Anterior approach to the Shoulder

Position

  • supine
  • sandbag under spine & medial border of scapula
  • beachchair to 30°
  • Mayfield head rest
  • Prep & drape arm free

Landmarks

  • Clavicle
  • Acromion
  • Coracoid process
  • Deltopectoral groove

Incision

1. Anterior incision

  • Start: just above coracoid process
  • 10-15 cm along line of deltopectoral groove

2. Axillary incision

  • abduct shoulder 90° & ER
  • start: midpoint of anterior axillary skin fold
  • vertical incision 8-10 cm
  • end: towards axilla

Internervous Plane

  • deltoid: axillary nerve
  • pectoralis major: medial & lateral pectoral nerves

Superficial Dissection

  • identify deltopectoral groove
  • cephalic vein laterally
  • deltoid laterally
  • pect major medially

Deep Dissection

  • conjoint tendon: short head of biceps (MC nerve), coracobracialis (MC nerve) taken medially
  • Dangers:
    • Axillary artery lie behind pect minor
      • Keep arm adducted during procedure to protect artery
    • Musculocutaneous nerve
      • On medial side of coracobracilis
  • Deltopectoral fascia
  • Subscapularis tendon
    • ER arm to stretch subscapularis & makes it easier to define
    • Also ↑ gap between subscapularis & axillary nerve (at its lower border, quadrangular space)
    • Ligate triad of small vessels*2 veins 1 artery) at inferior border
    • Superior border of SubS is indistinct & blends with supraspinatus
    • Tag tendon
    • Detach subscapularis off lesser tuberosity insertion
  • Capsule
    • Longitudinal incision

Dangers

  • Musculocutaneous nerve
    • Enters CB 5-8 cm distal to coracoid process
    • From medial side
  • Cephalic vein