Lateral Approach to the shoulder

Lateral Approach to the shoulder indications:

Lateral Approach to the shoulder (Deltoid Split Approach or transdeltoid lateral approach) provides limited access to the head and surgical neck of the humerus.

Lateral Approach to the shoulder is used for:

1. Open reduction and internal fixation (ORIF) of the proximal humerus fractures.
2. Open reduction and internal fixation of displaced fractures of the greater tuberosity of the humerus.
3. Removal of calcific deposits from the subacromial bursa.
4. Repair of the supraspinatus tendon.
5. Rotator cuff repair.
6. Debridement of the subacromial space.

In a comparative ctudy for lateral deltoid split approach and deltopectoral approaches in the treatment of proximal humerus fractures, the humeral head and tubercular fragment reduction were better with lateral deltoid split approach. ¹

Position of the Patient

• Lateral Approach to the shoulder is done in a supine position, with a bump or roll placed under the spine or ipsilateral scapula.
• Elevation of the head of the table reduces venous pressure in the operative field.
• Alternatively, a ‘beach chair’ positioning adaptor may be used depending on surgeon preference.
• The operative arm should be at the edge of the table to allow greatest manipulation of the extremity.

Landmarks and Incision

• Landmark:
  • The acromion bone.
• Incision:
  • A 5-cm longitudinal incision is made from the tip of the acromion down the lateral aspect of the arm.

Internervous plane

• There is no true internervous plane in Lateral Approach to the shoulder (deltoid is split in line with its fibers).

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Superficial dissection

• Deltoid muscle is split in the line with its fibers no more than 5 cm distal to the lateral edge of acromion (to protect the axillary nerve).
• A stay suture is placed at the inferior apex of the split to prevent propagation of the split.

Deep dissection

• Subacromial bursa lies directly deep to the deltoid muscle and can be excised to reveal the underlying rotator cuff insertion and proximal humerus.

Approach Extension

Lateral Approach to the shoulder is not a classically extensile approach, because it is limited distally
by the traverse of the axillary nerve over the deep surface of the deltoid muscle.

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.
• Incise the trapezius muscle and retract it superiorly.
• Incise the fascia overlying the supraspinatus.
• Split the acromion in the line of the skin incision, using an osteotome (reconstruct the acromion during closure ).

Distal extension:

• it is  possible by utilizing a separate deltoid split distal to the axillary nerve.

Dangers

The structure at risk during Lateral Approach to the shoulder is:

Axillary nerve:

• leaves posterior aspect of axilla by traversing quadrilateral space (teres minor, teres major, long head of triceps, medial border of humerus).
• it travels around the humerus coursing anteriorly and laterally to enter and innervate the deltoid via its deep surface.
• at this point, it runs transversely 5-7 cm distal to the edge of the acromion from posterior to anterior
• cannot extend split further due to risk to denervation of anterior deltoid.
• need to make a second incision distally in order to provide a safe “second window” if distal extension is needed (generally for fractures).

References

1. Korkmaz MF, Erdem MN, Karakaplan M, Görmeli G, Selçuk EB, Maraş Z, Karataş T. Proksimal humerus kırıklarının tedavisinde lateral deltoid split girişim ile deltopektoral girişimin karşılaştırılması [Comparison of lateral deltoid splitting and deltopectoral approaches in the treatment of proximal humerus fractures]. Ulus Travma Acil Cerrahi Derg. 2015 Mar;21(2):113-8. Turkish. doi: 10.5505/tjtes.2015.74150. PMID: 25904272.
2. Surgical Exposures in Orthopaedics book – 4th Edition
3. Campbel’s Operative Orthopaedics book 12th