- See:

• Anterior Approach to the Humerus
• Axillary Approach:
• Posterior Approach
• Posterior Approach to Humerus
• Surgical Approach for Proximal Humeral Fractures

Positioning and Draping:

• supine or beach chair;
• small soft bolster is placed beneath the shoulder blades to protract the shoulder;
• head is stabilized to prevent hyperextension and subsequent brachial plexus palsy;
• place patient in a beach chair position w/ torso flexed 45 deg and the knees flexed to 30 deg;
  • in the beach chair position, ensure that the patient is firmly fastened to prevent sliding;
• move patient to the edge of the table (operative side), and use a McConnel positioner to prevent the patient from failing off the table;
  • positioning is optimal when the scapula hangs over the edge of the table;
• place a folded towel under the spine and ipsilateral scapula;
• it is helpful to drape the should w/ a large Ioband sheet w/ a hole cut in the middle;
  • several Iobrand strips (2-3 inches in width) are also helpful;
    • consider the Mconnel Shoulder Positioner;
      

Instruments:

• Balfour Self Retaining Retractor;
• Homan Retractors:
• Fukuda Humeral Head Retractor:
• Gelpi retractors;

Superficial Dissection:

Deep Dissection:

• clavipectoral fascial incision:
  • once the deltopectoral interval has been fully developed, the clavipectoral fascia is exposed (which is most prominent lateral to coracoid muscles);
  • clavipectoral fascia is differentiated from the deeper tissues, because it will not move with internal and external rotation;
  • tip of the coracoid and the conjoined tendon (short head of biceps and the coraco-brachialis) is identified;
  • clavipectoral fascia is then divided vertically just lateral to the conjoined tendon, up to coracoacromial ligament, exposing subscapularis tendon & lesser tuberosity.
    • proximally, the fascia is divided at a point just lateral to the coracoid;
    • the incision is carried distally to the level of the anterior circumflex;
    • these vessels mark the level of the subscapularis tendon;
• identification of the musculocutaneous nerve:
  • musculocutaneous nerve can usually be palpated on deep surface of coracobrachialis;
  • nerve enters posterior of coracobrachialis about 5 cm distal to coracoid tip but can be as close as 1 to 2 cm;
• identification of the axillary nerve
• retraction:
  • often a "Charnley type" of self retaining retractor is inserted underneath the deltoid medially and the coracobrachialis laterally;
• coraco-acromial ligament:
  • in patients w/ traumatic arthritis or DJD, the shoulders may be tight and therefore, the ligament can be
    partially incised for better exposure of the upper portion of the subscapularis;
  • in patients w/ rheumatoid arthritis or cuff tear arthropathy, excision of the CA ligament may destabilize the shoulder arthroplasty;

Transection of the Subscapularis:

• subscapularis tendon and the underlying joint capsule are divided approximately 1 cm medial to the lesser tuberosity;
• medial retraction of the tendon and capsule will expose the glenoid;

Caspsular Transection:

• external rotation of the humerus affords better capsular exposure and relaxes the nerve;
• insert a blunt retractor inferiorly to protect the axillary nerve, insert two single pronged skin hooks to elevate the capsule superiorly and place it under tension;
• vertically transect the capsule at a point midway between the lesser trochanter and the edgle of the glenoid;
• carry this vertical capsular incision superiorly into the rotator interval, which converts the capsular incision into a T (since the rotator interval lies in a horizontal direction);
• at the end of the case, the superior and inferior capsular capsular flaps are closed (and shortened) in order to shift the inferior capsule in a superior direction;
• the vertical portion of the incision is closed anatomically (so that there will be no loss of external rotation);

Distal Exposure:

• lower part of shaft is exposed by incising brachialis longitudinally along lateral border of biceps;
• lowest part of the front of the shaft can be approached between brachioradialis which is retracted laterally and brachialis which is retracted medially