Courtesy: FRCS Orth Mentor Group, UK

Overview

Surgical approaches to the shoulder are fundamental in managing:

• Trauma
• Instability
• Degenerative conditions

The two most commonly used approaches are:

• Anterior deltopectoral approach
• Posterior approach

A thorough understanding of anatomy, positioning, and structures at risk is essential for safe and effective surgery.

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General Principles for Describing Surgical Approaches

A standardized framework ensures clarity and completeness when describing any surgical approach.

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Key Components

• Patient positioning
• Anatomical landmarks
• Intermuscular / internervous plane
• Structures at risk
• Extensibility of the approach
• Technical considerations and pitfalls

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Anterior Deltopectoral Approach

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Common Indications

• Shoulder arthroplasty
• Anterior shoulder stabilization
• Proximal humerus fracture fixation
• Combined reconstructive procedures

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Patient Positioning

• Beach chair position
• Pad placed between the scapulae
• Head securely supported
• Knees slightly flexed (to prevent sliding)
• Ensure access for fluoroscopic imaging

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Anatomical Landmarks

• Coracoid process
• Deltopectoral groove
• Lateral border of biceps brachii (for distal extension)

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Internervous Plane

The approach utilizes a safe interval between:

• Deltoid muscle
  • Innervation: Axillary nerve
• Pectoralis major muscle
  • Innervation: Medial and lateral pectoral nerves

This plane allows muscle separation without denervation

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Structures at Risk

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Cephalic Vein

• Located within the deltopectoral groove
• Options during surgery:
  • Retract medially
  • Retract laterally
  • Ligate if necessary

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Musculocutaneous Nerve

• At risk during mobilization of the conjoint tendon
• Excessive retraction can lead to injury

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Axillary Nerve

• Vulnerable during deep dissection
• Risk increases with distal extension of the approach

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Key Landmarks in Fracture Fixation

Long Head of Biceps Tendon

• Located in the bicipital groove
• Serves as a guide to identify:
  • Greater tuberosity
  • Lesser tuberosity

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Important Considerations in Trauma

• Avoid dividing the subscapularis tendon
• In proximal humerus fractures:
  • Lesser tuberosity remains attached to subscapularis
  • Preserving this attachment maintains anatomical alignment

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Extension of the Approach

Proximal Extension

• Toward the coracoid process

Distal Extension

• Along the lateral border of the biceps muscle
• Allows exposure of proximal humeral shaft

Precaution: Protect the axillary nerve

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Posterior Approach to the Shoulder

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Indications

• Posterior shoulder instability
• Posterior capsular procedures
• Fractures involving:
  • Posterior glenoid
  • Scapula

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Patient Positioning

• Lateral decubitus position
• Adequate padding of pressure points
• Proper support of the nonoperative side
• Free positioning of the arm for:
  • Manipulation
  • Imaging

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Anatomical Landmarks

• Acromion
• Spine of the scapula

Incision Options

• Along the scapular spine
• Vertical incision over the posterior shoulder

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Internervous Plane

The interval lies between:

• Infraspinatus muscle
  • Innervation: Suprascapular nerve
• Teres minor muscle
  • Innervation: Axillary nerve

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Structures at Risk

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Suprascapular Nerve

• Risk during retraction of infraspinatus

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Axillary Nerve

• Vulnerable near the quadrangular space

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Important Anatomical Spaces in Posterior Shoulder

Understanding these spaces is essential for safe dissection.

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Triangular Space

Boundaries

• Superior: Inferior border of teres minor
• Inferior: Superior border of teres major
• Lateral: Long head of triceps

Contents

• Circumflex scapular artery and vein

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Quadrangular Space

Boundaries

• Superior: Inferior border of teres minor
• Inferior: Superior border of teres major
• Medial: Long head of triceps
• Lateral: Surgical neck of humerus

Contents

• Axillary nerve
• Posterior circumflex humeral vessels

Clinical Importance:
Key zone for axillary nerve injury

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Triangular Interval

Boundaries

• Superior: Inferior border of teres major
• Medial: Long head of triceps
• Lateral: Shaft of humerus

Contents

• Radial nerve
• Profunda brachii artery

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Key Points for Describing Surgical Approaches

A structured description improves both learning and clinical application.

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Essential Elements

• Patient positioning
• Anatomical landmarks
• Skin incision
• Internervous plane
• Structures at risk
• Possible extensions
• Technical considerations

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Take-Home Message

Using a systematic approach ensures:

• Clear understanding
• Safer surgical execution
• Better communication in teaching and exams