The space between the pectoralis and the deltoid is well known as the anterior shoulder approach. It is easier to identify this space proximally near the clavicle, where there is a natural triangular fat (Fig. 1.3).

The cephalic vein is the most important landmark for the deltopectoral interval and is absent in 4 % of cases. It has an intimate relationship with the deltoid artery that originates from the brachial artery and has two common variants. In type I (71 %) the deltoid artery crosses the interval without bumping into the cephalic vein. In type II (21 %) it crosses the interval, reaches the cephalic vein, and then runs down emitting several small arterial branches that return back to the pectoralis major across the interval [5]. Take care to these branches during the deltopectoral interval opening, in order to avoid bleeding. Consider that in the deltopectoral groove there are more lateral than medial feeder vessels to the cephalic vein, so splitting the pectoralis from the deltoid leaving the cephalic vein laterally can reduce hematoma after the surgical procedure [6] (Fig. 1.4).

To have a good view, the best way is to use Hohmann retractors on the coracoid and on the upper border of the pectoralis major. Two large retractors are useful to retract the deltoid and the pectoralis major. If we need more view the upper part of the pectoralis major can be released, as well as the resection of the coracoacromial ligament could be performed (Fig. 1.5).

After muscle retraction it is possible to identify the coracoid process.

The coracoid can be considered as the center of a star composed by the coracoacromial ligament, the coracoclavicular ligaments, the pectoralis minor muscle, and the conjoint tendon. Deeper and medially to the conjoint tendon lies the musculocutaneous nerve. It enters into the coracobrachialis muscle in a very variable distance from 3.1 to 8.2 mm from the apex of the coracoid (Fig. 1.6).

The coracoclavicular ligaments are deep on the basis of the coracoid. In the Latarjet procedure only the superficial part of the coracoid process is detached. The trapezoid ligaments begin about 2 cm from the central point of the distal coracoid process, while the conoid ligaments begin at the medial posterior margin [7] (Fig. 1.7).

The coracoacromial ligament can be identified more easily in its origin from the coracoid. It is important to recognize, and sometimes it is necessary to release, it to increase the visibility of the rotator cuff and the fracture.

Medially to the bicipital groove and distally to the subscapularis tendon, it is possible to recognize the anterior circumflex artery that originates from the axillary artery (Fig. 1.8).

The anterior circumflex artery emits an anterolateral ascending branch that crosses the subscapularis tendon anteriorly and runs superiorly along the lateral border of the intertubercular groove before terminating as the arcuate artery [8].

The anterior circumflex artery has been historically considered the most important blood contribution to the proximal humerus. Nevertheless lately some authors pointed out that the majority of the blood supply actually belongs to the posterior circumflex artery. The authors showed that 64 % of the humeral head blood supply arises from the posterior artery, while the anterior is responsible for 36 % of the humeral head perfusion [9].

The posterior circumflex artery passes with the axillary nerve through the quadrangular space, delimited by the humerus laterally, the subscapularis and teres minor superiorly, the teres major inferiorly, and the triceps medially. The posterior circumflex artery originates from the axillary artery and enters into the humeral head from 0 to 33 mm from the inferior border of the articular cartilage in conjunction with the posterior line of the capsular insertion (Fig. 1.9). It is important to know this landmark. It permits to understand what Hertel says about humeral head ischemia in case of fractures of the proximal humeral head: “take care of the integrity of the medial hinge” [10].