Shoulder/Arm Approaches

Question 1

position for anterior approach to the clavicle

Answer 1

supine

elevate head

sandbag between scapula and spine

Question 2

incision for anterior approach to the clavicle

Answer 2

start medial after palpating subcutaneous border of clavicle

Question 3

internervous plane for anterior approach to the clavicle

Answer 3

none

Question 4

superficial dissection for anterior approach to the clavicle

Answer 4

through platysma

diathermy vessels

Question 5

deep dissection for anterior approach to the clavicle

Answer 5

strip soft tissue off clavicle in epiperiosteal plane

Question 6

danger for anterior approach to the clavicle

Answer 6

1) brachial plexus
2) subacromial artery and vein immediately inferior to clavicle - avoid inferior dissection

Question 7

position for anterior approach to shoulder joint

Answer 7

supine

sandbag between scapula and spine

elevate table 30°

Question 8

incision for anterior approach to shoulder joint

Answer 8

10-15 cm along deltopectoral groove starting at corocoid

alternatively, you can use the axillary incision, which is vertical in the axilla starting at the anterior crease

Question 9

internervous plane for anterior approach to shoulder joint

Answer 9

between deltoid and pecs

Question 10

superficial dissection for anterior approach to shoulder joint

Answer 10

retract pec medial and delt lateral

take the cephalic vein in the convenient direction

Question 11

deep dissection for anterior approach to shoulder joint

Answer 11

displace the short head of biceps and coracobrachialis medially

osteotomize the corocoid if necessary with the arm adducted (takes brachial plexus and artery away from field)

retract corocoid medially

externally rotate to ID subscap

divide subscap 1 cm from insertion and use stay sutures to anchor it (or take some bone with it)

incise joint capsule where appropriate

Question 12

danger for anterior approach to shoulder joint

Answer 12

1) MSK nerve as it enters the coracobrachialis 5-8 cm distal to corocoid
2) cephalic vein

Question 13

position for anterolateral approach to the AC joint and subacromial space

Answer 13

supine

sandbag between scapula and spine

elevate head 45°

Question 14

incision for anterolateral approach to the AC joint and subacromial space

Answer 14

transvers incision beginning at the anterolateral corner of the acromion ending just lateral ato the coracoid

Question 15

internervous plane for anterolateral approach to the AC joint and subacromial space

Answer 15

none - delt is detached

Question 16

superficial dissection for anterolateral approach to the AC joint and subacromial space

Answer 16

fascia

palpate AC joint

ligate the coracoacromial artery

spare as much deltoid as possible

split delt 5 cm down if approaching for rotator cuff repair

Question 17

deep dissection for anterolateral approach to the AC joint and subacromial space

Answer 17

detach coracoacromial ligament from acromion and coracoid - remove for decompression of teh subacromial space

Question 18

danger for anterolateral approach to the AC joint and subacromial space

Answer 18

1) axillary nerve runs deep to delt 7 cm below the acromion
2) acromial branch of the coracoacromial artery must be ligated just under the delt as you approach

Question 19

position for lateral approach to proximal humerus

Answer 19

supine with arm at edge of table

elevate head of table

sandbag for shoulder

Question 20

incision for lateral approach to proximal humerus

Answer 20

5 cm longitudinal from tip of acromion down lateral arm

Question 21

internervous plane for lateral approach to proximal humerus

Answer 21

none - split delt

Question 22

superficial dissection for lateral approach to proximal humerus

Answer 22

split delt in line with fibres from acromion down

insert stay suture at inferior margin

Question 23

deep dissection for lateral approach to proximal humerus

Answer 23

incise subacromial bursa

expose humerus and rotator cuff

Question 24

danger for lateral approach to proximal humerus

Answer 24

1) axillary nerve 7 cm below acromion travelling transversely under delt

*note that the minimally invasive lateral approach is also available with 2 incisions, but the key is ID the axillary nerve and go deep to it*

Question 25

position for posterior approach to the shoulder joint

Answer 25

lateral stand behind

Question 26

incision for posterior approach to the shoulder joint

Answer 26

linear along scapular spine extending to posterior corner of acromion

Question 27

internervous plane for posterior approach to the shoulder joint

Answer 27

between teres minor and infraspinatus

Question 28

superficial dissection for posterior approach to the shoulder joint

Answer 28

detach delt from scapular spine develop plane between infraspinatus and delt

Question 29

deep dissection for posterior approach to the shoulder joint

Answer 29

ID plane between infraspinatus and teres minor and develop retract superior and inferior respectively expose joint and incise

Question 30

danger for posterior approach to the shoulder joint

Answer 30

1) axillary nerve as it runs through quadrangular space beneath teres minor 2) suprascapular nerve passes around the base of the spine of scapula 3) posterior circumflex humeral artery runs with axillary nerve

Question 31

position for anterior approach to the humeral shaft

Answer 31

supine arm board tilt patient away NO tourniquet

Question 32

incision for anterior approach to the humeral shaft

Answer 32

longitudinal from tip of coracoid run distal and lateral along delto-pectoral groove then following the lateral border of biceps as far as necessary

Question 33

internervous plane for anterior approach to the humeral shaft

Answer 33

proximally between pec and delt distally between medial and lateral fibres of brachialis

Question 34

superficial dissection for anterior approach to the humeral shaft

Answer 34

ID deltopectoral groove using cephalic vein as a guide fascia interval betwen biceps and brachialis retract biceps medially

Question 35

deep dissection for anterior approach to the humeral shaft

Answer 35

incise periosteum lateral to pec insertion ligate anterior humeral circumflex artery may need to detach pec major and move medially split fibres of brachialis to expose distal shaft

Question 36

danger for anterior approach to the humeral shaft

Answer 36

1) radial nerve - vulnerable at 2 spots - spiral groove and anterior compartment of distal third of arm between brachialis and brachioradialis 2) axillary nerve running under deltoid 7 cm distal to acromion 3) anterior humeral circumflex artery 4) lateral ante-brachial cutaneous nerve medial to brachialis \*note that this can also be done via two small minimally invasive incisions

Question 37

position anterolateral approach to the distal humerus

Answer 37

supine arm board tourniquet

Question 38

incision anterolateral approach to the distal humerus

Answer 38

curved over lateral aspect of biceps starting 10 cm proximal to flexor crease

Question 39

internervous plane anterolateral approach to the distal humerus

Answer 39

none

Question 40

superficial dissection anterolateral approach to the distal humerus

Answer 40

incise deep fascia ID lateral biceps and retract medially ID interval between brachialis and brachioradialis develop plane find radial nerve

Question 41

deep dissection for anterolateral approach to the distal humerus

Answer 41

incise lateral border of the brachialis muscle down to bone and retract medially

Question 42

danger for anterolateral approach to the distal humerus

Answer 42

1) ID the radial nerve and protect it

Question 43

position for posterior approach to the distal humerus

Answer 43

either lateral or prone with arm abducted with sandbag under shoulder

Question 44

incision for posterior approach to the distal humerus

Answer 44

longitudinal in posterior midline from 8 cm below acromion to olecranon fossa

Question 45

internervous plane for posterior approach to the distal humerus

Answer 45

none - separate heads of triceps

Question 46

superficial dissection for posterior approach to the distal humerus

Answer 46

fascia ID 3 parts of triceps - the radial nerve will be between the lateral and medial heads

Question 47

Answer 47

lateral head of triceps

Question 48

Answer 48

profunda brachii artery and radial nerve

Question 49

Answer 49

hiatus in lateral intermuscular septum

Question 50

Answer 50

medial head of triceps

Question 51

Answer 51

long head of triceps

Question 52

deep dissection for posterior approach to distal humerus

Answer 52

incise medial head of triceps midline down to bone

Question 53

danger for posterior approach to the distal humerus

Answer 53

1) radial nerve between medial and lateral head of triceps 2) ulnar nerve as in passes posteromedially 3) profunda brachii artery with radial nerve

Question 54

position for lateral approach to distal humerus

Answer 54

supine arm across chest tourniquet

Question 55

incision for lateral approach to distal humerus

Answer 55

4-6 cm straight incision lateral aspect of elbow over lateral supracondylar ridge

Question 56

internervous plane for lateral approach to distal humerus

Answer 56

none - between triceps and brachioradialis

Question 57

superficial dissection for lateral approach to distal humerus

Answer 57

fascia find plane between brachioradialis and triceps and cut down to bone retract triceps posteriorly and brachioradialis anteriorly

Question 58

deep dissection for lateral approach to distal humerus

Answer 58

ID common extensor origin and release if needed

Question 59

dangers for lateral approach to distal humerus

Answer 59

1) radial nerve pierces lateral intermuscular septum in distal third of arm

Question 60

position for minimal access approach for humeral nailing

Answer 60

supine elevate table 45° shoulder over edge of table

Question 61

incision for minimal access approach for humeral nailing

Answer 61

2 cm from acromion vertically down arm

Question 62

internervous plane for minimal access approach for humeral nailing

Answer 62

none - split deltoid

Question 63

superficial dissection for minimal access approach for humeral nailing

Answer 63

insert wire under fluoro as guide remove and make small incision put wire back and use awl insert nail

Question 64

danger for minimal access approach for humeral nailing

Answer 64

1) axillary nerve 7 cm below the acromion under deltoid 2) brachial artery medial to proximal humerus 3) median nerve with brachial artery 4) supraspinatus tendon is partially incised - take care when drilling not to cause more damage