Posterior Approach to the shoulder

The posterior approach to the shoulder (Judet Approach) offers access to the posterior and inferior aspects of the shoulder joint.

Judet Approach can be used for:

1. Proximal humerus fracture-dislocations.
2. Glenoid fractures/osteotomy.
3. Removal loose bodies from the shoulder joint.
4. Irrigation and debridement of septic joint.
5. Scapular neck fractures.
6. Biopsy and excision of tumors.
7. Repairs in cases of recurrent posterior dislocation or subluxation of the shoulder.

Position of the Patient

The best positions in the posterior approach to the shoulder (Judet Approach) are:

• Prone position is the most common used.
• Lateral position.
• Beach-chair position.

Landmarks and Incision

Landmarks:

• Acromion.
• The spine of the scapula.

Incision:

The incision is made along the scapular spine, extending to the lateral acromial border.

Internervous plane

Internervous plane for Posterior Approach to the shoulder lies between:

• Teres minor muscle which is innervated by the axillary nerve.
• Infraspinatus muscle which is innervated by the suprascapular nerve.

Superficial dissection

• Attention must be paid to superficial skin vessels, as these can bleed significantly,
• The origin of the deltoid is released from the scapular spine,
• The plane between the deltoid and infraspinatus is encountered and bluntly developed, This is typically easiest to find at the lateral aspect of the incision,
• The deltoid is retracted distally/laterally.

Deep dissection

• The interval between the infraspinatus muscle (Innervated by the suprascapular nerve) and teres minor muscle (Innervated by the axillary nerve) is bluntly developed, this is often difficult to find, but should be done carefully.
• Retract the infraspinatus muscle superiorly and the teres minor muscle inferiorly to expose the posterior glenoid and scapular neck.

Approach Extension

• The Posterior Approach to the shoulder cannot be extended usefully.
• Its main goal is to provide access to the posterior aspect of the shoulder joint.

Dangers

The structures at risk during the posterior approach to the shoulder (Judet approach) include:

1. Suprascapular nerve:
   • It passes around the base of the scapular spine (do not retract infraspinatus too vigorously).
2. Axillary nerve:
   • It runs through the quadrangular space beneath the teres minor (stay superior to the teres minor).
   • This is accompanied by the posterior circumflex humeral artery.

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Related Anatomy

The posterior aspect of the shoulder is covered by two muscular sleeves. The posterior part of the deltoid muscle forms the outer sleeve of muscle. The inner sleeve consists of two muscles of the rotator cuff, the infraspinatus, and the teres minor.

The spine of the scapula

• 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.

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.

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.

	Infraspinatus	Teres Minor
Origin	Medial three fourths of infraspinous fossa of scapula	Axillary border of scapula
Insertion	Central facet on greater tuberosity of humerus	Lowest facet on greater tuberosity of humerus
Action	Lateral rotator of humerus	Lateral rotator of humerus
Nerve supply	Suprascapular nerve	Axillary nerve

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.
• 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.

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.
• 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.

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.
• The odds of endangering the radial nerve by this approach are remote. It cannot be damaged during the posterior approach to the shoulder unless the correct plane is deviated from substantially, below not only the teres minor but the 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.
• inferiorly, the upper border of the teres major.
  

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 of damage to these vessels, causing profuse hemorrhage that is difficult to control.

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.

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References

1. Surgical Exposures in Orthopaedics book – 4th Edition
2. Campbel’s Operative Orthopaedics book 12th
3. Fucentese SF, Jost B. Posteriorer Zugang zum Schultergelenk [Posterior approach to the shoulder]. Oper Orthop Traumatol. 2010 May;22(2):188-95. German. doi: 10.1007/s00064-010-8064-3. PMID: 20711829.