Anterior

(deltopectoral)

approach

Uses

Any anterior shoulder

surgery, e.g.

› Capsular shift &

dislocation procedures

› Proximal humerus

fracture work

› Shoulder arthroplasty

› Long head of biceps

repair

› Subscapularis repair

Uses

This approach is preferred for shoulder

arthroplasty and for plate-and-screw

fixation of proximal humeral fractures

because it affords greater visualization

than does the lateral approach.

Internervous Plane

Deltoid (axillary)

Pectoralis major (medial/lateral

pectoral)

Incision

Length: 10-15 cm (depending

on the procedure and build

of patient).

Extent: From coracoid

process running along the

deltopectoral groove

towards the deltoid insertion.

Expose deltopectoral groove.

› The cephalic vein and the

coracoid are landmarks to the

interval.

Exposure of deltopectoral groove

and cephalic vein

Identify the cephalic vein and preserve it during dissection. › Failure to preserve cephalic

vein = post-surgical arm edema.

Retract the cephalic vein laterally or medially, and open along the groove. › Failure to find this plane =

difficulty in dissection of deltoid

possible denervation of anterior portion of deltoid.

Laterally reflect the anterior part of

deltoid to expose the underlying

coracoid process and joint capsule.

Identification of the tuberosities and

the humeral head fragments

Expose the subscapularis tendon and the tendon of long head of biceps. › The long head of

biceps serves as a landmark to separate the greater and lesser tuberosities.

Distally, expose the pectoralis major.

Pearl:

If a wider exposure is necessary, place

ethibond stay sutures (c.3) into the

medial aspect of the last centimeter of

the subscapuaris tendon, and partially

divide it laterally to this.

External rotation of the shoulder during

subscapularis release moves the

dissection away from the axillary nerve

and decreases tension on the nerve.

Care should be taken to isolate and ligate the anterior humeral circumflex artery, along with, if necessary, its two venae communicantes at the distal margin of the subscapularis tendon during the exposure.

To maintain the blood supply to the humeral head, surgical dissection should not extend to the inferior margin of the subscapularis.

A cuff of muscle must be maintained to protect the anterior humeral circumflex vessels.

Likewise, by releasing the subscapularis medial to its tendinous insertion, the arcuate artery is not sacrificed at the point at which it enters the humeral head along the lateral border of the bicipital groove.

Pitfall:

The musculocutaneous nerve enters the

coracobrachialis muscle as close as 2.5

cm distal to the tip of coracoid.

› Retractors placed under the conjoint tendon

can cause neuropraxia; therefore vigorous

retraction must be avoided.

If more extensive exposure is required,

pre drill the coracoid and remove the tip

with an osteotome.

Structures at risk

Superiorly: Acromial branch of thoracoacromial artery:› Lies in the medial aspect of coracoacromial

ligament.

Inferiorly: Musculocutaneous nerve:› Comes out and enters the biceps approx. 5 cm distal

to the coracoid.

› Usually not cut, but can be retracted and damaged with the retraction.

› Dissection medial to the conjoint tendon should be avoided because it places the musculocutaneous nerve at risk.

Structures at risk

Axillary nerve:

› The axillary nerve should be palpated as it passes

inferior to the subscapularis and the inferior capsule,

and it should be protected throughout the

procedure.

› A retractor placed below the subscapularis and the

capsule puts this nerve in grave danger.

Cephalic vein:

› Can also be damaged if not identified and

protected as the deltopectoral groove is being

developed.

Tricks

Find the deltopectoral groove and take

whichever vein seems easiest (typically

laterally).

The coracoid is the best landmark for the

short head of biceps; split the fascia in

that direction, which will get you into the

interval between the 2 heads.

Tricks

Put a stay suture in the subscapularis

prior to cutting it free from the humeral

head so that it does not retract out of

the way.

Feel the shoulder joint and the glenoid

edge prior to doing the capsulotomy, so

you can place it correctly for whatever

procedure you are attempting to do.

› This is especially important when attempting

to do instability procedures.

Extension

When a greater exposure of the lateral

humeral shaft is needed, less than one

fifth of the anterior deltoid insertion can

be released.

Distal extension may be accomplished

via the anterolateral approach to the

humerus.