Updated: 8/28/2016

Shoulder Lateral (Deltoid Splitting) Approach

Review Topic
Videos / Pods
  • Overview
    • provides access to the lateral proximal humerus, rotator cuff, and acromion
    • it is not traditionally extensile -- to extend the approach distally, a second separate incision must be made or one long incision can be made, with identification of the axillary nerve being paramount
  • Indications
    • reduction and fixation of proximal humerus fractures
    • rotator cuff repair
    • debridement of the subacromial space
  • General
  • Regional
Internervous plane
  • Internervous plane
    • no true internervous plane (deltoid is split in line with its fibers)
Positioning & Preparation
  • Position
    • approach 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
  • Intraoperative imaging
    • C-arm can either come from above the head or across the bed from the opposite side of the table
    • ensure adequate fluoroscopic views can be obtained prior to preparation and draping
  • Incision
    • 5 cm incision is made from the tip of the acromion distally in line with the arm
      • this is generally made at the posterior edge of the clavicle, but can be adjusted according to pathology
  • Superficial dissection
    • deltoid is split in 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 propogation of the split
  • Deep dissection
    • subacromial bursa lies directly deep to the deltoid muscle and can be excised to reveal the underlying rotator cuff insertion and proximal humerus
  • Extension
    • distal extension is only possible by performing a second, separate deltoid split distal to the axillary nerve
    • the approach can be extended proximally parallel to the spine of the scapula to expose the entire supraspinatus
      • this requires division of the overlying trapezius muscle parallel to the spine of the scapula and division of the acromion in line with the incision, both of which require repair
  • 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)

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