Review Question - QID 217855

The interval for the modified Judet approach is between the infraspinatus and teres minor muscles.

Scapula fractures occur relatively infrequently overall, but make up ~5% of shoulder girdle injuries. Further, about 35-40% of scapula fractures affect the glenoid. Fixation of scapula fractures should be considered when there is intra-articular step-off >3-4mm, medialization of the lateral border >20mm, a glenopolar angle <20º or angulation of the scapula >40º. The modified Judet approach can be quite effective in accessing the scapular body and the glenoid. It begins with a "boomerang" shaped skin incision over the posterior shoulder as seen in Illustration A and proceeds through the muscular interval between the infraspinatus and teres minor muscles. This utilizes a true internervous plane between the suprascapular nerve (infraspinatus) and the axillary nerve (teres minor).

Cole et al. reviewed posterior scapular approaches including the extensile and modified Judet approaches. They note that the modified Judet, or "boomerang" incision follows the curve of the scapular spine and vertebral border and proceeds through the intermuscular interval described above. The extensile Judet starts through a similar incision but the posterior musculature is then elevated through a periosteocutaneous flap, which provides increased exposure at the cost of more soft tissue stripping.

Ball et al. performed an anatomic study evaluating the posterior branch of the axillary nerve in 19 cadaveric specimens. They note its origin just anterior to the long head of the triceps at the inferior glenoid rim, with further division occurring at this point to innervate the posterior shoulder cutaneously and the teres minor. Given the intimate relationship of the axillary nerve at this level, they point out that loss of posterior shoulder sensation over the deltoid may also indicate a lack of function in the teres minor.

Figure A demonstrates a cadaveric model of the posterior shoulder girdle musculature with labels indicating the following: (A) posterior deltoid, (B) infraspinatus, (C) teres minor, (D) teres major, (E) long head triceps. Illustration A depicts the muscular interval for the modified Judet approach.

Incorrect Answers:
Answers 1, 3-5: The modified Judet approach is centered on the internervous plane between the infraspinatus (suprascapular n.) and the teres minor (axillary n.).