Judet Approach to Scapula

Introduction

• Overview
  • A fairly limited approach to the shoulder, allowing little anterior exposure.
   
• Indications
  • Proximal humerus fracture-dislocations (posterior)
  • Scapula fractures 
    • Scapular neck
    • Posterior glenoid rim
    • Posterior articular segments
  • Glenoid osteotomy
  • Open posterior rotator cuff repair
  • Biopsy and tumour resection

Internervous plane

• Internervous plane between 
  • Suprascapular nerve (infraspinatus) and 
  • Axillary nerve (teres minor)

Approach

• Positioning
  • Standard positioning
    •  Prone 
  • Alternative positioning
    • Beach chair
    • Lateral decubitus
• Incision
  • Classic incision
    • Curved incision 
      • Starting from posterolateral lip of the acromion, 
      • Extending medial along the spine of the scapula,
      • Right angle turn at the medial border of the scapula
  • Modified incision  
    • Straight incision 
      • Starting from posterolateral lip of the acromion,
      • Extend incision in line with the tip of scapula,
        • Incision should be parallel, and lateral, to the medial scapular border 
• Superficial dissection
  • Incise through skin and fat
  • Identify and expose the posterior deltoid muscle belly
  • Sharply dissect deltoid muscle origin off the scapular spine and base of acrominon 
  • Retract muscle distal and lateral to reveal the underlying infraspinatus and teres minor muscles
• Deep dissection
  • Working through the infraspinatus and teres minor interval
    • Retract teres minor inferiorly
      • Avoid injury to posterior branch of axillary nerve  
    • Retract infraspinatus superiorly
      • Avoid injury to suprascapular nerve and artery
  • Deep dissection
    • Lateral
      • Identify underlying posterior glenoid capsule deep to musculature
      • Incise posterior capsule in line with muscular interval
      • Allows access to the posterior aspect of glenohumeral joint 
    • Medial 
      • Dissecting the infraspinatus along off the medial border of scapula 
      • Retract infraspinatus muscle belly superior and lateral, as this will maintain its suprascapular neurvascular pedicle
      • Allows access to the inferior aspect of scapular body
  • Improve exposure 
    • Lateral
      • The infraspinatus tendon insertion can be tagged and cut approx. 1-2 cm lateral to its insertion on greater tuberosity
      • Retract medially
    •  Medial
      • Dissection of infraspinatus off the medial border of scapula is extended superiorly to the scapular spine

  
Dangers

• Suprascapular nerve 
  • Anatomy 
    • Passes around the base of the spine of the scapula as it runs from the Supraspinous fossa to the infraspinous fossa
  • Risk of injury
    • Forceful medial and superior retraction of infraspinatus muscle 
• Axillary nerve 
  • Anatomy
    • Passes through the quadrangular space beneath the teres minor
  • Risk of injury
    • Dissection carried out inferior to the teres minor 

Judet Approach to Scapula 2017-04-09T03:18:00-07:00 Rating: 4.5 Diposkan Oleh: Unknown