Shoulder anterior approach: Delto-Pectoral



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Notes on anatomy surgical exposure

Anatomy without clinical is dead. Clinical without anatomy is deadly”


SHOULDER

Anterior approach: Delto-Pectoral (Evidence by Chin Hsien Wu et al Injury 2011 vs. deltoid split)

Interneural plane (axillary and medial and lateral pectoral nerves)



Surface markings:

  • Coracoid process and oblique incision inferiorly between deltopectoral region

Dangers:

  1. Musculocutaneous nerve

    1. 2-5cm under coracoid and coracobrachialis medially (do not over retract)

  2. Axillary Nerve

    1. Length of PIPJ to tip of index finger under Coracoid

    2. Adduction brings axillary nerve towards joint

  3. Brachial Plexus

  4. No medial instruments to humeral neck to avoid AVN

Waymarkers:

  • Cephalic vein

  • Tip of Coracoid

    • Lateral side of conjoint tendon is “safe side”

    • Conjoint tendon made up from SH of biceps and coracobrachialis

    • Proximal extension improves

  • Leash of vessels at inferior margin of subscapularis

  • To open joint split subscapularis tendon

    • Externally rotate humerus to improve visualisation

Important Notes:

  • Quadrangular space

    • Laterally – humerus

    • Medially – Triceps tendon

    • Superiorly – Teres minor

    • Inferiorly – Teres major

  • To open joint split subscapularis tendon aided with external rotation

Mackenzie Approach to the Shoulder: for access to proximal humerus, rotator cuff and subacromial space

Muscle splitting



Surface markings:

  • 5cm vertical incision from acromion down line of arm

Dangers:

Waymarkers:

  • Split deltoid in line of fibres – place a suture in apex distally to prevent split propagation

Important Notes:

  • Identify axillary nerve before making a 2nd vertical incision distally

Posterior Approach to the Shoulder: glenoid fractures

Interneural plane



Surface markings:

  • Longitudinal incision along scapular spine

  • Extending to lateral acromion boarder

Dangers:

  1. Axillary nerve - laterally

  2. Circumflex Scapular artery – medially

  3. Suprascapular nerve supplying infraspinatus – goes around spine of scapular

Waymarkers:

  • Junction between infraspinatus – multipennate muscle covered in fascia (Suprascapular nerve) and Teres Minor – a unipennate muscle (Posterior division of axillary nerve)

  • Peel off infraspinatus proximately watch for suprascapular nerve

  • Can gain access to capsule proximately

Important Notes:

Posterior arthroscopic to the shoulder:

Surface markings:

Dangers:

  1. Axillary nerve - laterally

  2. Circumflex Scapular artery - medially

Important Notes:

  • Rotator interval – between subscapularis and supraspinatus

  • Ligaments found in the interval

  • Subscapular bursa

    • Communicates with glenohumeral joint via foramen of Rouviere

    • Constantly found between superior and middle glenohumeral ligament

HUMERUS

Anterior approach to the humerus: Upper 2/3 of humerus approach can extend proximately via deltopectoral approach and further access by elevating deltoid anteriorly

Indications:

  • Open #

  • Vessel injury

  • Pathological

  • Floating elbow

Interneural plane (as Brachialis has dual innervation)

Surface markings:

Dangers: MUST STICK SUBPERIOSTEALLY TO AVOID NERVES

  • Radial nerve laterally – identify before brachialis is split

  • Ulnar nerve medially

  • Musculocutaneous nerve sub biceps



Waymarkers:

  • Split Brachialis (lateral 1/3 supplied by radius and medial 2/3 by musculocutaneous)

Important Notes:

  • Distally radial nerve is found between brachioradialis and Brachialis

  • Cannot extend distally


Anterolateral approach to the humerus: use for radial nerve exploration distal humerus or shantz pin

Interneural plane


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