Deltopectoral Approach to the Shoulder

  • Deltopectoral Approach to the Shoulder is used for:

    1. Shoulder arthroplasty.
    2. Proximal humerus fractures (especially 3 and 4 part fractures).
    3. Reconstruction of recurrent dislocations.
    4. Long head of the biceps injury.
    5. Septic glenohumeral joint.

  • Beach chair position or supine with an ipsilateral scapular bump is used in Deltopectoral Approach.

  • Landmarks:
    1. Coracoid Process.
    2. Deltopectoral Groove.
  • Incision:
    1. An incision is made following the line of the deltopectoral groove.
      • In obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable.
    2. A 10-15 cm incision is usually utilized, but is sized according to surgical need and size of patient.

  • Internervous plane in Deltopectoral Approach is between:
    • Deltoid muscle (axillary nerve.).
    • Pectoralis major (medial and lateral pectoral nerve).

  • Superficial dissection:
    • Attention must be paid to superficial skin vessels, as these can bleed significantly
    • The deltopectoral fascia is encountered first ; the cephalic vein is surrounded in a layer of fat and is used to identify the interval
    • The cephalic vein can be mobilized either medially or laterally, depending on patient factors and surgeon preference.
    • Fibers of the deltoid are retracted laterally and the pectoralis major is retracted medially.

  • Deep dissection:
    • The short head of the biceps and coracobrachialis arise from the coracoid process and are retracted medially:
      • The musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process; retraction of the conjoint tendon must be done with care.
    • The fascia on the lateral side of the conjoint tendon is incised to reveal the subscapularis:
      • External rotation puts the subscapularis fibers on stretch,
    • The subscapularis may be released from its insertion on the lesser tuberosity through the tendon or via an osteotomy,
    • The capsule is then incised (as needed) to enter the joint.

  • Proximal Extension of the Deltopectoral Approach:
    • 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 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.
    •  Take care not to damage the musculocutaneous nerve, which is the most superficial nerve in the
      brachial plexus.
  • Distal Extension of the Deltopectoral Approach:
    • 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 moving 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.

  • These structures are at danger in Deltopectoral Approach:
    • Musculocutaneous nerve:
      • renters medial side of biceps muscle 5-8 cm distal to coracoid (stay lateral)
      • can have neurapraxia if retraction is too vigorous
    • Cephalic vein:
      • should be preserved if possible; if injured, can ligate
      • Helpful to be preserved as anatomical landmark in case of revision cases needing same approach
    • Axillary nerve:
      • at risk with release of subscapularis tendon (runs distal and medial to) or with incision of teres major tendon or latissimus dorsi tendon (runs proximal to)
    • Anterior circumflex humeral artery:
      • runs anteriorly around the proximal humerus cephalad to pectoralis major tendon

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