Posterior Approach

POSTERIOR APPROACH

USES

This approach is used primarily for posterior capsular shift procedures. It would also be useful for scapular neck osteotomies and posterior dislocations, as well as for open reductions and internal fixations of the glenoid.

ADVANTAGES

For posterior dislocators, this is the only suitable approach.

DISADVANTAGES

This approach is made more difficult by the size of the muscles overlying the bone and shoulder capsule. Also, the neurovascular structures at the inferior aspect of the incision must be protected.

STRUCTURES AT RISK

The major structure at risk is the neurovascular bundle coming through the quadrilateral space. This should be well inferior to the intended approach. If you are too far superomedial, the suprascapular nerve to the infraspinatus, which wraps around the base of the spine of the scapula, could be damaged.

TECHNIQUE

The incision usually starts 1 cm superior and 1.0 to 1.5 cm medial to the posterolateral corner of the acromion. This bony prominence is palpable even in heavy or well-muscled patients. It is useful to place a needle into the shoulder joint to help guide the medial or lateral placement of the incision. The incision goes through the subcutaneous tissue down to the deltoid muscle. In some patients the deltoid can be retracted in its entirety anteriorly. In most patients, the incision ends up splitting the fibers of the deltoid in line with the fibers. It is important when doing so to be aware that there may be branches of the axillary nerve coming back toward this posterior corner of the deltoid, which should be avoided. Once you are deep to the deltoid, you will see the fibers of the infraspinatus. It is easy to tell them apart because the orientation of the fibers is at 90 degrees to those of the deltoid.

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