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Introduction
  • Overview
    • this approach is infrequently used
    • this approach offers access to the posterior and inferior aspects of the shoulder
  • Indications
    • proximal humerus fracture-dislocations
    • glenoid fractures/osteotomy
    • removal loose bodies
    • irrigation and debridement of septic joint
    • scapular neck fractures
 
Internervous plane
  • Internervous plane 
    • teres minor (axillary n.)
    • infraspinatus (suprascapular n.)
 
Preparation
  • Anesthesia
    • general anesthetic
  • Table
    • radiolucent flat-top table
  • Patient Position
    • prone is most common
    • lateral
    • beach-chair
Approach
  • Incision
    • the patient is positioned in the lateral decubitus position with the ipsilateral arm draped free
    • the incision is made along the scapular spine, extending to the lateral acromial border
  • Superficial dissection
    • attention must be paid to superficial skin vessels, as these can bleed significantly
    • the origin of the deltoid is released from the scapular spine
    • the plane between the deltoid and infraspinatus is encountered and bluntly developed
      • this is typically easiest to find at the lateral aspect of the incision
    • the deltoid is retracted distally/laterally
  • Deep dissection
    • the interval between the infraspinatus (suprascapular nerve) and teres minor (axillary nerve) is bluntly developed
      • this is often difficult to find, but should be done carefully
    • retract the infraspinatus superiorly and the teres minor inferiorly to expose the posterior glenoid and scapular neck
 



Dangers
  • Suprascapular nerve 
    • passes around the base of the scapular spine (do not retract infraspinatus too vigorously)
  • Axillary nerve
    • runs through the quadrangular space beneath the teres minor (stay superior to the teres minor)
    • this is accompanied by the posterior circumflex humeral artery
 
 

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