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Sunday, April 9, 2017

Shoulder Anterior (Deltopectoral) Approach


Introduction
     - Overview
-This approach can be a fairly extensile exposure, allowing access to the anterior, medial, and lateral aspects of the shoulder.
-This approach is done in a supine position with a roll or wedge under the medial scapula.
     - Indications
- Proximal humerus fractures
- Long head of the biceps injury
- Reconstruction of recurrent dislocations
- Septic glenohumeral joint
- Shoulder arthroplasty

Internervous plane
 
             - Deltoid muscle (axillary nerve.)
                    - Pectoralis major (medial and lateral pectoral nerve)

Approach
     - Incision
- 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
- A 10-15 cm incision is usually utilized, but is sized according to surgical need and size of patient
     - 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




Dangers
- Musculocutaneous nerve 
-Renters medial side of biceps muscle 5-8 cm distal to coracoid (stay lateral)
-Can have neuropraxia if retraction is too vigorous
- Cephalic vein
-Should be preserved if possible; if injured, can ligate
- Axillary nerve
-At risk with release of subscapularis tendon (runs distal 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

Shoulder Anterior (Deltopectoral) Approach Rating: 4.5 Diposkan Oleh: Unknown

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