approach to proximal arm
TRANSCRIPT
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Surgical Approaches to Shoulder and Arm
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Anterior ( Deltopectoral) approach
• Indications:– Open Capsulorraphy– Shoulder arthroplasty– Proximal humerus fractures.
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Beach chair position
• Mayfield headrest or comercially available beach chair attachment.
• Upper torso elevated 30-60 degrees.
• Operated side positioned off the table.
• Arm holders.
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Extended deltopectoral incision
• Arthroplasty / Fracture
• 10-15 cm incision just lateral to the coracoid process to the deltoid insertion.
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Limited anterior incision
• Open capsulorraphy• Coracoid bone block
transfers.• 5 cm vertical incision
from the coracoid to the inferior axillary crease.
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Superficial dissection
• Deltopectoral interval.• Cephalic vein is a key landmark• More easily dissected from PM and is
retracted with the deltoid.• Deltoid laterally, PM medially
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• Incision made in the clavipectoral fascia lateral to the conjoint tendon.
• Identify the subscapularis and conjoint tendon.
• Capsule may or may not be released.
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POSTERIOR APPROACH TO THE SHOULDER
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INDICATIONS
• Posterior capsulorrhaphy• Posterior glenoid fractures• Posterior glenoid osteotomy
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POSITIONING• Lateral Decubitus Position• Can follow arthroscopy in
this position• The nonoperative side
must be well protected– Use an axillary roll– Pad the elbow, fibular head,
and ankles– Secure the head
• Position and drape the operative arm so it is free
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INCISION• A 6- to 8-cm vertical
incision is made directly over the glenohumeral joint and extended towards the axillary fold.
• Typically 2 cm medial to the posterolateral edge of the acromion and can incorporate a posterior arthroscopic portal.
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SUPERFICIAL DISSECTION
• The deltoid is identified on the scapular spine
• The deltoid may be split in line with its fibers
• Deltoid can be retracted superiorly after detachment of the medial 2 cm of the deltoid origin
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DEEP DISSECTION
• Interval between the infraspinatus and teres minor is identified
• The infraspinatus is identified by -– Horizontal direction of
muscle fibers– Bipennate nature– Fatty raphe that divides
the muscle belly
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• Interval between the infraspinatus and teres minor is developed by blunt dissection.
• Taking down the infraspinatus from its humeral insertion.
• Splitting the two heads of the infraspinatus and using this interval
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• Do not dissect below the teres minor muscle because of risk to the axillary nerve and posterior humeral circumflex artery.
• Fat may be present at the inferior border of the teres minor to help identify that you have gone too low
• When performing a glenoid osteotomy, the suprascapular nerve should be identified by dissection and palpation 0.5 to 2 cm medial to the glenoid neck.
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SUPEROLATERAL APPROACH
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Indications
• Rotator cuff tears and acromion fractures.
• Beach chair position.
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Incision
• 5-cm oblique incision is made immediately proximal to the anterolateral corner of the acromion.
• Extended distally to the level of the inferior aspect of the coracoid.
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Superficial dissection
• Deep deltoid fascia is identified along with the anterolateral corner of the acromion.
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• The deltoid is detached and split-– Subperiosteally elevate
the deltoid from the anterolateral acromion and acromioclavicular joint.
– High-strength sutures are placed in the deltoid to aid in retraction and for later repair.
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Deep dissection
• Identify the coracoacromial ligament, subacromial bursa, and supraspinatus tendon.
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• The supraspinatus tendon and overlying bursa are exposed and explored by rotating the arm.
• The humeral head may be seen if a rotator cuff tear is present.
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Deltoid Splitting Approach
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• Rotator cuff repair and shoulder arthroplasty.
• Beach chair position.• Longitudinal incision up
to 5 cm is made from the midportion of the lateral acromion distally.
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• Subdeltoid bursa and supraspinatus insertion on the greater tuberosity can be exposed
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Anterior Approach to Humerus
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• Supine with use of an arm board.
• 8- to 12-cm incision is made along the lateral border of the biceps.
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Superficial Dissection
• Brachialis splitting/ Brachialis- biceps interval.
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Posterior Approach
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• Humerus fractures and radial nerve exploration.
• 10- to 15-cm midline longitudinal incision is made directly posteriorly.
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• Incision in the fascia in line with the skin incision.
• Identify and separate the lateral and long head of the triceps.
• interval is more obvious proximally as the tendons merge distally
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Deep dissection
• Medial (deep) head is exposed and split.
• Radial nerve passes from medial to lateral in the upper/middle portion of the field and should be identified and protected.
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