Anterior approach to the shoulder - Dr. Sachin M

By Dr. Sachin. M., 2 Junior resident, Dept of Orthopaedics, SMCH, SIlchar

1. Anterior approach TO THE shoulder Presented by: dr. Sachin. M. 2 nd year pgt, dept of orthopaedics, smch Moderator: dr. a. k. Sipani Prof & hod, dept of orthopaedics, smch

2. INTRODUCTION Also known as Deltopectoral approach Fairly extensile exposure – gives access to the anterior, medial and lateral aspects of the shoulder Can extend distally to include the anterior approach to the humerus.

3. INDICATIONS Shoulder arthroplasty Proximal humerus fractures Reconstruction of recurrent dislocations Injury to long head of the biceps – repair Septic glenohumeral joint – drainage Biopsy and excision of tumerus

4. INTERNERVOUS PLANE Deltoid muscle – Axillary nerve Pectoralis major – pectoral nerves

5. POSITION OF THE PATIENT Beach chair position – patient lying supine with head end of the table elevated by 30-45 degrees Sandbag under the spine at the medial end of the scapula

6. Landmarks Coracoid process Lies 2.5 cm distal to the point of maximum concavity of the distal clavicle Directed anterolaterally and covered by Pectoralis major Deltopectoral groove Look for cephalic vein which runs in this groove Easily seen in thin patients, but difficult in obese individuals

7. INCISION 10 - to 15 cm linear incision is made along the deltopectoral groove Begins at tip of coracoid process

8. Superficial dissection Superficial skin vessels can bleed significantly – cauterize Deltopectoral fascia is encountered first Cephalic vein is the landmark to identify the deltopectoral interval

9. Superficial dissection Mobilize the cephalic vein either medially or laterally Deltoid fibers are retracted laterally and fibers of pectoralis major are retracted medially

10. deep dissection Conjoint tendon of short head of biceps and coracobrachialis arise from the coracoid process – retracted medially Musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process – conjoint tendon to be retracted with care

11. deep dissection Fascia lateral to the conjoint tendon is cut to expose the subscapularis tendon External rotation of the shoulder makes the subscapularis tendon taut and pulls it away from the axillary nerve, which travels through the quadrangular space

12. deep dissection Subscapularis tendon can be mobilized either by incising the tendon perpendicular to its fibers or by releasing its insertion on the LT subperiosteally or via osteotomy

13. deep dissection Capsule is incised to gain access into the joint

14. Enlargement of exposure Extend the skin incision proximally along the clavicle and distally along the deltopectoral groove Release deltoid either from its origin from the clavicle or from its insertion on the humerus Partial detachment of pectoralis major tendon from its insertion Use of suitable retractors – Bankart skid Internal and external rotation of shoulder to expose the different areas of the joint

15. Enlargement of exposure

16. DANGERS Musculocutaneous nerve – neurapraxia if conjoint tendon is retracted vigorously Cephalic vein – has to be preserved, works as landmark in case of reversion surgeries Can be ligated if injured Axillary nerve – can be injured while incising the subscapularis tendon Can be avoided by external rotation of the shoulder Anterior circumflex humeral artery – runs anteriorly around the proximal humerus proximal to pectoralis major tendon

17. THANK YOU