Approaches - SHOULDER

Deltopectoral Approach 
For exposure of anterior , lateral and medial side of shoulder joint

Indications - Infection , trauma , tumor around the shoulder joint

Internervous Plane
Between Deltoid muscle supplied by Axillary Nerve and Pectoralis Major supplied by Medial/Lateral Pectoral Nerves .
Dangers 
Be careful to protect Musculocurtaneous Nerve while retracting conjoint tendon medially in deeper dissection which lies 5-8 cm distal to coracoid process.

Axillary Nerve

Cephalic Vein

Anterior Circumflex humeral Artery


Anterolateral Approach / Lateral Approach to Shoulder 
Deltoid Splitting approach ,
Incision starts from Coracoid Process
Acromial branch of thoracoacromial artery ligated near AC joint
Not to go below 5 cm from Acromion , axillary nerve runs transeversly 7 cm below acromion.



Posterior approach to shoulder 
less commonly used
Internervous Plane
Between Teres Minor (Axillary Nerve ) and Subscapularis (Suprascapular Nerve )




Shoulder Arthroscopic Approach
Primary Portals 

  • Posterior portal
      1. primary viewing portal used for diagnostic arthroscopy
    • location and technique
      1. located 2 cm inferior and 1 cm medial to posterolateral corner of acromion
      2. portal  between infraspinatus (supraspinatus nerve) and teres minor (axillary nerve) or pass through the substance of infraspinatus
      3.  first portal placed

  • Anterior portal-     viewing and subacromial decompression
      • location 
      1. lateral to coracoid process and anterior to AC joint
      2. portal passes between pectoralis major (medial and lateral pectoral nerves) and deltoid (axillary nerve)


  • Lateral portal - subacromial decompression
    • location
      • located 1-2 cm distal to lateral edge of acromium , portal passes through deltoid (axillary nerve)


Secondary Portals 
Anteroinferior (5 o'clock) portal-
 for placement of anchors in anterior labral repair 
slight inferior to coracoid 
placed under direct supervision from posterior portal after posterior portal

 Posteroinferior (7 o'clock) portal

 for anchors to repair  posterior labral repair 
Nevasier (supraspinatus) portal
   
anterior glenoid visualization and SLAP repairs

 lies just medial to lateral acromion , passes through supraspinatus muscle
Diagnostic Shoulder Arthroscopy 

        With 30° scope through the posterior portal to identify 
1.   Biceps tendon
2.   Supraspinatus
3.   Infraspinatus and teres minor.
4.   Rotator interval (formed by biceps tendon, superior edge of subscapularis, and glenoid)
5.   Anterior ligamentous complex (MGHL, IGHL)
6.   Subscapularis recess (loose bodies)
7.   Anterior labrum
8.   Glenoid

9.   Humeral head


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