One

 

The Shoulder

 

 

 

Anterior Approach to the Clavicle Anterior Approach to the Shoulder Joint

Applied Surgical Anatomy of the Anterior Approach to the Shoulder Joint

Anterolateral Approach to the Acromioclavicular Joint and Subacromial Space

Lateral Approach to the Proximal Humerus

Minimally Invasive Lateral Approach to the Proximal Humerus Minimally Invasive Anterolateral Approach to the Proximal Humerus

Applied Surgical Anatomy of the Anterolateral and Lateral Approaches

Posterior Approach to the Shoulder Joint

Applied Surgical Anatomy of the Posterior Approach to the Shoulder Joint

Arthroscopic Approaches to the Shoulder

General Principles of Arthroscopy

Posterior and Anterior Approaches

Arthroscopic Exploration of the Shoulder Joint through the Posterior Portal

 

The shoulder is the most mobile joint in the body. It is surrounded by two sleeves of muscle: The outer sleeve, or deltoid muscle; and the inner sleeve, or rotator cuff, which is critical for the stability of the joint. The three most common shoulder pathologies that necessitate surgery are instability, such as recurrent anterior dislocation of the shoulder (see Fig. 1-29), degenerative lesions of the rotator cuff, and fractures of the proximal humerus.

Nine surgical approaches are described in this chapter: Anterior and posterior approaches to the shoulder, anterolateral approach to the acromioclavicular joint and subacromial space, anterior approach to the clavicle, lateral and minimally invasive lateral approach to the proximal humerus, minimally invasive anterolateral approach for humeral nailing, and two arthroscopic approaches—anterior and posterior. Of these, the anterior approach is the “work-horse” incision of the shoulder, providing excellent exposure of both the joint, its anterior coverings and the proximal humerus. The anterolateral approach is used mainly to expose the acromioclavicular joint and subacromial structures, especially the rotator cuff. Use of this approach has declined with the increasing use of arthroscopic techniques. The lateral approach and minimally invasive lateral approach also expose the rotator cuff but their main use is in the treatment of fractures of the proximal humerus. The posterior approach, which is used rarely, is effective in treating recurrent posterior dislocations and is also used for open reduction and internal fixation of fractures of the posterior glenoid and fractures of the scapula neck. The arthroscopic approaches to the shoulder (anterior and posterior) provide excellent visualization of the internal structures of the joint.

The surgical anatomy of the area is divided into three sections: Anterior, anterolateral, and posterior. A description of each area is found immediately after its respective operative section in this chapter.

 

Anterior Approach to the Clavicle ‌

The anterior approach to the clavicle provides exposure of the entire bone allowing:

1. Open reduction and internal fixation of fractures

2. Reconstruction of the sternoclavicular and the acromioclavicular joints in case of dislocation or subluxation

3. Drainage of sepsis

4. Biopsy and excision of tumors

5. Osteotomy for malunion1

The brachial plexus and subacromial vessels can also be approached via this surgical approach. To do this an osteotomy of the clavicle is required (see page 16, Fig. 1-20).

Bleeding from subcutaneous vessels and vessels in the platysma muscle is very common. Because of the proximity of great vessels, such superficial bleeding must be controlled to ensure adequate visualization of the structures (see Fig. 1-1).

 

Position of the Patient

 

Place the patient supine on the operating table. Break the table and elevate the head end, so as to elevate the shoulder area. Place a sandbag between the medial border of the scapula and the spine. This will allow the shoulder to drop back and often this maneuver reduces fractures of the middle third.

 

Landmarks and Incision

 

The sternal notch is the most medial landmark of the incision. From the sternal notch, palpate the clavicle laterally to the acromioclavicular joint, palpating its subcutaneous surface.

Make an incision following the S-shaped clavicular anatomy, beginning from the medial end. The site and length of the incision depend on the clinical indication for surgery (Fig. 1-1).

 

Internervous Plane

 

Because the approach is directly onto the subcutaneous surface of the clavicle, there is no internervous plane. However, the incision cuts across numerous small subcutaneous nerves, branches of the supraclavicular nerve which cross the operating field from superior to inferior running in the substance of the platysma muscle.

 

 

Figure 1-1 The subclavian vessels are very close to the clavicle.

 

 

 

Figure 1-2 A: Make a longitudinal incision overlying the subcutaneous surface of the clavicle. The site and length of the incision are determined by the pathology to be treated and the implant to be used. B: Deepen the incision in the line of the skin incision to expose the platysma muscle. Note the presence of several cutaneous nerves.

 

Superficial Surgical Dissection

 

Deepen the skin incision through the platysma to reach the subcutaneous surface of the clavicle. Take care to diathermy the numerous vessels present within this muscle (Fig. 1-2). Try to preserve as many branches of the supraclavicular nerve as possible. Safe zones exist within 2.5 cm of the sternoclavicular joint and within 2 cm of the acromioclavicular joint where

no branches of the supraclavicular nerve are present. The nerve usually divides into a medial and a lateral branch2 both of which cross the operative field if the incision is used for fixation of a fracture of the middle third of the clavicle. Division of a single branch may not produce any postoperative numbness due to overlap in the cutaneous distribution of the branches of the nerve.

 

Deep Surgical Dissection

 

Gently strip soft tissues off the subcutaneous surface of the clavicle in an epiperiosteal plane. Take care to preserve as much soft tissue attachments as possible, particularly in cases of fracture fixation.

 

 

Dang

 

 

Nerves

The brachial plexus with the subclavian artery has a variable relationship with the clavicle. These structures lie posterior to the bone medially and then lie immediately inferior to the clavicle in the middle and lateral thirds (Fig. 1-3). To ensure that the plexus is uninjured, remain on the subcutaneous surface of the clavicle. If dissection is required inferior to the bone, develop a plane between the periosteum of the clavicle and the subclavius muscle. Also, be aware when drilling for fixation of fractures that penetration of the bone should be minimized in its posterior surface because of the close proximity of the nerves and vessels.3

Branches of the supraclavicular nerves cross the operative field from superior to anterior. There is wide variation in the position of these nerves which should be preserved if possible.

Vessels

The subclavian artery and vein lie immediately inferior to the clavicle in its middle and lateral thirds. Avoid dissection inferior to the clavicle, if possible. Dissection onto the subcutaneous surface and the anterior surface is safe.

 

How to Enlarge the Approach

 

The exposure can be enlarged longitudinally along the whole length of the clavicle as required (see Extensile Measures in this chapter).

The approach can be extended distally into the anterolateral approach

to the proximal humerus and midshaft of the humerus using the deltopectoral interval (see Fig. 1-20).

 

 

 

Figure 1-3 Deepen the incision through the platysma muscle in the line of the skin incision to expose the subcutaneous surface of the clavicle.

 

Anterior Approach to the Shoulder Joint ‌

The anterior surgical approach offers good wide exposure of the shoulder joint, allowing repairs to be made of its anterior, inferior, and superior coverings. Among its many uses, the anterior approach permits the following:

 

 

Figure 1-4 Position of the patient for the anterior approach to the shoulder. Elevate the table to 45 degrees. A sandbag placed under the spine at the medial end of the scapula will allow the shoulder to rotate externally and open the anterior part of the joint.

1. Reconstruction of recurrent dislocations4–9

2. Drainage of sepsis

3. Biopsy and excision of tumors

4. Repair or stabilization of the tendon of the long head of the biceps10

5. Shoulder arthroplasties or hemiarthroplasties which usually are inserted through modified anterior incisions11–13

6. Fixation of fractures of the proximal humerus14,15

The anterior approach is notorious for the amount of bleeding that occurs from skin and subcutaneous tissues during superficial dissection. The bleeding must be controlled before the deeper layers are dissected. Failure to do so may obscure important anatomic structures and endanger their integrity.

 

Position of the Patient

 

Place the patient in a supine position on the operating table. Wedge a sandbag under the spine and medial border of the scapula to push the affected side forward while allowing the arm to fall backward, opening up the front of the joint (Fig. 1-4). Elevate the head of the table 30 to 45 degrees to reduce venous pressure, and thereby decrease bleeding, and to allow the blood to drain away from the operative field during surgery. If a headrest is used, make sure that it is padded properly to prevent the development of a pressure sore on the occiput. Drape the arm free, because it will have to be moved during the approach. If image intensification is to be used during surgery, ensure that adequate images can be obtained prior to prepping and draping the patient.

 

Landmarks and Incision

Landmarks

 

Coracoid Process. Palpate the coracoid process by dropping your finger distally about 2.5 cm from the anterior edge of the clavicle at the deepest point in the clavicular concavity. Press laterally and posteriorly in an oblique line until the coracoid process is felt. The process faces anterolaterally; because it lies deep under the cover of the pectoralis major, it can be felt only by firm palpation.

 

Deltopectoral Groove. The deltopectoral groove is easier to see than to

feel, especially in thin patients. The cephalic vein, which runs in the groove, sometimes is visible.

Incisions

The anterior aspect of the shoulder can be approached through either of two skin incisions.

 

Anterior Incision. Make a 10- to 15-cm straight incision, following the line of the deltopectoral groove. The incision should begin just above the coracoid process (Fig. 1-5).

 

Axillary Incision. With the patient supine, abduct the shoulder 90 degrees and rotate it externally. Mark the anterior axillary skin fold with a sterile pen. Make a vertical incision 8 to 10 cm long, starting at the midpoint of the anterior axillary fold and extending posteriorly into the axilla.16 The skin flaps should be undermined extensively with a finger, especially superiorly in the area of the deltopectoral groove, using the cephalic vein as a guide to ensure correct position in the vertical plane. Retract the skin flaps upward and laterally so that the incision comes to lie over the deltopectoral groove (Figs. 1-6 and 1-7).

 

 

Figure 1-5 Make a straight incision in the deltopectoral groove, starting at the level of the coracoid process.

 

 

Figure 1-6 Make an incision in the axilla. Dissect subcutaneously to mobilize skin.

 

The axillary incision has a significant cosmetic advantage over the anterior incision, both because it is hidden in the axilla and because the resulting scar is covered by hair. In addition, the suture line remains free from tension while it heals; thus, the scar has little opportunity to spread. The incision may be contraindicated when, in extremely muscular patients, the skin flaps cannot be moved enough to allow adequate exposure of the muscular structures that lie in front of the shoulder. If adequate exposure cannot be obtained through the axillary incision, it should be extended

superiorly into the deltopectoral groove. This skin incision is not recommended for fracture fixation surgery.

 

Internervous Plane

 

The internervous plane lies between the deltoid muscle, which is supplied by the axillary nerve, and the pectoralis major muscle, which is supplied by the medial and lateral pectoral nerves (Fig. 1-8).

 

 

 

Figure 1-7 Retract the axillary incision cephalad to expose the cephalic vein and the deltopectoral groove.

 

 

Figure 1-8 The internervous plane lies between the deltoid muscle (axillary nerve) and the pectoralis major muscle (medial and lateral pectoral nerves).

 

 

Figure 1-9 Develop the groove between the fascia overlying the pectoralis major and the fascia overlying the deltoid. The cephalic vein will be of help in locating the groove.

 

Superficial Surgical Dissection

 

Find the deltopectoral groove, with its cephalic vein (Fig. 1-9). The vein may be difficult to visualize. It is often surrounded by some fatty tissue which can act as a guide to identifying it. Retract the pectoralis major medially and the deltoid laterally, splitting the two muscles apart. The vein may be retracted either medially or laterally. Taking a small cuff of deltoid with the vein may reduce the number of bleeding tributaries that require ligation, but it leaves a small amount of denervated muscle. For that reason, it is not recommended as a routine practice. Try to preserve the cephalic vein in order to reduce postoperative upper limb edema.

Deep Surgical Dissection

 

The short head of the biceps (which is supplied by the musculocutaneous nerve) and the coracobrachialis (which is supplied by the musculocutaneous nerve) must be displaced medially before access can be gained to the anterior aspect of the shoulder joint. Simple medial retraction after division of the overlying fascia may be enough for procedures such as the Magnuson–Stack subscapularis tendon advancement,6 the Putti–Platt subscapularis5 and capsule imbrication, and open reduction and internal fixation of a proximal humeral fracture but if more exposure is necessary, or if the coracoid process is to be transposed,8 the two muscles can be detached with the tip of the coracoid process. To release them, detach the tip of the coracoid process with an osteotome. The bone can be reattached later either with a screw or with sutures. If a screw is used, the coracoid process must be drilled and tapped before the osteotomy is carried out. Otherwise, the small piece of coracoid may split during drilling, and anatomic reduction can be obtained only with extreme difficulty (Figs. 1-10 and 1-11).

The axillary artery is surrounded by the cords of the brachial plexus,

which lie behind the pectoralis minor muscle. Abduction of the arm causes these neurovascular structures to become tight and brings them close to the tip of the coracoid and the operative site. Therefore, the arm should be kept adducted while work is being done around the coracoid process (Fig. 1-12).4

 

 

Figure 1-10 Retract the pectoralis major medially and the deltoid laterally to expose the conjoined tendon of the short head of the biceps and coracobrachialis muscle. Drill the tip of the coracoid process before cutting it. Incise the fascia on the lateral aspect of the conjoint tendon. Note the leash of vessels at the inferior end of the subscapularis muscle.

 

 

Figure 1-11 Cut through the predrilled coracoid process. Retract the conjoint tendon medially to give greater exposure to the subscapularis tendon.

 

 

 

Figure 1-12 Protect the axillary sheath during coracoid osteotomy by having the arm in the dependent position; abduction of the arm will draw the sheath against the coracoid process.

Retract the coracoid (with its attached muscles) medially. Divide the fascia that fans out from the conjoined tendons of the coracobrachialis and the short head of the biceps on the lateral side of the coracobrachialis—the safe side of the muscle, because the musculocutaneous nerve enters the coracobrachialis on its medial side. If a coracoid osteotomy has been used, take care in retracting the coracoid with its attached muscles; overzealous downward retraction can cause a neurapraxia of the musculocutaneous nerve. If the coracoid process is left intact, the attached coracoid muscles protect the nerve from traction injury (Fig. 1-13) but nevertheless do not apply vigorous medial retraction as this can also damage the nerve.

Beneath the conjoined tendons of the coracobrachialis and the short head of the biceps lie the transversely running fibers of the subscapularis muscle, which forms the only remaining anterior covering of the shoulder joint capsule (Fig. 1-14).4 As the muscle crosses the glenoid cavity, a bursa separates it from the joint capsule; that bursa may communicate with the shoulder joint. In cases of multiple anterior dislocations, adhesions often exist between the muscle and the joint capsule, making it difficult, if not impossible, to find the layer between the two. If you need to divide or detach the insertion of subscapularis to gain access to the shoulder joint apply external rotation to the arm to stretch the subscapularis, bringing the muscle belly into the wound and making its superior and inferior borders easier to define. External rotation of the humerus also increases the distance between the subscapularis and the axillary nerve as it disappears below the lower border of the muscle (see Fig. 1-14).

The most easily identified landmarks on the inferior border of the subscapularis are a series of small vessels that run transversely and often require ligation or cauterization. The vessels run as a triad: A small artery with its two surrounding venae comitantes, one above and one below the artery (Fig. 1-15). The superior border of the subscapularis muscle is indistinct and blends in with the fibers of the supraspinatus muscle.

Pass a blunt instrument between the capsule and the subscapularis, moving upward (see Fig. 1-15). Tag the muscle belly with stay sutures to prevent it from disappearing medially when it is cut and to allow easy reattachment of the muscle to its new insertion onto the humerus. Then divide the subscapularis 2 to 3 cm from its insertion onto the lesser tuberosity of the humerus (Fig. 1-16). Note that some of its muscle fibers insert onto the joint capsule itself; the capsule frequently may be opened inadvertently when the muscle is divided, because the two layers cannot always be defined.

Alternatively, rotate the shoulder internally and identify the insertion of the tendon of the subscapularis onto the humerus. Detach this insertion with a small flake of bone using a fine osteotome. This will allow more lateral reattachment of the muscle in a prepared channel in the bone, using staples.

Incise the capsule longitudinally to enter the joint wherever the selected repair must be performed. Each type of repair has its own specific location for incision (Fig. 1-17).

If the approach is used for treatment of fractures, the deep surgical dissection has often been performed by the trauma. Fractures of the greater and lesser tuberosities usually have their musculotendinous insertions preserved and the unopposed pull of the muscles causes displacement and rotation of the bony fragments. Attachment of sutures to the tendons allows manipulation and reduction of the tuberosities. Try to preserve any remaining blood supply to the head fragment if possible to reduce the risk of avascular necrosis. The biceps tendon, which runs in the groove between the greater and lesser tuberosities, is usually preserved and can act as a key surgical landmark for bony reconstruction.

 

Figure 1-13 Vigorous retraction of the conjoint tendon distally can injure the musculocutaneous nerve, causing neurapraxia or avulsion.

 

 

 

Figure 1-14 A: The subscapularis muscle lies in the deep part of the wound. It is to be incised perpendicular to its fibers, close to its tendon. The axillary nerve passes anteroposteriorly through the quadrangular space. B: External rotation of the arm during incision into the subscapularis tendon will draw the point of incision away from the axillary nerve.

 

 

 

Figure 1-15 Insert a curved artery clamp under the subscapularis muscle. A leash of vessels at the caudal end of the wound marks the lower border of the subscapularis.

 

 

Figure 1-16 Incise the end of the subscapularis. Tag and place stay sutures into the muscle to prevent it from retracting medially. Some of the subscapularis fibers insert directly into the joint capsule.

 

 

Figure 1-17 Incise the joint capsule longitudinally to expose the humeral head and the glenoid cavity.

 

 

Dang

 

 

Nerves

The musculocutaneous nerve enters the body of the coracobrachialis about 5 to 8 cm distal to the muscle’s origin at the coracoid process. Because the nerve enters the muscle from its medial side, all dissection must remain on the lateral side of the muscle. Great care should be taken not to retract the muscle inferiorly, to avoid stretching the nerve and causing paralysis of the elbow flexors (see Fig. 1-13). Also take care to avoid overzealous medial retraction if a coracoid osteotomy is not performed.

The axillary nerve runs on the deep surface of the deltoid muscle running from posterior to anterior. Retraction of the deltoid muscle posteriorly cannot therefore damage the nerve but instruments placed around the lateral side of the proximal humerus to facilitate retraction of the deltoid may press directly on the nerve causing a neurapraxia. The nerve is also in danger when dividing the subscapularis muscle tendon. The nerve lies just inferior to the inferior border of the muscle. The danger can be reduced by externally rotating the arm before dividing the tendon (see Fig. 1-14A,B). If the dissection is not carried out inferior to the triad of vessels marking the lower border of the muscle the nerve will be safe.

Vessels

The cephalic vein should be preserved, if possible to reduce the risk of postoperative upper limb edema. However a traumatized cephalic vein should be ligated to prevent the slight danger of thromboembolism. There are no valves between the cephalic vein and the superior vena cava.

 

 

 

Figure 1-18 Remove the origins of the deltoid from the anterior portion of the

clavicle to expose the joint further proximally. Identify the coracoacromial ligament.

 

How to Enlarge the Approach

Local Measures

The exposure can be enlarged in the following five ways:

1. Extend the skin incision superiorly by curving it laterally along the lower border of the clavicle. Detach the deltoid from its origin on the outer surface of the clavicle for 2 to 4 cm to permit better lateral retraction of the muscle (Fig. 1-18). Unfortunately, because reattaching the deltoid securely is very difficult, this maneuver is not recommended for routine use. If further deltoid retraction is required, it may be best to detach part of the muscle’s insertion onto the humerus.

2. Lengthen the skin incision inferiorly along the deltopectoral groove to separate the pectoralis major from the deltoid further inferiorly and to improve the exposure without having to detach the deltoid origin.

3. Partially detach the insertion of the pectoralis major tendon into the humerus.

4. Use a suitable retractor (such as the Bankart skid) for the humeral head. A humeral head retractor is the key to excellent exposure of the inside of the glenoid fossa once the joint has been opened (Fig. 1-19).

5. Rotate the shoulder internally and externally to bring different elements of the anterior shoulder coverings into view.

Extensile Measures

 

Proximal Extension. To expose the brachial plexus and axillary artery, and to gain control of arterial bleeding from the axillary artery, extend the skin incision superomedially, crossing the middle third of the clavicle. Next, dissect the middle third of the clavicle subperiosteally and perform a double osteotomy of the bone, removing the middle third. Cut the subclavius muscle, which runs transversely under the clavicle. Retract the trapezius superiorly and the pectoralis major and pectoralis minor inferiorly to reveal the underlying axillary artery and the surrounding brachial plexus (Fig. 1-20). Take care not to damage the musculocutaneous nerve, which is the most superficial nerve in the brachial plexus.

 

Distal Extension. The approach can be extended into an anterolateral

approach to the humerus.

Extend the skin incision down the deltopectoral groove, then curve it inferiorly, following the lateral border of the biceps. Deep dissection consists of retracting the biceps brachii medially to reveal the underlying brachialis, which then can be split along the line of its fibers to provide access to the humerus. For details of this approach, see Anterior Approach to the Humerus in Chapter 2, page 74–80, 4th edition.

 

 

 

Figure 1-19 A Bankart skid is used to retract the humeral head to expose the glenoid cavity and its labrum.

 

 

Figure 1-20 A, B: Extend the incision superomedially. Expose and resect the

middle third of the clavicle subperiosteally. C: Expose the brachial plexus and axillary artery.

 

Applied Surgical Anatomy of the Anterior Approach to the Shoulder Joint‌

 

 

Overview

 

All approaches to the shoulder involve penetrating the two muscular coverings, or sleeves that cover the joint. The outer sleeve is the deltoid muscle. The inner sleeve is the rotator cuff, which consists of four muscles: The supraspinatus, infraspinatus, teres minor, and subscapularis (Fig. 1-21).

Anteriorly, gaining access to the shoulder joint involves reflecting the outer sleeve (deltoid) laterally and incising the inner sleeve, specifically the subscapularis.

The deltoid, together with the pectoralis major and the latissimus dorsi (the two great muscles of the axillary fold), supplies most of the power that is required for shoulder movement. The muscles of the inner sleeve can act as prime movers of the humerus, but their most important action is to control the humeral head within the glenoid cavity while the other muscles are carrying out major movements.

The supraspinatus also has a key role as a prime mover of the humerus in initiating abduction. The teres minor and infraspinatus muscles are the only important external rotators of the shoulder. Pathology of this joint most often occurs in this inner group of muscles. Degenerative lesions of the rotator cuff are extremely common with increasing age. Their function is critical not only to the coordination of joint movement, but also to the stability of the shoulder joint itself.

Fracture patterns and bone displacement are dictated not only by the forces causing the injury but also by the soft tissue attachments of elements of the rotator cuff to the greater and lesser tuberosities.

A third group of muscles intervenes between the two muscular sleeves when the joint is approached from the front. These muscles (the short head of the biceps, the coracobrachialis, and the pectoralis minor) require medial retraction for exposure of the inner sleeve. They all are attached to the coracoid process (see Fig. 1-21).

 

 

Figure 1-21 Anatomy of the anterior portion of the shoulder.

 

Landmarks and Incision

Landmarks

The coracoid process of the scapula is a palpable bony protuberance that lies at the upper end of the deltopectoral groove and is the landmark for incisions based on that groove. It is also a critical landmark for injections and arthroscopic examinations of the shoulder joint. Hook shaped, the coracoid process sometimes is described as resembling a crow’s beak, as is implied by its name, corax. The tip of the coracoid process projects forward, laterally, and inferiorly toward the glenoid cavity. Therefore, it is palpated best by posterior and medial pressure. Be aware that palpation of the coracoid process often is painful; therefore, tenderness over this site is not diagnostic of local pathology. Attached to the coracoid process are the

six clinically important structures described below (Fig. 1-22).

 

Coracoacromial Ligament. The tough, fibrous coracoacromial ligament is variable. It is classically described as being triangular connecting the horizontal portion of the coracoid process to the tip of the acromion. Other authors describe it as trapezoidal.17

It is one of the few ligaments that connects two parts of the same bone. The coracoid process, the acromion, and the coracoacromial ligament form the coracoacromial arch. This structure may be implicated in the pathology of the impingement syndrome. The function of the coracoacromial ligament is unclear. It may act as a dynamic brace between the two portions of the scapular.18 Resection of the coracoacromial ligament, which is frequently carried out in subacromial decompression, does not appear to be associated with significant long-term clinical problems.

 

Conoid and Trapezoid Ligaments. The conoid and trapezoid ligaments are extremely strong. The conoid ligament, which resembles an inverted cone, extends upward from the upper surface of the coracoid to insert into the conoid tubercle on the underside of the clavicle. The trapezoid ligament runs from the upper surface of the coracoid process and extends superiorly and laterally to the trapezoid ridge on the undersurface of the clavicle. These two structures are the main accessory ligaments of the acromioclavicular joint. They are extremely difficult to repair in cases of acromioclavicular dislocation and, once they are torn, are difficult to identify as individual structures.

 

Coracohumeral Ligament. This ligament arises from the undersurface of the coracoid process and runs laterally over the shoulder to blend in with the shoulder joint capsule. It is the most important and most constant thickening of the fibrous capsule of the shoulder but probably of little clinical significance.19

 

Conjoined Tendons of the Coracobrachialis and Biceps Brachii. See Figure 1-25.

 

Pectoralis Minor Muscle. See Applied Surgical Anatomy of the Anterior Approach in this chapter.

Incision

Because a skin incision that runs down the deltopectoral groove cuts

almost transversely across the relaxed skin tension lines (cleavage lines of the skin), it often leaves a broad scar, even if a subcuticular skin closure is used. An incision in the axilla runs with the relaxed skin tension lines and leaves a much narrower scar. The latter scar is almost invisible, because it is hidden in the axillary fold and is covered by hair.

 

 

 

Figure 1-22 Five clinically important structures are attached to the coracoid process.

 

 

Figure 1-23 The superficial anatomy of the anterior shoulder, revealing the deltopectoral groove and the neurovascular bundle.

 

Superficial Surgical Dissection

 

Three major structures are involved in the superficial surgical dissection of the anterior approach to the shoulder joint: The deltoid muscle laterally, the pectoralis major muscle medially, and the cephalic vein, which lies between them in the deltopectoral groove (Fig. 1-23).

Deltoid Muscle

The anterior fibers of the deltoid muscle run parallel to each other, without fibrous septa between them. Because sutures placed in this kind of muscle fiber tend to tear out, it is difficult to reattach the deltoid to the clavicle. Sutures must be placed through the full thickness of the muscle, including its fascial coverings, to effect a strong reattachment. Transosseous sutures are also frequently required. The attachment should be protected from active stress for 4 to 6 weeks to allow for adequate healing. For these

reasons routine detachment of the muscle from the clavicle is not advised.

The axillary nerve is the nerve supply of the muscle and runs on its undersurface from posterior to anterior. The anterior portion of the deltoid can be denervated only if the entire anterior part of the muscle is stripped and retracted vigorously in a lateral direction (Fig. 1-24) or if a retractor is placed under the muscle directly over the nerve.

Pectoralis Major Muscle

The two nerve supplies of the pectoralis major allow the muscle to be split without the loss of innervation to either part. The attachment of the pectoralis tendon to the humerus may need to be partially detached especially if the approach is used for fixation of a proximal humeral fracture (see Fig. 1-24).20

Cephalic Vein

The cephalic vein drains into the axillary vein after passing through the clavipectoral fascia. On occasion, it may be absent. Few complications result from its ligation (see Fig. 1-23) but routine ligation is not advised because of the slight risk of postoperative upper limb edema.

 

Deep Surgical Dissection

 

The coracobrachialis and the short head of the biceps brachii share a common origin from the tip of the coracoid process. They also share a common nerve supply, the musculocutaneous nerve. These muscles form an intermediate layer during the surgical approach (Fig. 1-25).

Coracobrachialis Muscle

The coracobrachialis muscle is largely vestigial and has little function. It acts as a weak flexor and abductor of the arm and may help to stabilize the shoulder. Extremely variable in size, it is the counterpart in the arm of the adductors in the thigh.

 

 

Figure 1-24 The anterior portion of the deltoid has been resected from its origin, revealing the insertion of the pectoralis major muscle and the subscapularis tendon, supraspinatus tendon, and coracoacromial ligament.

 

The coracobrachialis used to have three heads of origin. The musculocutaneous nerve passes between two of the original heads, which now are fused during development. Its course represents one of the few instances in which a nerve appears to pass through a muscle. When a nerve does this, it always is passing between two heads of origin (see Fig. 1-25).

Biceps Brachii Muscle

The tendon of the long head of the biceps is an anatomic curiosity; it is one of only two tendons to pass through a synovial cavity. The joint capsule of the shoulder is incomplete inferiorly, so the tendon can escape under the transverse ligament. From there, it runs in the bicipital groove of the humerus. It is easy to palpate the tendon in the groove as long as the arm is rotated externally (see Fig. 1-27). The biceps tendon is a common site of

inflammatory changes, partly because it is capable of tremendous excursion, moving some 6 cm between full abduction and full adduction of the shoulder. This continual movement may produce attrition between the tendon and the bicipital groove. The tendon also may rupture, producing a characteristic change in the contour of the muscle. Surgeons have speculated whether the anatomic shape of the bicipital groove may be a factor in predisposing to inflammatory/degenerative changes but recent MRI studies suggest that this is not the case.21

The biceps can slip medially out of the bicipital groove. This dislocation usually is painful,22 although it sometimes is found during postmortem examinations of individuals who have had no known shoulder symptomatology.23

Considerable variability exists in the depth of the bicipital groove and in the angle that its medial wall makes with its floor.24 Shallow grooves with flat medial walls may be predisposed to such tendon dislocation. Nevertheless, the transverse humeral ligament (retinaculum), which is the chief stabilizer for the tendon, must be ruptured before the tendon can be displaced. The tendon is a useful surgical landmark in the reconstruction of complex proximal humeral fractures.

Pectoralis Minor Muscle

The only surgical importance of the pectoralis minor muscle lies in its neurovascular relations. The second part of the axillary artery and the cords of the brachial plexus lie directly behind the muscle and below the coracoid process (see Fig. 1-25).

 

 

Figure 1-25 The pectoralis major and deltoid muscles have been removed completely, revealing the two heads of the biceps tendon, the rotator cuff, the coracoacromial ligament, and the neurovascular bundle.

 

 

Figure 1-26 The neurovascular bundle lying on the subscapularis is revealed. The axillary nerve exits through the quadrangular space, and the radial nerve exits through the triangular interval. Deltoid. Origin. Anterior border of lateral third of clavicle. Outer border of acromion and inferior lip of crest of scapular spine. Insertion. Deltoid tubercle of humerus. Action. Abduction of shoulder. Anterior fibers act as flexors of shoulder; posterior fibers act as extensors of shoulder. Nerve supply. Axillary nerve. Pectoralis Major. Origin. From two heads. Clavicular head: from medial half of clavicle. Sternocostal head: from manubrium and body of sternum, upper six costal cartilages, and aponeurosis of external oblique. Insertion. Lateral lip of bicipital groove of humerus. Action. Adduction of arm. Nerve supply. Medial and lateral pectoral nerves. (A separate branch of the lateral pectoral nerve supplies the clavicular fibers.) Coracobrachialis. Origin. Tip of coracoid process. Insertion. Middle of medial border of humerus. Action. Weak flexor of arm and weak adductor of arm. Nerve supply. Musculocutaneous nerve. Biceps Brachii. Origin. Short head from tip of coracoid process. Long head from

supraglenoid tubercle of scapula. Insertion. Bicipital tuberosity of radius. Action. Flexor of elbow. Supinator of forearm. Weak flexor of shoulder. Nerve supply. Musculocutaneous nerve. Pectoralis Minor. Origin. Outer borders of third, fourth, fifth, and sixth ribs. Insertion. Coracoid process of scapula. Action. Lowers lateral angle of scapula. Protracts scapula. Nerve supply. Medial pectoral nerve.

 

Subscapularis Muscle

The deep layer of the dissection is formed by the subscapularis muscle, which covers the shoulder joint capsule (Fig. 1-26).

The subscapularis, which is the anterior portion of the rotator cuff, inserts partly into the capsule of the joint. The muscle tendon undergoes degeneration in the same way as do other muscles of the rotator cuff, but to a lesser extent. The problem rarely is severe or symptomatic, because there are other internal rotators of the shoulder and the loss of subscapularis action is not functionally disabling. The subscapularis may be stretched in cases of anterior dislocations of the shoulder or it may be contracted as a result of previous surgery.24 Traumatic rupture of the tendon due to trauma has also been described.25

 

 

 

Figure 1-27 The fibrous joint capsule inserts into the humerus around the articular margin of the neck, except inferiorly where it inserts below that articular margin. The capsule bridges the gap across the bicipital groove, forming a structure known as the transverse ligament. Subscapularis. Origin. Medial four-fifths of anterior surface of scapula. Insertion. Lesser tuberosity of humerus. Action. Internal rotator of humerus. Nerve supply. Upper and lower subscapularis nerves.

 

The subscapularis limits external rotation, helping to prevent anterior dislocations; it also may block anterior dislocation physically because of its size and its position in front of the shoulder joint. Because the two subscapular nerves enter the subscapularis medially, incising it 2.5 cm from its insertion does not denervate the muscle (Fig. 1-27).

Superiorly, the muscle is connected intimately to the supraspinatus. The plane of cleavage between the two muscles, which represents a true internervous plane between the suprascapular and subscapular nerves, may be impossible to define, especially near the insertions of the muscles. The tendon of the long head of the biceps corresponds to the interval between the muscles and can be used as a surgical guideline to that interval.

Shoulder Joint Capsule

The shoulder joint has an enormous range of motion. The capsule is loose and redundant, particularly inferiorly and anteriorly. The area of the fibrous capsule itself is about twice the surface area of the humeral head (Fig. 1-28). Anteriorly, the capsule is attached to the scapula via the border of the glenoid labrum and the bone next to it. The anterior part of the capsule usually has a small gap that allows the synovial lining of the joint to communicate with the bursa underlying the subscapularis.26,27 This bursa extends across the front of the neck of the scapula toward the coracoid process (see Fig. 1-27).

Posteriorly and inferiorly, the capsule is attached to the border of the labrum. A second gap may exist at this point to allow communication between the synovial lining of the joint and the infraspinatus bursa.

The fibrous capsule inserts into the humerus around the articular margins of the neck, except inferiorly, where the insertion is 1 cm below the articular margin. The capsule bridges the gap across the bicipital groove, forming a structure known as the transverse ligament. The long head of the biceps enters the joint beneath this ligament (see Fig. 1-27).

The shoulder joint capsule receives reinforcement from all four muscles of the rotator cuff. Further reinforcement is provided by the three glenohumeral ligaments, which appear as thickenings in the capsule. These

ligaments are extremely difficult to identify during open surgery, but are usually obvious in arthroscopic procedures. They appear to be of no clinical relevance (see Figs. 1-83A and 1-85A).

 

 

 

Figure 1-28 Cross section of the joint. The joint capsule is redundant inferiorly to allow abduction. The long head of the biceps tendon traverses the joint. The tendon is surrounded by synovium and, therefore, is anatomically intracapsular but extrasynovial.

 

Synovial Lining of the Shoulder Joint

 

The synovial membrane, which is attached around the glenoid labrum, lines the capsule of the joint. The membrane usually communicates with the subscapularis bursa and, occasionally, with the infraspinatus bursa (see Figs. 1-27 and 1-54). It envelopes the tendon of the long head of the biceps within the shoulder joint. The synovium forms a tubular sleeve that permits the tendon to glide back and forth during abduction and adduction of the arm. Therefore, the tendon is anatomically intracapsular, but extrasynovial (see Figs. 1-28 and 1-54).

Glenoid Labrum

The glenoid labrum is a triangular, fibrocartilaginous structure that rings

the glenoid cavity (see Fig. 1-28). The joint capsule attaches to it superiorly, inferiorly, and posteriorly. Anteriorly, the attachment depends on the presence or absence of the synovial recess running across the scapular neck (subscapularis bursa; see Fig. 1-54); the presence of the synovial recess leaves a gap in the attachment of the glenoid to the scapula (see Fig. 1-27).

It is the detachment of the glenoid labrum anteriorly with or without a bone fragment that creates the Bankart lesion in cases of recurrent anterior dislocation of the shoulder (Fig. 1-29).

 

 

Dang

 

 

Nerves

The musculocutaneous nerve is a branch of the lateral cord of the brachial plexus. It supplies the coracobrachialis, biceps brachii, and brachialis muscles, and terminates as the upper lateral cutaneous nerve of the forearm (see Figs. 1-13 and 1-25).

The nerve passes through the coracobrachialis, entering the muscle from its medial side about 8 cm below the tip of the coracoid process. The nerve rarely is cut during surgery, but a neurapraxia resulting from excessive retraction can occur. If the coracoid process is detached then a traction lesion may occur if downward retraction is applied to the coracoid process with its attached muscles. If the coracoid process is not detached vigorous medial retraction of the muscles may cause a neurapraxia.

When the arm is abducted, the musculocutaneous nerve becomes the most superficial nerve structure in the axillary bundle. Therefore, it is the most common nerve structure to be injured in types of trauma, such as fractures of the clavicle. Care should be taken not to overpenetrate the inferior cortex when using a drill on the superior surface of the clavicle in its middle or lateral thirds.

Vessels

The second part of the axillary artery lies inferior to the coracoid process under cover of the pectoralis minor muscle. It may be damaged if the arm is not kept adducted while work is being performed on the coracoid process (see Figs. 1-12 and 1-26).

 

 

Figure 1-29 A: The normal relationship of the humerus to the glenoid cavity. B:

Anterior dislocation of the humerus.

 

Anterolateral Approach to the Acromioclavicular Joint and Subacromial Space‌

 

 

The anterolateral approach to the shoulder offers excellent exposure of the acromioclavicular joint and the underlying coracoacromial ligament and supraspinatus tendon. Its uses include the following:

1. Anterior decompression of the shoulder28

2. Repair of the rotator cuff

3. Repair or stabilization of the long head of a biceps tendon

4. Excision of osteophytes from the acromioclavicular joint

The use of arthroscopic subacromial decompression has reduced the use of this approach in the treatment of impingement syndrome and for some cases of rotator cuff repair.29

The approach, however, remains clinically relevant in large numbers of cases involving extensive degenerative disease of the rotator cuff.30

 

Position of the Patient

 

Place the patient in the supine position on the operating table, with a

sandbag under the spine and medial border of the scapula to push the affected side forward (see Fig. 1-4). Elevate the head of the table to 45 degrees. Apply surgical drapes in such a way that the limb can be moved easily during the operation. This allows different structures to be brought into view.

 

Landmarks and Incision

Landmarks

 

Coracoid Process. Palpate the coracoid process 1 in from the anterior end of the clavicle just inferior to the deepest point of the clavicular concavity.

 

Acromion. Palpate the acromion at the shoulder summit.

Incision

Make a transverse incision that begins at the anterolateral corner of the acromion and ends just lateral to the coracoid process (Fig. 1-30).

 

Internervous Plane

 

No internervous plane is available for use. The deltoid muscle is detached at a point well proximal to its nerve supply, which, therefore, is not in danger.

 

Superficial Surgical Dissection

 

Deepen the incision through the subcutaneous fat to the deep fascia. Numerous small vessels will be divided. Coagulate these meticulously to ensure adequate visualization of the deeper structures. Incise the deep fascia in the line of the skin incision (Fig. 1-31). Palpate the acromioclavicular joint. If the approach is to be used for a subacromial decompression and access to the rotator cuff is not required, detach the fibers of the deltoid that arise from the acromioclavicular joint and continue this detachment by sharp dissection laterally to expose 1 cm of the anterior aspect of the acromion (Fig. 1-32). Bleeding will be encountered during this dissection as a result of the division of the acromial branch of the coracoacromial artery. This must be coagulated. Do not detach more of the deltoid than is necessary because reattachment is difficult and extensive stripping of the deltoid from the acromion may be associated with poor long-term results of surgery.

 

 

Figure 1-30 Make a transverse incision beginning at the anterolateral corner of the acromion, ending just lateral to the coracoid process. For alternate skin incision, see Figure 1-60.

 

 

Figure 1-31 Incise the deep fascia in the line of the skin incision to reveal the underlying deltoid muscle.

 

 

Figure 1-32 Detach the deltoid from the acromioclavicular joint and 1 cm of the anterior aspect of the acromion.

 

If the approach is to be used for repairs of the rotator cuff, split the deltoid muscle in the line of its fibers starting at the acromioclavicular joint. The deltoid muscle is multipennate in its middle third and distinct fibrous septi are present. Splitting the muscle may therefore involve some sharp as well as blunt dissection. Extend this split 5 cm down from the acromioclavicular joint (Fig. 1-33). Insert stay sutures in the apex of the split to prevent the muscle from splitting inadvertently further down during retraction and damaging the axillary nerve. Continue the dissection as for subacromial decompression by detaching the fibers of the deltoid that arise from the acromioclavicular joint, and, as before, continue this detachment by sharp dissection laterally to expose 1 cm of the anterior aspect of the acromion. Retract the split edges of the deltoid muscle to reveal the underlying coracoacromial ligament.

 

Deep Surgical Dissection

 

Detach the coracoacromial ligament from the acromion, either by sharp

dissection or by removing it with a block of bone from the undersurface of the acromion. Detach the medial end of the coracoacromial ligament just proximal to the coracoid process and excise the ligament. The supraspinatus tendon with its overlying subacromial bursa now is revealed. Rotate the head of the humerus to expose different portions of the rotator cuff (Fig. 1-34). Full external rotation will reveal the long head of the biceps tendon in its groove.

 

 

Dang

 

 

Nerves

The axillary nerve runs transversely across the deep surface of the deltoid muscle about 5 to 7 cm below the tip of the acromion. There is variability in the position of the nerve with relation to the edge of the acromion. In general term however the longer the humerus is the greater will be the distance from the nerve to the anterior edge of the acromion.31,32

Splitting the deltoid below this level may damage the nerve. Inserting the stay suture in the apex of the deltoid split will prevent this possibility. The nerve can easily be palpated under the under surface of the muscle, if you are in doubt as to its position.

 

 

Figure 1-33 Split the deltoid muscle in the line of its fibers for 5 cm.

 

 

Figure 1-34 Resect the coracoacromial ligament with a block of bone from the undersurface of the acromion to reveal the underlying subacromial bursa and supraspinatus tendon.

 

Vessels

The acromial branch of the coracoacromial artery that runs immediately under the deltoid muscle will be divided during the superficial surgical dissection. Unless bleeding from this site is controlled, it will be very difficult to identify deeper structures, which may cause inadvertent deviation from the proper surgical plane. Damage to this vessel is also a problem in arthroscopic surgery of this area.

 

How to Enlarge the Approach

Local Measures

Because reattaching the deltoid to its insertion is so difficult, extensive detachment of this muscle is not recommended, even though it does facilitate the exposure.

Extensile Measures

Because this approach does not operate in an internervous plane, no useful extensions, either proximal or distal, are possible.

 

Lateral Approach to the Proximal Humerus‌

 

 

The lateral approach provides limited access to the head and surgical neck of the humerus. It is not a classically extensile approach, because it is limited distally by the traverse of the axillary nerve running on the deep surface of the deltoid muscle. Distal extension is however possible by utilizing a separate deltoid split distal to the nerve (see minimally invasive approach to proximal humerus). It can be extended usefully in a proximal direction to reveal the entire length of the supraspinatus muscle. Its use in fracture surgery is reserved for fractures of the surgical neck and tuberosities of the humerus. Most distal fractures are best approached through the anterior approach to the shoulder (see page 7, Fig. 1-8) or the minimally invasive lateral approach to the proximal humerus (see page 14, Fig. 1-41).

The uses of the lateral approach include the following:

1. Open reduction and internal fixation of displaced fractures of the greater tuberosity of the humerus

2. Open reduction and internal fixation of humeral neck fractures

3. Insertion of intramedullary nails into the humerus

4. Removal of calcific deposits from the subacromial bursa

5. Repair of the supraspinatus tendon

6. Repair of the rotator cuff

 

Position of the Patient

 

Place the patient in a supine position with the affected arm at the edge of the table. Elevate the head of the table to reduce venous pressure and operative bleeding (Fig. 1-35). A sandbag should be placed under the patient’s shoulder. Ensure that adequate intraoperative imaging can be obtained before prepping and draping the patient.

 

Landmarks and Incision

Landmarks

The acromion is rectangular. Its bony dorsum and lateral border are easy to palpate on the outer aspect of the shoulder.

 

 

 

Figure 1-35 Position of the patient on the operating table for the lateral approach to the shoulder. Elevate the table to 45 degrees. Place a sandbag under the shoulder to lift it off the operating table.

 

 

Figure 1-36 Make a 5-cm longitudinal incision from the tip of the acromion down the lateral aspect of the arm.

 

The lateral side of the proximal humerus is also easily palpable.

Incision

Make a 5-cm longitudinal incision from the tip of the acromion down the lateral aspect of the arm (Fig. 1-36).

 

Internervous Plane

 

There is no true internervous plane; the lateral approach involves splitting

the deltoid muscle.

 

Superficial Surgical Dissection

 

Split the multipennate deltoid muscle in the line of its fibers from the acromion downward for 5 cm. This may involve sharp as well as blunt dissection. Insert a suture at the inferior apex of the split to help prevent it from extending accidentally, with consequent axillary nerve damage, as the exposure is worked on (Figs. 1-37 and 1-38).

 

Deep Surgical Dissection

 

The lateral aspect of the upper humerus and its attached rotator cuff lie directly under the deltoid muscle and the subacromial bursa (Fig. 1-39). In fractures of the neck of the humerus, the bare ends of bone usually appear at this point without further dissection.

Small tears of the supraspinatus muscle also can be reached through this approach. Most defects in the supraspinatus muscle are large, however. Some surgical procedures require that the whole supraspinatus be mobilized so that the muscle can be advanced and the tendon repaired (Fig. 1-40).

 

 

Figure 1-37 Split the deltoid muscle in line with its fibers and insert a stay suture at the inferior apex of the split to prevent it from extending distally and causing axillary nerve damage.

 

 

Figure 1-38 Expose the subdeltoid portion of the subacromial bursa by retracting the deltoid muscle anteriorly and posteriorly.

 

 

Figure 1-39 Incise the bursa to reveal the insertion of the supraspinatus tendon into the greater tuberosity.

 

In the upper part of the wound, the exposed subacromial bursa must be incised longitudinally to provide access to the upper lateral portion of the head of the humerus (see Fig. 1-39).

 

 

Dang

 

 

Nerves

The axillary nerve leaves the posterior wall of the axilla by penetrating the quadrangular space. Then it winds around the humerus with the posterior circumflex humeral artery (see Figs. 1-37 and 1-52). The nerve enters the deltoid muscle posteriorly from its deep surface, about 5 to 7 cm

below the tip of the acromion. From that point, its fibers spread anteriorly. Because of the nerve’s course, the dissection cannot be extended farther in an inferior direction without denervating that portion of the deltoid muscle that is located anterior to the muscle split.

 

How to Enlarge the Approach

Extensile Measures

 

Proximal Extension. Extend the incision superiorly and medially across the acromion and parallel to the upper margin of the spine of the scapula, about 1 cm above it along the lateral two-thirds of the scapular spine.33

Incise the trapezius muscle parallel to the spine of the scapula and about 1 cm above it. Retract the muscle superiorly to reveal the supraspinatus and its fascial covering.

Incise the fascia overlying the supraspinatus in the line of the skin incision to expose the muscle.

Split the acromion in the line of the skin incision, using an osteotome. Retract the two parts of the acromion with a self-retaining retractor.

The entire length of the supraspinatus, from its origin in the supraspinous fossa to its insertion onto the greater tuberosity of the humerus, now is exposed (see Figs. 1-40 and 1-52). Take great care to reconstruct the divided acromion during closure.

 

 

Figure 1-40 To expose the entire supraspinatus muscle, cut the acromion and split the trapezius muscle to reveal the underlying supraspinatus muscle belly and tendon. The entire muscle can be advanced and the tendon repaired.

 

Minimally Invasive Lateral Approach to‌

 

the Proximal Humerus

The minimally invasive approach to the proximal humerus provides access to the head, surgical neck and proximal third of the humerus. It utilizes two windows, proximal and distal, on either side of the axillary nerve as it runs transversely on the under surface of the deltoid muscle. The use of the lateral minimally invasive approach is for internal fixation of displaced fractures of the proximal third of the humerus. It is of most use in segmental fractures and those fractures of the proximal humerus that have extension down into the humeral shaft.34,35

 

Position of the Patient

 

Place the patient in a supine position with the affected arm at the edge of the table. Elevate the head of the table to reduce venous pressure and operative bleeding (see Fig. 1-35). A sandbag should be placed under the patient’s shoulder. Ensure that adequate intraoperative imaging can be obtained before prepping and draping the patient (see Fig. 1-35).

 

Landmarks and Incision

 

Palpate the lateral border of the acromion. Define the lower end of the incision by marking the skin with a transverse line 5 cm below the acromion. This line will be approximately 1 cm above the axillary nerve. Make a 5- to 6-cm longitudinal incision from the tip of the acromion down the lateral aspect of the upper arm (see Fig. 1-36). Make a second 5-cm incision distally in the line of the proximal incision (Fig. 1-41). The position of this second incision will depend on the site of the fracture and the length of the implant to be used. Accurate positioning of the distal incision is best achieved by using the image intensifier.

 

 

Figure 1-41 Proximally make a 5- to 6-cm longitudinal incision from the tip of the acromion down the lateral aspect of the upper arm. Distally make an incision in the line of the first incision. The length and position of the distal incision will depend on the pathology to be treated and the implant to be used.

 

Internervous Plane

 

There is no internervous plane. The lateral approach involves splitting the deltoid muscle.

 

Superficial Surgical Dissection

 

Deepen the proximal window in the line of the skin incision to approach the lateral aspect of the deltoid muscle (Fig. 1-42). Carefully split the muscle fibers of the deltoid, but do not extend this split more than 5 cm distal to the acromion. Deepen the distal incision through subcutaneous tissue to expose the lateral aspect of the deltoid muscle (Fig. 1-43).

 

Deep Surgical Dissection

 

Through the proximal window, carefully develop an epiperiosteal plane on the lateral surface of the humerus. Using your finger, carefully palpate the axillary nerve, running on the under surface of the deltoid (Fig. 1-44).

Having successfully identified the position of the axillary nerve, split the deltoid in the line of its fibers through the distal incision.

 

 

 

Figure 1-42 Deepen the incisions through subcutaneous tissue to expose the fascia covering the deltoid muscle.

 

Carefully connect the proximal and distal exposures of the bone by gently developing an epiperiosteal plane using your finger and subsequently the implant (Fig. 1-45).

 

 

Dang

 

 

The axillary nerve runs on the under surface of the deltoid. As long as one works beneath the deltoid on the bone, the nerve will not be injured. Take care, however, not to aggressively retract the deltoid muscle fibers, either proximally or distally, as this may induce a traction lesion of the nerve.

 

Figure 1-43 Proximally split the muscle fibers of the deltoid to expose the periosteum overlying the lateral aspect of the proximal humerus. Do not extend this split more than 5 cm distal to the acromion. Distally split the fibers of the deltoid.

 

 

 

Figure 1-44 Palpate the axillary nerve as it runs along the undersurface of the deltoid muscle and develop an epiperiosteal plane on the lateral aspect of the humerus, using blunt dissection.

 

How to Enlarge the Approach

 

The proximal incision can be extended proximally, but cannot be extended distally (see page 31, Fig. 1-37). The distal incision can be extended distally to expose the middle third of the humerus by stripping some of the insertion of the deltoid to the lateral aspect of the humerus. The distal window cannot be extended proximally through the substance of deltoid, because this will inevitably damage the axillary nerve.

 

 

 

Figure 1-45 Continue to develop the epiperiosteal plane to connect the two incisions.

 

Minimally Invasive Anterolateral Approach to the Proximal Humerus‌

 

 

The minimally invasive approach to the proximal humerus is used for the

insertion of intramedullary nails for the treatment of the following:

1. Acute humeral shaft fractures

2. Pathologic humeral shaft fractures

3. Delayed union and nonunion of humeral shaft fractures

The presence of the overlying acromion and the fact that the upper end of the humerus is covered entirely with articular cartilage mean that most nails are angled at their upper end and are inserted via the lateral cortex of the humerus. The entry point for an intermedullary nail into the humerus is determined radiographically, with a template of the required nail superimposed over a radiograph of the injured humerus. The entry point depends on the specific design of the nail. The most usual entry point is just lateral to the articular surface of the humeral head and just medial to the greater tuberosity (see Fig. 1-50).

 

Position of the Patient

 

Place the patient in a supine position. Elevate the upper portion of the table to approximately 60 degrees (see Fig. 1-78). Position the patient so that the shoulder lies over the edge of the table. Alternatively, use a specialized table that allows radiographic visualization of the shoulder in both anterior–posterior and lateral planes. Ensure that the cervical spine is adequately supported and that lateral flexion of the cervical spine is avoided to prevent a traction lesion of the brachial plexus.

 

 

Figure 1-46 Palpate the lateral border of the acromion and then make a 2-cm incision from that border down the lateral aspect of the arm.

 

Landmarks and Incision

Landmark

The acromion is rectangular. Its bony dorsum and lateral border are easy to palpate on the outer aspect of the shoulder (see Figs. 1-51 and 1-52).

Incision

Make a 2-cm incision from the outer aspect of the acromion down the lateral aspect of the arm (Fig. 1-46 and see Fig. 1-39).

 

Internervous Plane

 

This approach does not exploit an internervous plane. The dissection involves splitting the deltoid muscle.

 

Superficial and Deep Surgical Dissections

 

Insert a wire under image intensifier control through the skin incision, down through the substance of the deltoid muscle and rotator cuff to the correct insertion point on the humerus (Fig. 1-47). This position has been determined on the preoperative x-ray plan. Confirm that the wire is in the correct position by the use of a C-arm image intensifier in both anterior–

posterior and lateral planes.

 

 

 

Figure 1-47 Insert a guidewire through the substance of the deltoid muscle under image intensifier control.

 

 

Figure 1-48 Enlarge the track made by the wire using a point-ended scalpel. You will incise part of the deltoid and part of the supraspinatus tendon.

 

Withdraw the wire and insert a point-ended scalpel blade, following the track of the wire using a C-arm image intensifier to confirm position (Fig. 1-48). Incise a small portion of the deltoid and make a small clean-edged incision through part of the supraspinatus tendon. Withdraw the blade and reinsert the wire. Enter the proximal end of the humerus using an awl or drill, depending on the nail to be used (Figs. 1-49 and 1-50).

 

 

Dang

 

Nerves

The axillary nerve lies approximately 7 cm below the tip of the acromion, running transversely on the deep aspect of the deltoid muscle.

The brachial artery and median nerve lie medial to the proximal humerus. They are also at risk during insertion of proximal locking bolts. This incision should, therefore, not risk damage to the axillary nerve (see Fig. 1-39). The nerve may, however, be damaged by proximal interlocking bolts inserted from lateral to medial (see Fig. 1-50).

Tendons

Part of the supraspinatus tendon and the overlying subacromial bursa will be incised by this approach. A degree of damage to the rotator cuff is therefore inevitable in proximal humeral nailing using conventional nails (see Fig. 1-39). Damage to the rotator cuff is minimized by ensuring that any drills used are passed through protection sleeves. Formal repair of the supraspinatus tendon is important during closure of the surgical approach. Despite these maneuvers a significant degree of stiffness of the shoulder may occur postoperatively in a number of patients following antegrade humeral nailing.36

 

How to Enlarge the Approach

Extensile Measures

 

Distal Extension. The approach can be extended to a formal lateral approach to the proximal humerus. This extension may be needed if closed reduction of proximal humeral fractures cannot be obtained (see Fig. 1-39).

 

 

Figure 1-49 Insert the wire into the proximal end of the humerus under image intensifier control.

 

 

Figure 1-50 Lateral view of the shoulder, revealing insertion of the guidewire. The most common entry point is just lateral to the articular surface of the humeral head and just medial to the greater tuberosity.

 

Applied Surgical Anatomy of the Anterolateral and Lateral Approaches‌

 

 

Overview

 

Two muscular sleeves cover the lateral aspect of the shoulder joint: The outer sleeve consists of the lateral portion of the deltoid muscle, and the inner sleeve is the supraspinatus tendon (part of the rotator cuff) (Figs. 1-51 and 1-52).

Landmarks and Incision

Landmark

The acromion, which is the lateral continuation of the spine of the scapula, is the summit of the shoulder, overhanging the greater tuberosity of the humerus. Muscles either insert onto it or take origin from it, but no muscle crosses it. Thus, it is partially subcutaneous and can be palpated (see Fig. 1-51). The anatomical shape of the acromion has considerable variation, which may be associated with an impingement syndrome.37

Incision

Because the lateral skin incision crosses the lines of relaxed skin tension line almost transversely, it is likely to leave a broad scar.

 

Superficial Surgical Dissection

 

Superficial surgical dissection involves splitting the fibers of the deltoid muscle. Proximal extension of the approach to expose the supraspinatus involves splitting the fibers of the trapezius muscle (see Fig. 1-40).

Deltoid Muscle

The lateral approach affects the portion of the deltoid muscle that arises from the lateral border of the acromion. The lateral deltoid consists of oblique fibers arising in a multipennate fashion from tough tendinous bands that originate from the acromion. These bands actually mark the bone with a series of notches. Similar bands arise from the insertion of the muscle onto the humerus halfway down the lateral border; the muscle fibers arising from these tendinous bands interdigitate in a herringbone pattern.

This multipennate arrangement provides the deltoid muscle with maximum strength, although it limits the degree to which it can contract. Nevertheless, despite the arrangement of the fibers, it is relatively easy to split the muscle in a longitudinal fashion. The tough tendinous bands also prevent excessive damage to the muscle when it is split during surgery (Fig. 1-53).

 

 

Figure 1-51 The superficial muscles of the lateral aspects of the shoulder. The muscles take origin from or insert into the acromion and the spine of the scapula, but do not cross them.

 

Whether the deltoid muscle should be detached from the acromion still is in question, because reattachment is difficult and often unsuccessful.38 An acromial osteotomy and subsequent reattachment of the bone, with the muscle still attached to it, may be the best solution, although acromial nonunion may occur because the anterior and posterior portions of the deltoid tend to pull apart the site subjected to osteotomy. In the vast majority of cases, widespread detachment of the deltoid from the acromion

should not be necessary for the adequate exposure of the underlying structures.

Trapezius Muscle

See the section regarding the posterior approach to the cervical spine.

Axillary Nerve

See the sections regarding dangers in the lateral approach to the shoulder.

Acromial Branch of the Acromiothoracic Artery

The acromial branch of the acromiothoracic artery is a tributary of the acromiothoracic artery which arises from the second part of the axillary artery. Running immediately deep to the insertion of the deltoid muscle to the acromioclavicular joint, it is coagulated easily.

Subacromial (Subdeltoid) Bursa

The subacromial bursa separates the two sleeves of muscle that cover the lateral aspect of the shoulder joint. It helps them glide past each other and protects the rotator cuff (the inner sleeve) from the hard overlying bone and ligamentous complex—the acromial process (acromion), the coracoacromial ligament (which spans the gap between the coracoid process and the acromion), and the coracoid process of the scapula. Because the bursa lies between the supraspinatus and deltoid muscles, and between the supraspinatus and coracoacromial ligaments, it is called both the subacromial bursa and the subdeltoid bursa (Figs. 1-54 and 1-55).

 

 

Figure 1-52 Portions of the deltoid and trapezius have been removed to reveal the underlying rotator cuff and the axillary nerve, usually beneath the teres minor in the quadrangular space.

 

The bursa is a large structure, extending anteriorly from beneath the coracoid process. At this point, it provides lubrication between the conjoined tendons of the coracobrachialis and biceps brachii muscles, and the underlying subscapularis muscle.

The bursa ordinarily does not communicate with the shoulder joint. Rupture of the supraspinatus tendon, however, can cause the two synovial-lined cavities to join; an arthrogram of the shoulder can reveal this

communication (Fig. 1-56).39,40

With the arm in the dependent position, the bursa lies under the deltoid muscle and the coracoacromial ligament. When the arm is abducted, the bursa retreats under the cover of this ligament. At this point, the patient feels pain if there is inflammation of the bursa, mainly because the bursa is compressed between the undersurface of the acromion and the humeral head (Fig. 1-57). Classically, this painful arc of movement occurs between

80 and 120 degrees of shoulder abduction. Paradoxically, there is no tenderness on the lateral aspect of the shoulder in this position, because the bursa now is protected from palpation completely by the coracoacromial ligament. When the arm is adducted again, the pain disappears, because the bursa no longer is compressed between the ligament and the supraspinatus. Tenderness on palpation may be elicited on the lateral aspect of the shoulder below the acromion, however, because the bursa now is accessible. Passive extension of the shoulder also brings the bursa out anteriorly from beneath the acromion and makes it palpable.

 

 

Figure 1-53 The multipennate arrangement of the muscle fibers of the middle portion of the deltoid muscle.

 

 

Figure 1-54 The subacromial bursa. Note the expansion of the subacromial bursa and the large subdeltoid portion. The subscapularis bursa frequently pierces the joint capsule to communicate with the joint.

 

Figure 1-55 The subacromial bursa directly protects the supraspinatus tendon from the bone and ligamentous complex that covers it.

 

 

 

Figure 1-56 Rupture of the supraspinatus tendon allows direct communication between the joint and the subacromial bursa. An arthrogram of the shoulder will reveal this communication, helping to establish the diagnosis of a torn rotator cuff.

 

Deep Surgical Dissection and Its Dangers

Supraspinatus Muscle

The supraspinatus, which is a multipennate muscle, passes laterally beneath the coracoacromial ligament. This muscle is the most frequent site of degenerative changes and frank tears within the rotator cuff. Within the rotator cuff. Degeneration in its tendon invokes an inflammatory response in the overlying subacromial bursa, and most cases of subacromial bursitis probably reflect pathology in the muscle.41 The close relationship of the supraspinatus to the coracoacromial ligament may result in mechanical abrasion between the two structures during abduction of the arm, causing degeneration of the tendon. The subacromial bursa minimizes this tendency (see Figs. 1-55 and 1-59).

 

 

 

Figure 1-57 Abduction of the arm can impinge the subacromial bursa between the greater tuberosity and the undersurface of the acromion and coracoacromial ligament.

 

 

Figure 1-58 Superior view of the shoulder, showing the rotator cuff and the acromioclavicular joint. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles after passing through the suprascapular notch and ligament. Supraspinatus. Origin. Medial three-fourths of supraspinous fossa of scapula. Insertion. Upper facet of greater tuberosity of humerus. Action. Initiates abduction of shoulder. Nerve supply. Suprascapular nerve.

 

When the arm is by the patient’s side, the supraspinatus tendon takes a 90-degree turn over the humeral head before its insertion, putting the blood supply to the tendon on a stretch. Vascular insufficiency may result, which is another possible cause of degenerative change.42

Regardless of the mechanism of degeneration, about one-fourth of all individuals who reach 65 years of age rupture their supraspinatus tendon.43 Patients with complete ruptures of the supraspinatus are unable to abduct their arms without adopting such trick movements as a shrug mechanism because the supraspinatus muscle is the initiator of shoulder abduction. If patients with a ruptured supraspinatus lower the affected arm slowly from the vertical, they lose control of it at about 30 degrees and it drops suddenly to their side.

The suprascapular nerve is a branch of the upper trunk of the brachial plexus; it enters the muscle on its deep surface. Some methods of repairing

tears of the supraspinatus tendon involve mobilizing the entire muscle belly and advancing it laterally to take tension off the suture line of the repair.33 Take great care in mobilizing the supraspinatus muscle from its fossa, to avoid damaging its nerve (Fig. 1-58).

 

Impingement Syndrome

 

Abduction of the arm may pinch the supraspinatus muscle between the head of the humerus and the arch created by the acromion and the coracoacromial ligament. The anatomy of the acromion varies considerably from individual to individual, and certain acromial shapes have been associated with an impingement syndrome. Performing an acromioplasty and cutting the coracoacromial ligament may provide relief in some patients with impingement syndrome. This procedure can be carried out by an open operation (see Anterolateral Approach to the Acromioclavicular Joint and Subacromial Space) or by arthroscopic techniques.

 

Special Anatomic Points

 

The acromioclavicular joint is a synovial joint between the lateral end of the clavicle and the medial border of the acromion. The lateral end of the clavicle is higher than the acromion; the joint can be palpated by pushing medially against the thickness at the end of the clavicle.

 

 

Figure 1-59 A: Superior view of the shoulder joint, revealing the bone structure and acromioclavicular joint capsule. B: Cross section of anterior view of the shoulder, revealing the acromioclavicular joint and meniscus, as well as the supraspinatus tendon and its relationship to the coracoacromial ligament.

 

The acromioclavicular joint contains a fibrocartilaginous meniscus, which usually is incomplete; the meniscus may be displaced during traumatic subluxation of the joint (Fig. 1-59B).

The two most common disease processes affecting the acromioclavicular joint are acromioclavicular dislocations and acromioclavicular arthritis. In cases of acromioclavicular dislocation, it is important to remember that the major accessory ligaments of the joint from the coracoid process to the undersurface of the clavicle are some

distance from it. They cannot be repaired directly to restore joint stability; however, if the joint is reduced and stabilized by another technique, they will heal. Acromioclavicular arthritis commonly is associated with the development of inferior osteophytes, which are a contributing factor to cases of impingement syndromes.

The joint is exposed easily by way of a superior approach because it is essentially subcutaneous. The insertions of the trapezius and deltoid muscles to the superior surface of the clavicle are confluent; however, the two muscles are separated easily by subperiosteal dissection (Fig. 1-60). In cases of acromioclavicular dislocation, however, this dissection will have been done for you and the distal end of the clavicle often lies in a subcutaneous position.

The joint may also be approached from its anterior surface (see Anterolateral Approach to the Shoulder).

 

 

 

Figure 1-60 Superior approach to the acromioclavicular joint.

 

Posterior Approach to the Shoulder Joint‌

The posterior approach offers access to the posterior and inferior aspects of the shoulder joint.44 It rarely is needed, but can be used in the following instances:

1. Repairs in cases of recurrent posterior dislocation or subluxation of the shoulder45,46

2. Glenoid osteotomy47

3. Biopsy and excision of tumors

4. Drainage of sepsis (the approach allows dependent drainage with the patient in the normal position in bed)

5. Treatment of fractures of the scapula neck, particularly those in association with fractured clavicles (floating shoulder48,49)

6. Treatment of posterior fracture dislocations of the proximal humerus

 

Position of the Patient

 

Place the patient in a lateral position on the edge of the operating table with the affected side uppermost. Drape the patient to allow independent movement of the arm (Fig. 1-61). Stand behind the patient and take care that the ear is not folded accidentally under the head.

 

Landmarks and Incision

Landmarks

The acromion and the spine of the scapula form one continuous arch. The spine of the scapula extends obliquely across the upper four-fifths of the dorsum of the scapula and ends in a flat, smooth triangle at the medial border of the scapula. It is easy to palpate.

Incision

Make a linear incision along the entire length of the scapular spine, extending to the posterior corner of the acromion (Fig. 1-62). Alternatively make a 10- to 15-cm longitudinal incision centered on a point 2 cm inferomedial to the posterior corner of the acromion.

 

 

Figure 1-61 Position of the patient on the operating table for the posterior approach to the shoulder. Drape the involved arm to allow for independent motion.

 

 

Figure 1-62 Make a linear incision over the entire length of the scapular spine, extending to the posterior corner of the acromion. You may choose to curve the medial end of the incision distally to enhance the exposure.

 

 

Figure 1-63 The internervous plane lies between the teres minor (axillary nerve) and the infraspinatus (suprascapular nerve).

 

Internervous Plane

 

The internervous plane lies between the teres minor muscle, which is supplied by the axillary nerve, and the infraspinatus muscle, which is supplied by the suprascapular nerve (Fig. 1-63).

 

Superficial Surgical Dissection

 

Identify the origin of the deltoid on the scapular spine and detach the

muscle from this origin. The plane between the deltoid muscle and the underlying infraspinatus muscle may be difficult to find, mainly because there is a tendency to look for it too close to the bone and to end up stripping the infraspinatus off the scapula. The plane is easier to locate at the lateral end of the incision. Once it has been found, it is not difficult to develop if the deltoid is retracted inferiorly and the infraspinatus is exposed (Fig. 1-64). Note that the plane also is an internervous plane, because the deltoid is supplied by the axillary nerve and the infraspinatus is supplied by the suprascapular nerve. If the longitudinal incision is used, elevate the skin flaps sufficiently to see the fibers of the deltoid. Split these fibers from the spine of the scapula downward revealing the underlying infraspinatus muscle. The distal end of the split is the teres minor muscle.

 

Deep Surgical Dissection

 

Identify the internervous plane between the infraspinatus and teres minor muscles, and develop it by blunt dissection, using a finger. This important plane is difficult to define (Fig. 1-65). Retract the infraspinatus superiorly and the teres minor inferiorly to reach the posterior regions of the glenoid cavity and the neck of the scapula (Fig. 1-66). The posteroinferior corner of the shoulder joint capsule now is exposed. To explore the joint, incise it longitudinally, close to the edge of the scapula (Figs. 1-67 and 1-68). In cases of posterior instability, the capsule will be detached from the posterior aspect of the glenoid with or without the presence of a bony fragment (posterior Bankart lesion). To access the neck of the scapula and its lateral border dissect inferiorly in a subperiosteal plane stripping off part of the origin of the long head of the triceps brachii muscle.

 

 

Figure 1-64 Identify the origin of the deltoid muscle, the spine of the scapula, and the attachment from its origin. Begin detaching the muscle from the lateral to the medial point.

 

 

Dang

 

 

Nerves

The axillary nerve runs through the quadrangular space beneath the teres minor. Because a dissection carried out inferior to the teres minor can damage the axillary nerve, it is critical to identify the muscular interval between the infraspinatus and teres minor muscles, and to stay within that

interval.

The suprascapular nerve passes around the base of the spine of the scapula as it runs from the supraspinous fossa to the infraspinous fossa. It is the nerve supply for both the supraspinatus and infraspinatus muscles. The infraspinatus must not be retracted forcefully too far medially during the approach because a neurapraxia may result from stretching the nerve around the unyielding lateral edge of the scapular spine (see Fig. 1-72). Wasting of the infraspinatus muscle is not uncommon following this approach.50

Vessels

The posterior circumflex humeral artery runs with the axillary nerve in the quadrangular space beneath the inferior border of the teres minor muscle. Damage to this artery leads to hemorrhaging that is difficult to control. This danger can be avoided by staying in the correct intermuscular plane (see Fig. 1-71).

 

 

Figure 1-65 Identify the internervous plane between the infraspinatus and teres minor. Note that it is difficult to define.

 

How to Enlarge the Approach

Local Measures

To gain better exposure of the deep layer of muscles, split the detached deltoid muscle at the lateral edge of the wound. To gain better access to the posterior aspect of the shoulder joint, detach the infraspinatus 1 cm from its insertion onto the greater tuberosity of the humerus. Retract the muscle medially, taking care not to damage the suprascapular nerve, which

enters the undersurface of the muscle just below the spine of the scapula. Such an exposure is necessary for correct placement of a posterior bone block (Fig. 1-69). Even with care neurapraxias of the suprascapular nerve are not uncommon following this maneuver.

 

 

 

Figure 1-66 Retract the infraspinatus superiorly and the teres minor inferiorly to reach the posterior aspect of the joint capsule of the shoulder.

 

 

Figure 1-67 Incise the joint capsule close to the glenoid cavity.

 

 

 

Figure 1-68 Retract the joint capsule to reveal the posterior regions of the glenoid cavity, the neck of the scapula, and the head of the humerus.

 

 

Figure 1-69 To gain greater exposure of the joint, cut the infraspinatus muscle close to its attachment to the humerus and retract it medially. Be careful to retract the muscle gently to avoid stretching the suprascapular nerve, which enters the muscle on its undersurface.

 

Extensile Measures

The incision cannot be extended usefully. Its sole function is to provide access to the posterior aspect of the shoulder joint.

 

Applied Surgical Anatomy of the‌

 

Posterior Approach to the Shoulder Joint

 

Overview

 

The posterior aspect of the shoulder is similar to the anterior and lateral aspects, being covered by two muscular sleeves. The posterior part of the deltoid muscle forms the outer sleeve of muscle, as it does for all other approaches to the shoulder joint. The inner sleeve consists of two muscles of the rotator cuff, the infraspinatus, and the teres minor (Figs. 1-70 and 1-71).

 

Landmark and Incision

Landmark

The spine of the scapula is a thick, bony ridge projecting from the back of the blade of the scapula. Its base runs almost horizontally, and its free lateral border curves forward to form the acromion. The spine separates the supraspinous fossa from the infraspinous fossa. The trapezius muscle inserts into it from above; part of the deltoid muscle originates from its inferior border (see Fig. 1-70).

 

 

Figure 1-70 The superficial muscles of the posterior aspect of the shoulder. The posterior portion of the deltoid as it takes origin from the spine of the scapula is aponeurotic, and the plane between it and the underlying infraspinatus is difficult to identify.

 

 

Figure 1-71 The posterior portion of the deltoid is detached from the spine of the scapula, revealing the infraspinatus, teres minor, and teres major muscles, as well as the long and lateral heads of the triceps muscle. The boundaries of the quadrangular space are, superiorly, the lower border of the teres minor; laterally, the surgical neck of the humerus; medially, the long head of the triceps; and, anteriorly, the upper border of the teres major. Through this space run the axillary nerve and the posterior circumflex humeral artery. Infraspinatus. Origin. Medial three-fourths of infraspinous fossa of scapula. Insertion. Central facet on greater tuberosity of humerus. Action. Lateral rotator of humerus. Nerve supply. Suprascapular nerve. Teres Minor. Origin. Axillary border of scapula. Insertion. Lowest facet on greater tuberosity of humerus. Action. Lateral rotator of humerus. Nerve supply. Axillary nerve.

Incision

Because the transverse skin incision runs across the relaxed skin tension line, the resultant scar usually is broad. A vertical incision at the lateral end of the scapular spine is more cosmetic, but provides very poor

exposure of the joint and the neck of the glenoid.

 

Superficial Surgical Dissection

 

In the posterior approach, only those fibers of the deltoid muscle that arise from the spine of the scapula are detached. Because the fibers are straight and blend intimately with the periosteum of the scapula, the muscle can be removed subperiosteally. During closure, the good, tough tissue that remains attached to the muscle provides an excellent anchor for sutures, in contrast to the anterior and lateral portions of the muscle. Drill holes may need to be placed through the spine, however, to anchor the muscular sutures.

 

Deep Surgical Dissection

 

The deep dissection in this approach lies between the infraspinatus and teres minor muscles (see Fig. 1-71).

Infraspinatus Muscle

The fibers of the infraspinatus muscle are multipennate; numerous fibrous intramuscular septa give attachment to them.

The infraspinatus forms its tendon just before crossing the back of the shoulder joint; a small bursa lies between the muscle and the posterior aspect of the scapular neck to help the tendon glide freely over the bone. The muscle also inserts into the capsule of the shoulder joint, mechanically increasing the capsule’s strength (Fig. 1-72).

 

 

Figure 1-72 The lateral portion of the infraspinatus and the teres minor has been removed to reveal the joint capsule. The suprascapular nerve and the circumflex scapular artery are seen curving medially and distally around the lateral border of the spine of the scapula. The axillary nerve is seen emerging through the quadrangular space and splitting into many branches. The medial branch splits to supply the teres minor muscle. The radial nerve is seen crossing through the triangular interval and entering the spiral groove in the upper portion of the humerus. The triangular interval is formed superiorly by the lower border of the teres major muscle, medially by the long head of the triceps, and laterally by the shaft of the humerus.

 

Teres Minor Muscle

The teres minor runs side by side with the infraspinatus. Its fibers run parallel with one another, in contrast to the multipennate fibers of the infraspinatus; this difference may help in identification of the interval between the two muscles.

The axillary nerve enters the muscle from its inferior border. The superior border (the boundary between the infraspinatus and teres minor muscles), therefore, is the safe side of the muscle and a true internervous

plane (see Fig. 1-71).

 

 

Dang

 

 

Axillary Nerve

The axillary nerve is a branch of the posterior cord of the brachial plexus. It runs down along the posterior wall of the axilla on the surface of the subscapularis, far from the incision made in that muscle during the anterior approach to the shoulder (see Fig. 1-26). The nerve then runs through the quadrangular space, where it touches the surgical neck of the humerus. At that point, it can be damaged easily by surgery, by fractures of the surgical neck of the humerus, or by anterior dislocation of the shoulder.

The boundaries of the quadrangular space differ when viewed from the front and from the back (see Fig. 1-71).

 

Posterior View. The boundaries from the posterior view are as follows: Superiorly, the lower border of the teres minor; laterally, the surgical neck of the humerus; medially, the long head of the triceps; and inferiorly, the upper border of the teres major.

 

Anterior View. The boundaries from the anterior view are as follows: Superiorly, the subscapularis; laterally, the surgical neck of the humerus; medially, the long head of the triceps; and inferiorly, the upper border of the teres major (see Fig. 1-26).

The axillary nerve disappears beneath the lower border of the subscapularis and, after traversing the quadrangular space, emerges in the back of the shoulder beneath the lower border of the teres minor. The posterior circumflex humeral vessels run with it (see Fig. 1-71).

Dissections carried out above the teres minor do not damage the axillary nerve; however, if the dissection strays out of the correct plane and below the teres minor, the axillary nerve can be damaged. Because the axillary nerve is the sole nerve supply to the deltoid muscle, any damage will produce severe functional impairment.

Within the quadrangular space, the axillary nerve divides into two branches after giving off a twig to the shoulder joint. The deep branch enters and supplies the deep surface of the deltoid (see Fig. 1-71). The superficial branch supplies the teres minor muscle and sends a cutaneous branch to the lateral aspect of the upper arm, namely, the upper lateral cutaneous nerve of the arm, which supplies the skin over the insertion of

the deltoid muscle (see Fig. 1-70).

The upper lateral cutaneous nerve of the arm is of clinical importance in cases of traumatic axillary nerve palsy following, for instance, an acute anterior dislocation of the shoulder. Examination of the paralyzed deltoid and teres minor muscles may be difficult or impossible because of the pain that follows this injury. Diminution of sensation over the insertion of the deltoid is good presumptive evidence of the presence of an axillary nerve palsy.

The axillary nerve is the best example of Hilton’s law, which states that the motor nerve to a muscle tends to send a branch to the joint that the muscle moves and another branch to the skin over the joint.51 Pain in the shoulder is perceived via the axillary nerve and, therefore, may be referred to the cutaneous distribution of that nerve.

Radial Nerve

The radial nerve, which is the other major branch of the posterior cord of the brachial plexus, leaves the axilla by passing backward through a triangular space that is defined superiorly by the lower border of the teres major, laterally by the shaft of the humerus, and medially by the long head of the triceps (see Figs. 1-61 and 1-72).

The chances of endangering the radial nerve by this approach are remote. It cannot be damaged during the posterior approach to the shoulder unless dissection is carried out not only below teres minor but below teres major as well.

Circumflex Scapular Vessels

Yet another triangular space exists when the inner sleeve of shoulder muscles is viewed from the back. Its boundaries are as follows: Superiorly, the lower border of the teres minor; laterally, the long head of the triceps; and inferiorly, the upper border of the teres major (see Fig. 1-71).

This triangular space contains the circumflex scapular vessels, which form part of the extremely rich blood supply to the scapula. Dissection carried out between the teres minor and teres major muscles should not be carried out in elective surgical procedures because damage to these vessels will cause profuse hemorrhage that is difficult to control (see Fig. 1-71). Because the scapula has such a rich blood supply, fractures of the scapula are often associated with profuse blood loss. The hematoma is constrained within the fascia surrounding the scapula muscles and is not obvious. Potential blood loss from a fractured scapula always must be considered during vascular assessment of a polytraumatized patient.

Arthroscopic Approaches to the Shoulder‌

 

 

General Principles of Arthroscopy

 

Visualization of anatomic structures in open surgical approaches is straightforward. If a given structure is not visible, it may be exposed by extending the incision, thus expanding the surgical approach. By contrast, visualization of structures in arthroscopic approaches is achieved by using a telescope. The most commonly used arthroscope is angulated 30 degrees at its tip so that the view obtained shows the structures that are 30 degrees from the long axis of the arthroscope and not the structures that are directly in front of the scope. This is the arthroscope described in this book (Fig. 1-73, inset).

Angled scopes are required because the bony structure of the joint allows the arthroscope to be placed only in certain positions. The use of an angled scope allows the surgeon to see “around the corner” and thereby greatly increases the view obtained within any joint.

Visualization of structures using an arthroscope can be achieved in several ways. Moving the scope forward or backward (advancing or withdrawing it) will reveal structures in front of or behind the original view (see Fig. 1-73). Keep the following important points in mind during arthroscopic use:

1. Because the scope is angled 30 degrees from its axis, it is not possible to zoom in on an object merely by advancing the scope.

2. Rotating the arthroscope will reveal a series of views angled at 30 degrees from the axis of the scope (Fig. 1-74).

3. Angling the scope will change the direction of the view (Fig. 1-75). You will not be able to visualize those structures directly in front of the arthroscope unless you angle it.

4. It is possible to change the view by moving the joint while leaving the arthroscope in the same position. This maneuver is vital for full inspection of any joint.

 

 

Figure 1-73 Visualization of structures using an arthroscope is achieved in several ways. Moving the arthroscope forward and backward (advancing or withdrawing) will show you structures in front of or behind your original view. Withdrawing the arthroscope from Position 1 to Position 2 changes the view from B to B′. Because the tip of the scope is angled at 30 degrees from its axis, it is not possible to zoom in on an object merely by advancing the scope.

 

 

 

Figure 1-74 Rotating the scope will provide a series of views at angles of 30 degrees from the axis of the scope. Rotating the arthroscope 90 degrees counterclockwise from Position 2 to Position 3 changes the view from B′ to C.

 

 

Figure 1-75 Angling the scope changes the direction of the view. It is the only way to be able to visualize those structures directly in front of the scope. Angling the arthroscope from Position 2 to Position 4 changes the view from B′ to A.

 

Posterior and Anterior Approaches ‌

The shoulder is a large ball and shallow socket joint with a generous capsule that allows a large range of movement in all planes. Therefore, the anatomy of the joint makes it ideal for arthroscopic approaches. However, the shoulder is covered by thick layers of muscles, and this can make arthroscopic approaches somewhat difficult (Figs. 1-76 and 1-77). Neurovascular structures also are potentially at risk in arthroscopic approaches to the shoulder. The presence of the main neurovascular bundle anteroinferior to the joint limits anterior approaches. Other neurovascular structures may also be at risk if the entry portals are inaccurately positioned (see Dangers).

Arthroscopy of the shoulder is indicated for the following:

1. Arthroscopic subacromial decompression for chronic rotator cuff tendonitis52

2. Treatment of partial thickness tears of the rotator cuff53,54

3. Treatment of tears of the glenoid labrum55,56

4. Treatment of degenerative disease of the acromioclavicular joint

5. Removal of loose bodies

6. Treatment of osteochondritis dissecans

7. Synovectomy

Numerous arthroscopic portals have been described in shoulder arthroscopy surgery. The posterior portal is the one most commonly used

for diagnostic purposes. It is nearly always used in conjunction with the anterior portal. The combination of these approaches allows the use of the arthroscope along with arthroscopic instrumentation. Usually the arthroscope is inserted via the posterior portal, and instruments are inserted via the anterior portal. However, either portal can be used for either purpose. These two approaches are described in this section.

 

 

 

Figure 1-76 Anatomy of the shoulder joint. Lateral view of the right shoulder with the lateral aspect of deltoid muscle removed, showing the thick muscular covering of the joint.

 

 

Figure 1-77 Lateral view of glenoid cavity with the humeral head removed.

 

Position of the Patient

 

Place the patient supine on the operating table. Elevate the upper half of the table to 60 degrees. Position the patient so that the operative shoulder is off the edge of the table, allowing access to both sides of the shoulder (Fig. 1-78). Prep and drape the arm so that it can be freely manipulated during arthroscopy. This position, known as the beach chair position,10 reduces venous pressure around the shoulder and reduces bleeding. Arm traction is useful in arthroscopic subacromial decompression but is not necessary for diagnostic arthroscopy.

 

 

Figure 1-78 Position of the patient for arthroscopy. Elevate the upper half of the table to 60 degrees. Position the patient so that the operative shoulder is off the edge of the table, allowing access to both sides of the shoulder. This is known as the “beach chair” position.10

 

Landmarks and Incision

 

The shoulder is surrounded on all sides by thick muscular coverings (see Figs. 1-51 and 1-76). The joint line cannot be palpated, therefore arthroscopic approaches rely on landmarks distant from the joint.

Landmarks

The acromion and the spine of the scapula form one continuous arch. The bony dorsum and lateral aspect of the acromion are easy to palpate on the outer aspect of the shoulder (see Figs. 1-51, 1-53, and 1-59A).

To identify the coracoid process, drop your fingers distally about 1 in from the anterior edge of the lateral one-third of the clavicle. Press laterally and posteriorly in an oblique line until you feel the coracoid process.

Incisions

 

Posterior. Make an 8-mm stab incision 2 cm inferior and 1 cm medial to the posterolateral tip of the acromion (Fig. 1-79).

 

 

Figure 1-79 Posterior incision. Make an 8-mm stab incision 2 cm inferior and 1 cm medial to the posterior lateral tip of the acromion.

 

 

Figure 1-80 Anterior incision. Make an 8-mm stab incision halfway between the tip of the coracoid process and the anterior aspect of the acromion.

 

Anterior. Make an 8-mm stab incision halfway between the tip of the coracoid process and the anterior aspect of the acromion (Fig. 1-80).

 

Internervous Plane

Posterior

The internervous plane lies between the teres minor muscle (supplied by the axillary nerve) and the infraspinatus muscle (supplied by the suprascapular nerve) (see Fig. 1-71).

Anterior

The internervous plane lies between the pectoralis major muscle (supplied by the medial and lateral pectoral nerves) and the deltoid (supplied by the axillary nerve) (see Fig. 1-8).

 

Surgical Dissection

Posterior

Place your finger on the coracoid process. Insert the trocar and arthroscopic sheath through the posterior skin incision, aiming the tip of the arthroscope toward your finger (Fig. 1-81). You will enter the glenohumeral joint at a point just above its equator. Although, in theory, the arthroscope may penetrate the rotator cuff between the infraspinatus and teres minor, the scope usually traverses through the substance of the infraspinatus (see Fig. 1-81).

 

 

Figure 1-81 Posterior insertion of the arthroscope. Place your finger on the coracoid process. Insert the trocar and arthroscopic sheath through the posterior skin incision, aiming the tip of the arthroscope toward your finger.

 

Anterior

Two techniques are possible. The safest technique is to insert the arthroscope through the posterior portal to allow you to visualize the anterior capsule of the shoulder joint. Next, insert a long hypodermic needle through the anterior skin incision and enter the joint under direct vision of the arthroscope. This will ensure that you enter the joint in a correct and safe position (Fig. 1-82).

 

 

Figure 1-82 Anterior insertion of the arthroscope. Insert an arthroscope through the posterior portal to allow you to visualize the anterior capsule of the shoulder joint. Next, insert a long hypodermic needle through the anterior skin incision and enter the joint under direct vision of the scope.

 

Arthroscopic Exploration of the Shoulder Joint through the Posterior Portal‌

 

 

Order of Scoping

1. Insert a 30-degree arthroscope through the posterior incision (see Fig. 1-79).

2. Identify the biceps tendon and its origin as it runs from superior to inferior (Fig. 1-83A,B, View 1).

3. Next, rotate the arthroscope superiorly to allow visualization of the

   supraspinatus (Fig. 1-83A,B, View 2). The supraspinatus lies posterior to the biceps tendon.

4. To visualize infraspinatus and teres minor you will need to rotate not only the arthroscope but also the humeral head (Fig. 1-84A,B, View 3).

5. Next, note the anterior triangle of the shoulder, formed by the biceps tendon, the superior edge of the subscapularis, and the glenoid (Fig. 1-85A,B, View 4; see Fig. 1-83A,B, View 1). This triangle marks the safe spot for entry through the anterior portal (see Fig. 1-82).

6. Pass the arthroscope to the upper anterior margin of the glenoid and rotate the scope inferiorly to allow examination of the anterior glenohumeral complex (Fig. 1-85A,B, View 5). You may need to apply a distraction force to the shoulder at that time, or alternatively use a 70-degree rather than a 30-degree telescope.

7. Pass the arthroscope anteriorly into the anterior triangle and rotate the scope so as to allow you to look inferiorly into a space underlying the subscapularis (Fig. 1-85A,B, View 6). This space is a frequent site for loose bodies.

8. Next, redirect the arthroscope inferiorly and rotate the telescope posteriorly to allow access to the posterior recess of the shoulder (Fig. 1-86A,B, View 7; see Fig. 1-84). Visualization of the humeral head and glenoid are easily accomplished through the posterior portal. Careful manipulation of the shoulder is required to visualize the whole of the articular surface.

 

 

Figure 1-83 A: Lateral view of the shoulder joint with the scope in place (right), correlated with their respective arthroscopic views (left). View 1: Insert the arthroscope through a posterior approach and identify the biceps tendon. Identify the long head of biceps as it runs superiorly to its origin. Note the position of the arthroscope in the joint and the view obtained. View 2: Rotate the arthroscope superiorly to visualize the rotator cuff. Observe the supraspinatus portion of the rotator cuff. B: Overall views of the shoulder joint seen from the direction of the arthroscope in Views 1 and 2 (left), correlated with their respective arthroscopic views (right).

 

 

 

Figure 1-84 A: Lateral view of the shoulder joint with the scope in place (right), correlated with its arthroscopic view (left). View 3: Rotate the arthroscope to look inferiorly and identify the inferior portion of the rotator cuff (infraspinatus and teres minor). Rotate the humeral head to visualize the infraspinatus tendon. B: Overall view of the shoulder joint seen from the direction of the arthroscope in View 3 (left), correlated with its arthroscopic view (right).

 

 

Figure 1-85 A: Lateral views of the shoulder joint with the scope in place (right), correlated with their respective arthroscopic views (left). View 4: Advance the arthroscope anteriorly and identify the anterior triangle. Observe the anterior triangle formed by the biceps tendon, the superior edge of subscapularis, and the glenoid labrum. View 5: Pass the arthroscope to the upper margin of the glenoid and rotate the arthroscope inferiorly. Observe the anterior glenohumeral complex. View 6: Pass the arthroscope anteriorly and then rotate it to allow you to look

inferiorly. Observe the space underlying the subscapularis. Direct the arthroscope inferiorly and then rotate it to look posteriorly. B: Overall views of the shoulder joint seen from the direction of the scope in Views 4, 5, and 6 (left), correlated with their respective arthroscopic views (right).

 

 

 

Figure 1-86 A: Lateral view of the shoulder joint with the scope in place (right), correlated with its arthroscopic view (left). View 7: Direct the arthroscope inferiorly and then rotate it to look posteriorly. Observe the posterior recess of the shoulder. B: Overall view of the shoulder joint seen from the direction of the arthroscope in View 7 (left), correlated with its arthroscopic view (right).

Dang

 

 

Nerves

 

Posterior. The axillary nerve leaves the posterior wall of the axilla by penetrating the quadrangular space. It winds around the humerus running on the deep surface of the deltoid muscle, about 7 cm below the tip of the acromion (see Figs. 1-26, 1-36, 1-52, and 1-71). If the posterior portal is correctly located with regard to the posterolateral tip of the acromion, this portal should lie about 3 cm superior to the nerve. Only a very inferiorly placed incision will endanger the nerve.

The suprascapular nerve, the nerve supplied to both the supraspinatus and infraspinatus, runs around the base of the spine of the scapula as it runs from the supraspinatus fossa to the infraspinatus fossa (see Figs. 1-58 and 1-72). This nerve is at risk if the posterior portal is made too medially. The correctly positioned portal is approximately 2 cm lateral to the nerve.

 

Anterior. The axillary nerve may be in danger as it traverses along the deep surface of the deltoid from inferiorly placed incisions.

The musculocutaneous nerve, the nerve supply of the flexor muscles of the upper arm, enters those muscles some 2 to 8 cm distal to the tip of the coracoid process. The nerve, therefore, is unlikely to be damaged by a portal made superior and lateral to the level of the coracoid process (see Figs. 1-13, 1-21, and 1-25).

Vessels

The cephalic vein runs superficially between the deltoid and pectoralis major muscle. It can only be damaged from incisions made too laterally.

The acromial branches of the thoracoacromial artery lie along the medial side of the coracoacromial ligament and will not be endangered through the classic anterior portal. Branches of the artery will, however, be damaged by more superior approaches used to enter the subacromial space.

 

How to Enlarge the Approach

 

To use the posterior portal to access the subacromial space, withdraw the arthroscope from the shoulder; using the same skin incision, redirect the scope more superiorly to run on the underside of the acromion. To do this you will need to create a separate arthroscopic penetration of the deltoid

muscle. Access to the subacromial space is often difficult due to disease processes, especially of the subacromial bursa. Continuous traction is indicated. Bleeding is frequently encountered.

The anterior portal cannot be extended.

 

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