection
• Split the deltoid in the line of its fibres from the
acrimony downward for 5 cm
• Suture at inferior apex of split

37. Deep dissection
• Lateral aspect of upper humerus and its attached
rotator cuff lie directly under the deltoid muscle and
subacromial bursa
• In the upper part of the wound, the exposed
subacromial bursa must be incised longitudinally to
provide access to the upper lateral portion of the
head of humerus

40. Dangers
• Axillary nerve;
- Leaves the posterior wall of the axilla by penetrating
the quadrangular space. Then winds around the
humerus with the posterior circumflex humeral arteries
-Enters deltoid muscle posteriorly from its deep
surface, about 7 cm below the tip of acrimony
-Then its fibers spread anteriorly

41. Transacromial Approach
• Excellent for surgery of the musculotendinous cuff
and for fracture dislocations of the shoulder
• Skin incision just lateral to ACJ from the posterior
aspect of acromian, superiorly and anteriorly to a
point 5 cm distal to the anterior edge of acromian,

42. • Detach deltoid from acromial, origin and divide
coracoacromial ligament
• Osteotomy of acromian.
• Split any of tendons of the cuff or separate two of
them to expose joint

44. Posterior approach
• Offers access to posterior and inferior aspects of
shoulder joint

45. Indications
• Treatment of posterior fracture dislocations of proximal humerus
• Repairs in cases of recurrent posterior dislocation of the shoulder
• Glenoid fracture/ osteotomy
• Treatment of fractures of scapula neck (esp in case of floating
shoulder)
• Removal of loose bodies in the posterior recess of shoulder
• Drainage of sepsis
• Biopsy and excision of tumors

46. Position
• Lateral position

47. Incision
• Linear incision along the entire length of the
scapular spine, extending to the posterior corner of
the acromian

48. Internervous plane
• Between the teres minor muscle (Axillary nerve)and
the infraspinatus muscle (suprascapular nerve)

49. Superficial dissection
• Detach origin of deltoid on the scapular spine and
retract inferiorly following which infraspinatus is
exposed

51. Deep dissection
• Develop internervous plane between infraspinatus
and teres minor by blunt dissection
• Retract infraspinatus superiorly and the teres minor
inferiorly to reach the posterior regions of glenoid
cavity and the neck of scapula
• Posteroinferior corner of shoulder joint capsule is
now exposed

55. Dangers
• Axillary nerve;
-Runs through the quadrangular space beneath the teres
minor
• Suprascapular nerve
-Passes around the base of spine of scapula as it runs from
the supraspinous fossa to the infraspinous fossa.
• Posterior circumflex humeral artery
-Rus with axillary nerve in the quadrangular space

56. Posterior Inverted U
Approach (Abbott &Lucas)
• Begin the incision 5 cm distal to the spine of
scapula at the junction of middle and medial thirds,
extend it superiorly over the spine and laterally to
the angle of acromian,
• Curve incision distally for about 7.5 cm over the
tendinous interval between posterior and middle
thirds of deltoid

57. • Free deltoid subperiosteally from the spine of
scapula, split it distally in the interval and turn the
resulting flap of skin and muscle distally for 5 cm to
expose the infraspinatus and teres minor muscles
and quadrangular space
• Incise the shoulder cuff in its tendinous part and
retract to expose the glenohumeral joint capsule

59. Approaches to elbow
• Posterior Approach
• Anterior Approach
• Medial Approach
• Anterolateral Approach
• Lateral J shaped Approach (Kocher’s)
• Posterolateral Approach
• Boyd Approach

60. Posterior approach
• Best possible view of the bones that comprise the
elbow joint.

62. Indications
• ORIF of fractures of distal humerus
• Removal of loose bodies within the elbow joint
• Treatment of nonunions of distal humerus

63. Position
• Prone with 90 degree arm abduction ,allowing the
elbow to flex and the forearm to hang over the side
of the table

64. Incision
• Longitudinal incision on, beginning 5 cm above the
olecranon in the midline.
• Curve laterally just above tip of olecranon

65. Superficial dissection
• Incise deep fascia in the midline
• Dissect ulnar nerve & pass tape around it
• V shaped osteotomy of olecranon

67. Deep dissection
• Strip the soft tissue attachments off the medial and
lateral sides of the portion of the olecranon that has
been subjected to osteotomy & retract it proximally,
retracting triceps from the back of the humerus

71. Dangers
• Ulnar nerve
• Radial nerve

72. Medial Approach
• Gives good exposure of the medial compartment of the
joint
Indications
• Decompression/Transposition of Ulnar nerve
• Removal of loose bodies
• ORIF of fractures of the coronoid process of the ulna
• ORIF of fractures of medial humeral condyle & epicondyle

73. • Supine with arm supported on an arm board

74. Incision
• Curved incision 8-10 cm long on the medial aspect
of the elbow, centering the incision on the medial
epicondyle

75. Internervous plane
• Proximally, between brachialis and triceps
• Distally between brachialis and pronator trees

76. Dissection
• Isolate the Ulnar nerve

80. Anterior Approach
• Provides access to the neuromuscular structures found
in the cubital fossa
Indications
• Repair of lacerations to median nerve,radial
nerve,brachial artery,biceps tendon
• Release of post traumatic anterior capsular
contractions
• Excision of tumor

81. Incision
• Curved incision beginning 5 cm above the flexion
crease on the medial side of biceps then curve
along the medial border of brachioradialis

82. Internervous plane
• Distally between brachioradialis and pronator teres
• Proximally between brachioradialis and brachialis

83. Dissection

87. Dangers
• Lateral cutaneous nerve of forearm (Sensory
branch of musculocutaneous nerve)
• Radial artery
• PIN

88. Anterolateral Approach
• Exposes lateral half of the elbow, especially
capitulum and proximal third of anterior aspect of
radius

89. Indications
• Surgery of capitulum (ORIF, Aseptic necrosis)
• Neural compression (PIN,Radial tunnel)
• Total elbow replacement
• Drainage of septic elbow joint.
• Excision of tumors of proximal radius

90. Position

91. Incision

92. Internervous plane

93. Dissection

97. Dangers
• Radial nerve
• PIN
• Lateral cutaneous nerve of forearm
• Recurrent branches of radial artery

98. Lateral J shaped Approach
• Kocher’s approach

99. • Skin incision beginning 5 cm proximal to the elbow
over the lateral supracondylar ridge and continue 5
cm distal to the radial head & curve it medially and
posteriorly to end at the posterior border of the ulna

100. • Dissect between triceps posteriorly and the
brachioradialis and ECRL anteriorly to expose
lateral condyle and capsule over lateral surface of
radial head.
• Distal to head, separate the ECU from anconeus,
• Incise the joint capsule longitudinally.

102. Posterolateral Approach
Indications
• Useful for all surgeries to the radial head (ORIF,
Prosthetic replacement, Excision)
• LCL reconstruction/repair

103. Position
• Supine with arm positioned over the chest and
pronate the forearm

104. Incision• Gently curved incision, beginning over the posterior
surface of the lateral humeral epicondyle and
continuing downward and medially to a point over
the posterior border of ulna, about 6 cm distal to the
tip of olecranon

105. Internervous plane

106. Dissection

109. Dangers
• PIN
• Radial nerve

110. Boyd Approach
• Useful when treating fractures of proximal third of
ulna associated with dislocation of radial head

111. Dissection
• Begin the incision 2.5cm proximal to elbow joint just
lateral to triceps tendon , continue it distally over the
lateral side of the tip of olecranon and along the
subcutaneous border of ulna and end it at the
junction of proximal and middle thirds of ulna
• Develop the interval between ulna on medial side
and the anconeus and ECU on lateral side
• Strip the anconeus, and reflect radially to expose
radial head

113. References
• Hoppenfeld surgical exposure in orthopaedics, The
anatomic approach, 4th edition
• Campbel’s operative orthopaedics 13th edition