The anterior deltopectoral approach is used for various shoulder surgeries and fractures. It provides exposure of the shoulder joint and proximal humerus. The key steps are to identify the deltopectoral groove, preserve the cephalic vein, and laterally reflect the anterior deltoid. This exposes the coracoid process, joint capsule, tuberosities, and humeral head for procedures like shoulder arthroplasty and plating of humeral fractures. Care must be taken to protect structures like the axillary nerve and musculocutaneous nerve.

1. Anterior
(deltopectoral)
approach

2. Uses
 Any anterior shoulder
surgery, e.g.
› Capsular shift &
dislocation procedures
› Proximal humerus
fracture work
› Shoulder arthroplasty
› Long head of biceps
repair
› Subscapularis repair

3. Uses
 This approach is preferred for shoulder
arthroplasty and for plate-and-screw
fixation of proximal humeral fractures
because it affords greater visualization
than does the lateral approach.

4. Internervous Plane
 Deltoid (axillary)
 Pectoralis major (medial/lateral
pectoral)

5. Incision
 Length: 10-15 cm (depending
on the procedure and build
of patient).
 Extent: From coracoid
process running along the
deltopectoral groove
towards the deltoid insertion.
 Expose deltopectoral groove.
› The cephalic vein and the
coracoid are landmarks to the
interval.

7. Exposure of deltopectoral groove
and cephalic vein
 Identify the cephalic vein
and preserve it during
dissection.
› Failure to preserve cephalic
vein = post-surgical arm
edema.
 Retract the cephalic vein
laterally or medially, and
open along the groove.
› Failure to find this plane =
 difficulty in dissection of deltoid
 possible denervation of anterior
portion of deltoid.

9.  Laterally reflect the anterior part of
deltoid to expose the underlying
coracoid process and joint capsule.

11. Identification of the tuberosities and
the humeral head fragments
 Expose the
subscapularis tendon
and the tendon of
long head of biceps.
› The long head of
biceps serves as a
landmark to separate
the greater and lesser
tuberosities.
 Distally, expose the
pectoralis major.

13. Pearl:
 If a wider exposure is necessary, place
ethibond stay sutures (c.3) into the
medial aspect of the last centimeter of
the subscapuaris tendon, and partially
divide it laterally to this.
 External rotation of the shoulder during
subscapularis release moves the
dissection away from the axillary nerve
and decreases tension on the nerve.

14.  Care should be taken to isolate
and ligate the anterior humeral
circumflex artery, along with, if
necessary, its two venae
communicantes at the distal
margin of the subscapularis
tendon during the exposure.
 To maintain the blood supply to
the humeral head, surgical
dissection should not extend to
the inferior margin of the
subscapularis.
 A cuff of muscle must be
maintained to protect the
anterior humeral circumflex
vessels.
 Likewise, by releasing the
subscapularis medial to its
tendinous insertion, the arcuate
artery is not sacrificed at the
point at which it enters the
humeral head along the lateral
border of the bicipital groove.

15. Pitfall:
 The musculocutaneous nerve enters the
coracobrachialis muscle as close as 2.5
cm distal to the tip of coracoid.
› Retractors placed under the conjoint tendon
can cause neuropraxia; therefore vigorous
retraction must be avoided.

16.  If more extensive exposure is required,
pre drill the coracoid and remove the tip
with an osteotome.

17. Structures at risk
 Superiorly: Acromial branch of
thoracoacromial artery:
› Lies in the medial aspect of coracoacromial
ligament.
 Inferiorly: Musculocutaneous nerve:
› Comes out and enters the biceps approx. 5 cm distal
to the coracoid.
› Usually not cut, but can be retracted and damaged
with the retraction.
› Dissection medial to the conjoint tendon should be
avoided because it places the musculocutaneous
nerve at risk.

18. Structures at risk
 Axillary nerve:
› The axillary nerve should be palpated as it passes
inferior to the subscapularis and the inferior capsule,
and it should be protected throughout the
procedure.
› A retractor placed below the subscapularis and the
capsule puts this nerve in grave danger.
 Cephalic vein:
› Can also be damaged if not identified and
protected as the deltopectoral groove is being
developed.

19. Tricks
 Find the deltopectoral groove and take
whichever vein seems easiest (typically
laterally).
 The coracoid is the best landmark for the
short head of biceps; split the fascia in
that direction, which will get you into the
interval between the 2 heads.

20. Tricks
 Put a stay suture in the subscapularis
prior to cutting it free from the humeral
head so that it does not retract out of
the way.
 Feel the shoulder joint and the glenoid
edge prior to doing the capsulotomy, so
you can place it correctly for whatever
procedure you are attempting to do.
› This is especially important when attempting
to do instability procedures.

21. Extension
 When a greater exposure of the lateral
humeral shaft is needed, less than one
fifth of the anterior deltoid insertion can
be released.
 Distal extension may be accomplished
via the anterolateral approach to the
humerus.