The patient is placed on the operating room table in the beach-chair position (Fig. 33-3). Bony landmarks are outlined with a marking pen (Fig. 33-4). An incision is made in Langer lines, centered over the glenohumeral joint and running from the superior to the inferior margin of the humeral head (Fig. 33-5). The deltoid muscle is exposed (Fig. 33-6) and split in the line of its fibers directly over the coracoid process (Fig. 33-7). The conjoined
tendon and the pectoralis major muscle are retracted medially, while the deltoid muscle is retracted laterally. The arm is externally rotated onto a sterile arm support or positioner and the subacromial bursa is removed, exposing the subscapularis tendon (Fig. 33-8). (For fractures involving the superior aspect of the glenoid fossa, opening the rotator interval may allow sufficient exposure; Fig. 33-9.) The subscapularis tendon is incised 2.5 cm medial to the medial border of the bicipital groove and along its superior and inferior borders. It is then dissected off the underlying anterior glenohumeral capsule/glenoid neck periosteum and turned back medially (Fig. 33-10). The anterior glenohumeral capsule is incised in the same fashion and turned back medially (Fig. 33-11). With a humeral head retractor inserted into the glenohumeral joint (a Fukuda ring retractor is especially useful) and holding the humeral head out of the way, the entire glenoid cavity can be inspected and the surgeon has ready access to the anterior rim (Fig. 33-12). Support of the humerus, slight abduction, and slight external rotation of the humerus aid in relaxing the soft tissues and augment the anterior exposure. One must take care to avoid injury to the nearby axillary nerve.

Figure 33-13 is an example of a case that required an anterior approach.

The patient is placed on the operating room table in the lateral decubitus position—nonoperative side down (a towel roll placed in the axilla), operative side up, and the torso stabilized by a beanbag (Fig. 33-14). The upper extremity and shoulder complex are prepped and draped free; the elbow, forearm, and wrist/hand are encased in a sterile wrap; and a well-padded sterile-draped Mayo stand is prepared to serve as a mobile, adjustable armrest. Bony landmarks are outlined with a marking pen (Fig. 33-15). An incision is made over the lateral third of the scapular spine, along the posterior aspect of the acromion to its lateral tip and distally in the midlateral line for a distance of 2.5 cm (Fig. 33-16). Via sharp and blunt dissection deep to the subcutaneous layer, soft-tissue flaps are developed and retracted, exposing the posterior deltoid muscle (Fig. 33-17). The posterior deltoid is dissected sharply off the scapular spine and acromion and split in the line of its fibers for a distance of not more than 2.5 cm, starting at the lateral tip of the acromion. A blunt retractor such as a Darrach is helpful in identifying the deltoid-infraspinatus interval along the spine of the scapula. The posterior deltoid is bluntly separated off the underlying infraspinatus and teres minor musculotendinous units and retracted down to but not below the inferior margin of the teres minor (Fig. 33-18). The inferior half of the infraspinatus tendon is incised vertically 2 cm posterior to the greater tuberosity, and the infraspinatus/teres minor interval is opened. The infraspinatus can then be dissected off the underlying posterior glenohumeral joint capsule and retracted superiorly (Fig. 33-19). The posterior glenohumeral capsule is incised in the same fashion, separated subperiosteally off the posterior glenoid process, and retracted superiorly (Fig. 33-20). With a Fukuda retractor inserted into the joint and holding the humeral head out of the way, the entire glenoid cavity can be inspected and the surgeon has ready access to the posterior aspect of the glenoid process (Fig. 33-21). The entire infraspinatus tendon/posterior glenohumeral capsule can be detached laterally and superiorly and turned back medially for maximal exposure. With injuries that involve only the posteroinferior or inferior aspect of the glenoid cavity, one may be able to avoid detaching these structures completely—simply developing the infraspinatus/teres minor interval and making a linear incision in the capsule may allow adequate access. This is the so-called safe interval, safe because the infraspinatus is innervated by the suprascapular nerve from above, and the teres minor is innervated by the axillary nerve from below. The interval between the infraspinatus and teres minor muscles can be developed further, the underlying soft tissues elevated subperiosteally, and the long head of the triceps detached to gain access to the inferior aspect of the glenoid process and lateral border of the scapular body (Fig. 33-22). One must take particular care to protect and avoid injury to the nearby suprascapular and axillary nerves.