Surgical Approaches to the Shoulder and Elbow
Surgical Approaches to the Shoulder and Elbow
Luke S. Austin
Joseph A. Abboud
Matthew L. Ramsey
Gerald R. Williams Jr.
SHOULDER APPROACHES
ANTERIOR APPROACH TO THE SHOULDER
Surgical Dissection
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Skin flaps are developed around the deltopectoral interval.
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The deltopectoral interval, with its cephalic vein, is identified.
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The deltopectoral interval is developed by retracting the pectoralis major medially and the deltoid laterally.
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Vein may be retracted either medially or laterally.
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We prefer to take it laterally, as fewer tributaries are disrupted.
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The lateral border of the conjoint tendon is identified and the short head of the biceps (supplied by the musculocutaneous nerve) and coracobrachialis (supplied by the musculocutaneous nerve) are retracted medially to allow access to the anterior aspect of the shoulder joint.
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Simple medial retraction of the conjoined tendon may be enough for a procedure such as subscapularis repair or capsular repair.
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If more exposure is necessary, the conjoint tendon can be detached with the tip of the coracoid process.
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The axillary artery is surrounded by cords of brachial plexus, which lie behind the pectoralis minor muscle.
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To minimize risk for nerve injury, the arm should be kept adducted while work is being done around the coracoid process.
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Remember, the musculocutaneous nerve enters the coracobrachialis on its medial side.
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Overly aggressive retraction can cause a neurapraxia of the musculocutaneous nerve.
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Behind the conjoined tendon of the coracobrachialis and the short head of biceps lies the subscapularis muscle.
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Externally rotating the arm brings the subscapularis further into the operative field.
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Identifiable landmarks on the inferior border of the subscapularis are three small vessels (from the anterior humeral circumflex artery) that run transversely and often require ligation or cauterization.
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The superior border of the subscapularis muscle blends in with the fibers of the supraspinatus muscle in the rotator interval
(FIG 1C).
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The inferior border of the subscapularis is the easiest location to allow separation between the subscapularis and capsule.
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The capsule is incised longitudinally to enter the joint wherever the selected repair must be performed.
ANTEROSUPERIOR APPROACH TO THE SHOULDER
Incision
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An incision is made paralleling the lateral acromion that begins at the anterolateral corner of the acromion and ends just lateral to the tip of the coracoid
(FIG 2A).
Surgical Dissection
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The incision is deepened to the deep deltoid fascia.
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Subcutaneous flaps are raised.
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The location of the deltoid split depends on the pathology being managed. When the pathology requires more exposure, moving the deltoid split posteriorly will improve exposure
(FIG 2B).
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Subperiosteally, the anterior deltoid is elevated from the acromion and the acromioclavicular joint. Continue the detachment by sharp dissection laterally to expose the anterior aspect of the acromion.
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Bleeding will be encountered during this dissection as a result of the division of the acromial branch of the coracoacromial artery.
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The surgeon should not detach more of the deltoid than is necessary.
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The deltoid split is extended 2 to 3 cm distal to the acromion.
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Stay sutures are inserted in the apex of the split to prevent the muscle from inadvertently splitting distally during retraction and damaging the axillary nerve.
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The split edges of the deltoid muscle are retracted to reveal the underlying coracoacromial ligament.
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The coracoacromial ligament is detached from the acromion by sharp dissection.
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The supraspinatus tendon with its overlying subacromial bursa now can be visualized.
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The head of the humerus is rotated to expose different portions of the rotator cuff.
POSTERIOR APPROACH TO THE SHOULDER
Incision
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A horizontal incision is made along the scapular spine extending to the posterolateral corner of the acromion
(FIG 3A).
Internervous Plane
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Between teres minor (axillary nerve) and infraspinatus (suprascapular nerve)
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The suprascapular nerve passes around the base of the spine of the scapula as it runs from the supraspinatus fossa to the infraspinatus fossa.
Surgical Dissection
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The origin of the deltoid is identified on the scapular spine. There are three ways to manage the deltoid during posterior exposures:
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Detach the origin on the scapular spine.
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Split the deltoid muscle along the length of its fibers.
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Elevate the deltoid from the inferior margin.
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The plane between the deltoid muscle and the underlying infraspinatus muscle is identified.
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The internervous plane between the infraspinatus and teres minor muscles is identified
(FIG 3B).
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The axillary nerve runs longitudinally in the quadrangular space beneath the teres minor.
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The posterior circumflex humeral artery runs with the axillary nerve in the quadrangular space between the inferior border of the teres minor muscle and the superior boarder of the teres major muscle.
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The infraspinatus is retracted superiorly and the teres minor inferiorly to reach the posterior regions of the glenoid cavity and the neck of the scapula.
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The posteroinferior corner of the shoulder joint capsule should be visible.
HUMERUS APPROACHES
ANTERIOR APPROACH TO THE HUMERUS
Surgical Dissection
Proximal Humeral Shaft
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The deltopectoral interval is identified using the cephalic vein as a guide and the two muscles are separated, retracting the cephalic vein either medially with the pectoralis major or laterally with the deltoid.
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The muscular interval is developed distally down to the insertion of the deltoid into the deltoid tuberosity and the insertion of the pectoralis major into the lateral lip of the bicipital groove
(FIG 4D,E).
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To expose the bone fully, the surgeon may need to detach part or all of the insertion of pectoralis major muscle.
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The minimum amount of soft tissue should be detached to allow adequate visualization and reduction of the fracture.
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If further exposure is needed, the surgeon dissects medially in a subperiosteal manner to avoid damage to the radial nerve, which lies in the spiral groove of the humerus and crosses the back of the middle third of the bone in a medial to lateral direction.
Distal Humeral Shaft
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The surgeon identifies the muscular interval between the biceps brachii and brachialis.
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The interval is developed by retracting the biceps medially
(FIG 4F).
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Beneath it lies the brachialis muscle, which covers the humeral shaft.
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The fibers of the brachialis are split longitudinally in the interval between the medial two-thirds and the lateral one-third to expose the periosteum on the anterior surface of the humeral shaft.
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The periosteum is incised longitudinally in line with the muscle dissection, and the brachialis is stripped off the anterior surface of the bone
(FIG 4G).
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In the anterior compartment of the distal third of the arm, the radial nerve pierces the lateral intermuscular septum and lies between the brachioradialis and brachialis muscles.
POSTERIOR APPROACH TO THE HUMERUS
Incision
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A longitudinal incision is made in the midline of the posterior aspect of the arm, from 8 cm below the acromion to the olecranon fossa
(FIG 5A).
Internervous Plane
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There is no true internervous plane; dissection involves separating the heads of the triceps brachii muscles, all of which are supplied by the radial nerve.
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The medial head, which is the deepest, has a dual nerve supply (radial and ulnar nerves).
Surgical Dissection
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The surgeon incises the deep fascia of the arm in line with the skin incision.
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The triceps muscle has two layers.
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The outer layer consists of two heads: The lateral head arises from the lateral lip of the spiral groove and the long head arises from the infraglenoid tubercle of the scapula
(FIG 5B).
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The inner layer consists of the medial head, which arises from the whole width of the posterior aspect of the humerus below the spiral groove all the way down to the distal fourth of the bone.
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The spiral groove contains the radial nerve; the radial nerve separates the origins of the lateral and medial heads
(FIG 5C).
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To avoid iatrogenic nerve injury, the surgeon should never continue dissection down to bone in the proximal two-thirds of the arm until the radial nerve has been identified.
MODIFIED POSTERIOR APPROACH TO THE HUMERUS
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