Downloaded 66 times
Uploaded bySijan Bhattachan
Surgical Approach to Shoulder & Elbow
This document describes several surgical approaches to the shoulder and elbow. For the shoulder, it discusses the anterior, anterolateral, lateral, posterior, posterior inverted U, and transacromial approaches. For the elbow, it covers the posterior, anterior, medial, anterolateral, lateral J-shaped, posterolateral, and Boyd approaches. Each approach is described in terms of indications, patient positioning, incision details, exposure of relevant structures, and potential dangers.
More Related Content
Similar to Surgical Approach to Shoulder & Elbow
Surgical Approach to Shoulder & Elbow
- 1. SURGICAL APPROACHES TO SHOULDER & ELBOW Dr.Sijan Bhattachan 2nd year resident NAMS
- 2. Approaches to shoulder •Anterior Approach • Anterolateral Approach • Lateral Approach • Posterior Approach • Posterior Inverted U Approach
- 3. Anterior approach to shoulder •Offers good wide exposure of shoulder joint, allowing repairs to be made of its anterior,inferior and superior coverings.
- 4. Indications • Fixation offractures of proximal humerus • Shoulder arthroplasties • Reconstruction of recurrent dislocations • Drainage of sepsis • Biopsy and excision of tumors • Repair or stabilisation of the tendon of the long head of biceps
- 5. Position • Supine • Sandbagunder the spine and medial border of scapula • Elevate the head of table 30-45 degrees to reduce venous pressure and thereby decrease bleeding.
- 6. Incision • Anterior; 10-15cm straight incision,beginning just above the coracoid and following the line of deltopectoral groove. • Axillary; -Abduct shoulder 90 degree and rotate it externally -Vertical incision 8-10 cm long, starting at the midpoint of anterior axillary fold and extending posteriorly into the axilla.
- 8. Internervous plane • Betweenthe Deltoid muscle (Axillary nerve) and the Pectoralis major muscle (Medial & Lateral Pectoral nerves)
- 9. Superficial dissection • Deltopectoralgroove; Cephalic vein • Retract pectoralis major medially and deltoid laterally
- 11. Deep dissection • Shorthead of biceps and the coracobrachialis must be displaced medially. • Two muscles can be detached with the tip of coracoid process for more exposure. • Beneath the conjoined tendons, lies the transversely running fibers of subscapularis muscle • Series of small vessels that run transversely on the inferior border of subscapularis • Divide subscapularis from its insertion • Incise capsule longitudinally to enter the joint
- 16. Dangers • Musculocutaneous nerve -Entersthe body of coracobrachialis about 5-8 cm distal to the muscle’s origin at the coracoid process • Cephalic vein • Axillary nerve
- 17. Anterolateral approach to ACJand subacromial space • Offers excellent exposure of the ACJ and the underlying coracoacromial ligament and supraspinatus tendon
- 18. Indications • Repair ofrotator cuff • Anterior decompression of shoulder • Repair or stabilisation of the long head of biceps tendon • Excision of osteophytes from the ACJ
- 19.
- 20. Incision • Transverse incisionthat begins at the anterolateral corner of the acromian and ends just lateral to the coracoid process
- 21. Internervous plane • Nointernervous plane • Deltoid muscle is detached at a point well proximal to its nerve supply
- 22. Superficial dissection For subacromialdecompression • Detach the fibers of deltoid that arise from ACJ and continue this detachment by sharp dissection laterally to expose 1 cm of the anterior aspect of acromian • Acromial branch of coracoacromial artery; coagulate
- 23. For rotator cuffrepair • Split deltoid muscle in the line of its fibers starting at ACJ • Extend the split 5 cm down from ACJ; stay surfers at apex
- 27. Deep dissection • Detachcoracoacromial ligament from acromian. • Also detach medial end of coracoacromial ligament just proximal to the coracoid process and excise ligament • Supraspinatus tendon with its overlying subacromial bursa is now revealed
- 29. Dangers • Axillary nerve -Runstransversely across the deep surface of the deltoid muscle about 7 cm below the tip of acromian. • Acromial branch of coracoacromial artery -Runs immediately under the deltoid muscle
- 30. Lateral approach to Proximalhumerus • Limited access to the head and surgical neck of humerus; not extensile.
- 31. Indications • ORIF ofdisplaced fractures of greater tuberosity of humerus • ORIF of humeral neck fractures • Removal of calcific deposits from the subacromial bursa • Repair of rotator cuff
- 32.
- 33. Incision • 5 cmlongitudinal incision from the tip of acromian down the lateral aspect of the arm
- 34. • No trueinternervous plane • Involves splitting of deltoid muscle
- 35. Superficial dissection • Splitthe deltoid in the line of its fibres from the acrimony downward for 5 cm • Suture at inferior apex of split
- 37. Deep dissection • Lateralaspect of upper humerus and its attached rotator cuff lie directly under the deltoid muscle and subacromial bursa • In the upper part of the wound, the exposed subacromial bursa must be incised longitudinally to provide access to the upper lateral portion of the head of humerus
- 40. Dangers • Axillary nerve; -Leaves the posterior wall of the axilla by penetrating the quadrangular space. Then winds around the humerus with the posterior circumflex humeral arteries -Enters deltoid muscle posteriorly from its deep surface, about 7 cm below the tip of acrimony -Then its fibers spread anteriorly
- 41. Transacromial Approach • Excellentfor surgery of the musculotendinous cuff and for fracture dislocations of the shoulder • Skin incision just lateral to ACJ from the posterior aspect of acromian, superiorly and anteriorly to a point 5 cm distal to the anterior edge of acromian,
- 42. • Detach deltoidfrom acromial, origin and divide coracoacromial ligament • Osteotomy of acromian. • Split any of tendons of the cuff or separate two of them to expose joint
- 44. Posterior approach • Offersaccess to posterior and inferior aspects of shoulder joint
- 45. Indications • Treatment ofposterior fracture dislocations of proximal humerus • Repairs in cases of recurrent posterior dislocation of the shoulder • Glenoid fracture/ osteotomy • Treatment of fractures of scapula neck (esp in case of floating shoulder) • Removal of loose bodies in the posterior recess of shoulder • Drainage of sepsis • Biopsy and excision of tumors
- 46.
- 47. Incision • Linear incisionalong the entire length of the scapular spine, extending to the posterior corner of the acromian
- 48. Internervous plane • Betweenthe teres minor muscle (Axillary nerve)and the infraspinatus muscle (suprascapular nerve)
- 49. Superficial dissection • Detachorigin of deltoid on the scapular spine and retract inferiorly following which infraspinatus is exposed
- 51. Deep dissection • Developinternervous plane between infraspinatus and teres minor by blunt dissection • Retract infraspinatus superiorly and the teres minor inferiorly to reach the posterior regions of glenoid cavity and the neck of scapula • Posteroinferior corner of shoulder joint capsule is now exposed
- 55. Dangers • Axillary nerve; -Runsthrough the quadrangular space beneath the teres minor • Suprascapular nerve -Passes around the base of spine of scapula as it runs from the supraspinous fossa to the infraspinous fossa. • Posterior circumflex humeral artery -Rus with axillary nerve in the quadrangular space
- 56. Posterior Inverted U Approach(Abbott &Lucas) • Begin the incision 5 cm distal to the spine of scapula at the junction of middle and medial thirds, extend it superiorly over the spine and laterally to the angle of acromian, • Curve incision distally for about 7.5 cm over the tendinous interval between posterior and middle thirds of deltoid
- 57. • Free deltoidsubperiosteally from the spine of scapula, split it distally in the interval and turn the resulting flap of skin and muscle distally for 5 cm to expose the infraspinatus and teres minor muscles and quadrangular space • Incise the shoulder cuff in its tendinous part and retract to expose the glenohumeral joint capsule
- 59. Approaches to elbow •Posterior Approach • Anterior Approach • Medial Approach • Anterolateral Approach • Lateral J shaped Approach (Kocher’s) • Posterolateral Approach • Boyd Approach
- 60. Posterior approach • Bestpossible view of the bones that comprise the elbow joint.
- 62. Indications • ORIF offractures of distal humerus • Removal of loose bodies within the elbow joint • Treatment of nonunions of distal humerus
- 63. Position • Prone with90 degree arm abduction ,allowing the elbow to flex and the forearm to hang over the side of the table
- 64. Incision • Longitudinal incisionon, beginning 5 cm above the olecranon in the midline. • Curve laterally just above tip of olecranon
- 65. Superficial dissection • Incisedeep fascia in the midline • Dissect ulnar nerve & pass tape around it • V shaped osteotomy of olecranon
- 67. Deep dissection • Stripthe soft tissue attachments off the medial and lateral sides of the portion of the olecranon that has been subjected to osteotomy & retract it proximally, retracting triceps from the back of the humerus
- 71. Dangers • Ulnar nerve •Radial nerve
- 72. Medial Approach • Givesgood exposure of the medial compartment of the joint Indications • Decompression/Transposition of Ulnar nerve • Removal of loose bodies • ORIF of fractures of the coronoid process of the ulna • ORIF of fractures of medial humeral condyle & epicondyle
- 73. • Supine witharm supported on an arm board
- 74. Incision • Curved incision8-10 cm long on the medial aspect of the elbow, centering the incision on the medial epicondyle
- 75. Internervous plane • Proximally,between brachialis and triceps • Distally between brachialis and pronator trees
- 76. Dissection • Isolate theUlnar nerve
- 80. Anterior Approach • Providesaccess to the neuromuscular structures found in the cubital fossa Indications • Repair of lacerations to median nerve,radial nerve,brachial artery,biceps tendon • Release of post traumatic anterior capsular contractions • Excision of tumor
- 81. Incision • Curved incisionbeginning 5 cm above the flexion crease on the medial side of biceps then curve along the medial border of brachioradialis
- 82. Internervous plane • Distallybetween brachioradialis and pronator teres • Proximally between brachioradialis and brachialis
- 83.
- 87. Dangers • Lateral cutaneousnerve of forearm (Sensory branch of musculocutaneous nerve) • Radial artery • PIN
- 88. Anterolateral Approach • Exposeslateral half of the elbow, especially capitulum and proximal third of anterior aspect of radius
- 89. Indications • Surgery ofcapitulum (ORIF, Aseptic necrosis) • Neural compression (PIN,Radial tunnel) • Total elbow replacement • Drainage of septic elbow joint. • Excision of tumors of proximal radius
- 90.
- 91.
- 92.
- 93.
- 97. Dangers • Radial nerve •PIN • Lateral cutaneous nerve of forearm • Recurrent branches of radial artery
- 98. Lateral J shapedApproach • Kocher’s approach
- 99. • Skin incisionbeginning 5 cm proximal to the elbow over the lateral supracondylar ridge and continue 5 cm distal to the radial head & curve it medially and posteriorly to end at the posterior border of the ulna
- 100. • Dissect betweentriceps posteriorly and the brachioradialis and ECRL anteriorly to expose lateral condyle and capsule over lateral surface of radial head. • Distal to head, separate the ECU from anconeus, • Incise the joint capsule longitudinally.
- 102. Posterolateral Approach Indications • Usefulfor all surgeries to the radial head (ORIF, Prosthetic replacement, Excision) • LCL reconstruction/repair
- 103. Position • Supine witharm positioned over the chest and pronate the forearm
- 104. Incision• Gently curvedincision, beginning over the posterior surface of the lateral humeral epicondyle and continuing downward and medially to a point over the posterior border of ulna, about 6 cm distal to the tip of olecranon
- 105.
- 106.
- 109.
- 110. Boyd Approach • Usefulwhen treating fractures of proximal third of ulna associated with dislocation of radial head
- 111. Dissection • Begin theincision 2.5cm proximal to elbow joint just lateral to triceps tendon , continue it distally over the lateral side of the tip of olecranon and along the subcutaneous border of ulna and end it at the junction of proximal and middle thirds of ulna • Develop the interval between ulna on medial side and the anconeus and ECU on lateral side • Strip the anconeus, and reflect radially to expose radial head
- 113. References • Hoppenfeld surgicalexposure in orthopaedics, The anatomic approach, 4th edition • Campbel’s operative orthopaedics 13th edition