APPROACH TO APPROACH TO SHOULDERSHOULDER

TYPES OF APPROACHESTYPES OF APPROACHES

ANTERIOR – MC ANTERIOR – MC ANTEROLATERALANTEROLATERAL LATERALLATERAL POSTERIORPOSTERIOR MINIMAL ACCESS TO PROX MINIMAL ACCESS TO PROX

HUMERUSHUMERUS ARTHROSCOPICARTHROSCOPIC

ANTERIOR APPROACHANTERIOR APPROACH INDICATIONSINDICATIONS

• Reconstruction of recurrent Reconstruction of recurrent disloctionsdisloctions

• Drainage of sepsisDrainage of sepsis• Biopsy and excision of tumoursBiopsy and excision of tumours• Repair of long head of bicepsRepair of long head of biceps• ArthroplastiesArthroplasties

PositionPosition

- supine- supine- sandbag beneath spine & med border of - sandbag beneath spine & med border of

scapulascapula- elevate HOB 30-45 deg- elevate HOB 30-45 deg- drape arm free - drape arm free

CORACOID PROCESS AND DELTOPECTORAL CORACOID PROCESS AND DELTOPECTORAL GROOVEGROOVE

LANDMARKLANDMARK

INCISIONINCISION

AXILLARY INCISIONAXILLARY INCISION

INTERNERVOUS PLANEINTERNERVOUS PLANE

There are several ways in which the subscapularis There are several ways in which the subscapularis muscle and tendon can be dissected off themuscle and tendon can be dissected off theanterior capsule of the shoulder.anterior capsule of the shoulder.

1.1. Rowe et al. recommend sharply dividing the Rowe et al. recommend sharply dividing the subscapularis tendon in a vertical direction subscapularis tendon in a vertical direction approximately 1 cm lateral to the bicipital approximately 1 cm lateral to the bicipital groove groove

2.2. Rockwood recommends cutting only the Rockwood recommends cutting only the upper three fourths of the subscapularis upper three fourths of the subscapularis tendon. The lower fourth of the tendon is left tendon. The lower fourth of the tendon is left in place to protect the axillary nerve and in place to protect the axillary nerve and underlying vesselsunderlying vessels

3. Jobe et al. expose the capsule by 3. Jobe et al. expose the capsule by dividing the subscapularis muscle dividing the subscapularis muscle and tendon in theand tendon in the

direction of their fibers and inserting direction of their fibers and inserting long, bent Gelpi retractors to retract long, bent Gelpi retractors to retract the muscle fibers superiorly and the muscle fibers superiorly and inferiorly inferiorly

(In muscular patients, dissecting the (In muscular patients, dissecting the tendon off the capsule laterally and tendon off the capsule laterally and retracting it medially gives the best retracting it medially gives the best exposure.) exposure.)

Place the shoulder in complete external Place the shoulder in complete external rotation before the capsule is entered. If rotation before the capsule is entered. If the capsule is lax or redundant while the the capsule is lax or redundant while the shoulder is held in complete external shoulder is held in complete external rotation, the slack should be taken up rotation, the slack should be taken up during the course of the capsular repair. during the course of the capsular repair.

While the shoulder is held in complete While the shoulder is held in complete external rotation,make an incision in the external rotation,make an incision in the capsule in a vertical direction about 5 cm capsule in a vertical direction about 5 cm long, 5 mm lateral to the rim of the long, 5 mm lateral to the rim of the glenoid;glenoid;

DANGERS AND HOW TO ENLARGE DANGERS AND HOW TO ENLARGE THE INCISIONTHE INCISION

Musculocutaneous nerveMusculocutaneous nerve Cephalic veinCephalic vein Axillary artery and nerveAxillary artery and nerve

EXTENSION OF THE APPROACHEXTENSION OF THE APPROACH

1. Local measures-1. Local measures-

2. Extensile measures- proximal2. Extensile measures- proximal

distaldistal

SUMMARYSUMMARY

MC approachMC approach IncisionIncision Inter-nervous planeInter-nervous plane Coracoid process and conjoint tendonCoracoid process and conjoint tendon Keep limb externally rotated adductedKeep limb externally rotated adducted Avoid damaging musculocutaneous nerve, Avoid damaging musculocutaneous nerve,

axillary nerve and artery, cephalic vein.axillary nerve and artery, cephalic vein.

POSTERIOR APPROACHPOSTERIOR APPROACH

INDICATIONSINDICATIONS1.Repair of recurrent posterior dislocation1.Repair of recurrent posterior dislocation

2. Glenoid osteotomy2. Glenoid osteotomy

3.Biopsy excision of tumors3.Biopsy excision of tumors

4.Removal of loose bodies4.Removal of loose bodies

5.Drainage of sepsis5.Drainage of sepsis

6.Rx of fracture of neck of scapula6.Rx of fracture of neck of scapula

7.Rx of posterior fracture dislocation of prox 7.Rx of posterior fracture dislocation of prox humerushumerus

POSITIONPOSITION

LANDMARKLANDMARKAcromian & spine of Acromian & spine of

scapulascapula

INTERNERVOUS PLANEINTERNERVOUS PLANE

SUPERFICIAL AND DEEP SUPERFICIAL AND DEEP DISSECTIONDISSECTION

Reflect the deltoid of the insertion on the Reflect the deltoid of the insertion on the spine of scapulaspine of scapula

Locate the plane B/W deltoid and Locate the plane B/W deltoid and infraspinatus and retract the deltoid and infraspinatus and retract the deltoid and expose infraspinatusexpose infraspinatus

I/N plane infraspinatus and teres minor I/N plane infraspinatus and teres minor retract the infraspinatus superiorly and retract the infraspinatus superiorly and teres inferiorlyteres inferiorly

Now we reach posterior aspect of glenoidNow we reach posterior aspect of glenoid

DANGERSDANGERS

axillary nerve – axillary nerve –

Runs through the quadrangular space Runs through the quadrangular space beneath the teres minorbeneath the teres minor

suprascapular nerve- base of spine of suprascapular nerve- base of spine of scapulascapula

posterior circumflex humeral arteryposterior circumflex humeral artery Quadrangular space- boundaries and Quadrangular space- boundaries and

contentscontents Triangular space- boundaries and contentsTriangular space- boundaries and contents

Quadrangular spaceQuadrangular space