Lateral Approach to the shoulder indications:
- Lateral Approach to the shoulder (or Deltoid Split Approach) provides limited access to the head and surgical neck of the humerus.
Lateral Approach to the shoulder is used for:
- Open reduction and internal fixation (ORIF) of the proximal humerus fractures.
- Open reduction and internal fixation of displaced fractures of the greater tuberosity of the humerus.
- Removal of calcific deposits from the subacromial bursa.
- Repair of the supraspinatus tendon.
- Rotator cuff repair.
- Debridement of the subacromial space.
Position of the Patient
- Lateral Approach to the shoulder is done in a supine position, with a bump or roll placed under the spine or ipsilateral scapula.
- Elevation of the head of the table reduces venous pressure in the operative field.
- Alternatively, a ‘beach chair’ positioning adaptor may be used depending on surgeon preference.
- The operative arm should be at the edge of the table to allow greatest manipulation of the extremity.
Landmarks and Incision
- The acromion bone.
- A 5-cm longitudinal incision is made from the tip of the acromion down the lateral aspect of the arm.
- There is no true internervous plane in Lateral Approach to the shoulder (deltoid is split in line with its fibers).
- Deltoid muscle is split in the line with its fibers no more than 5 cm distal to the lateral edge of acromion (to protect the axillary nerve).
- A stay suture is placed at the inferior apex of the split to prevent propagation of the split.
- Subacromial bursa lies directly deep to the deltoid muscle and can be excised to reveal the underlying rotator cuff insertion and proximal humerus.
- Lateral Approach to the shoulder is not a classically extensile approach, because it is limited distally
by the traverse of the axillary nerve over the deep surface of the deltoid muscle.
- Proximal Extension:
- Extend the incision superiorly and medially across the acromion and parallel to the upper margin of the spine of the scapula, about 1 cm above it along the lateral two thirds of the scapular spine.
- Incise the trapezius muscle and retract it superiorly.
- Incise the fascia overlying the supraspinatus.
- Split the acromion in the line of the skin incision, using an osteotome (reconstruct the acromion during closure ).
- Distal extension:
- it is possible by utilizing a separate deltoid split distal to the axillary nerve.
The structure at risk during Lateral Approach to the shoulder is:
- Axillary nerve:
- leaves posterior aspect of axilla by traversing quadrilateral space (teres minor, teres major, long head of triceps, medial border of humerus).
- it travels around the humerus coursing anteriorly and laterally to enter and innervate the deltoid via its deep surface.
- at this point, it runs transversely 5-7 cm distal to the edge of the acromion from posterior to anterior
- cannot extend split further due to risk to denervation of anterior deltoid.
- need to make a second incision distally in order to provide a safe “second window” if distal extension is needed (generally for fractures).
- Surgical Exposures in Orthopaedics book – 4th Edition
- Campbel’s Operative Orthopaedics book 12th