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Updated: Mar 30 2016

Judet Approach to Scapula

https://upload.orthobullets.com/topic/12069/images/judet.jpg
https://upload.orthobullets.com/topic/12069/images/judet_modified_illustraiton.jpg
Introduction
  • Overview
    • a fairly limited approach to the shoulder, allowing little anterior exposure.
  • Indications
    • proximal humerus fracture-dislocations (posterior)
    • scapula fractures 
      • scapular neck
      • posterior glenoid rim
      • posterior articular segments
    • glenoid osteotomy
    • open posterior rotator cuff repair
    • biopsy and tumour resection
Internervous plane
  • Internervous plane between  
    • suprascapular nerve (infraspinatus) and 
    • axillary nerve (teres minor)
Approach
  • Positioning
    • standard positioning
      •  prone 
    • alternative positioning
      • beach chair
      • lateral decubitus
  • Incision
    • classic incision
      • curved incision 
        • starting from posterolateral lip of the acromion
        • extending medial along the spine of the scapula,
        • right angle turn at the medial border of the scapula
    • modified incision  
      • straight incision  
        • starting from posterolateral lip of the acromion,
        • extend incision in line with the tip of scapula,
          • incision should be parallel, and lateral, to the medial scapular border 
  • Superficial dissection
    • incise through skin and fat
    • identify and expose the posterior deltoid muscle belly
    • sharply dissect deltoid muscle origin off the scapular spine and base of acrominon 
    • retract muscle distal and lateral to reveal the underlying infraspinatus and teres minor muscles
  • Deep dissection
    • working through the infraspinatus and teres minor interval
      • retract teres minor inferiorly
        • avoid injury to posterior branch of axillary nerve  
      • retract infraspinatus superiorly
        • avoid injury to suprascapular nerve and artery
    • deep dissection
      • lateral
        • identify underlying posterior glenoid capsule deep to musculature
        • incise posterior capsule in line with muscular interval
        • allows access to the posterior aspect of glenohumeral joint 
      • medial 
        • dissecting the infraspinatus along off the medial border of scapula 
        • retract infraspinatus muscle belly superior and lateral, as this will maintain its suprascapular neurvascular pedicle
        • allows access to the inferior aspect of scapular body
    • improve exposure 
      • lateral
        • the infraspinatus tendon insertion can be tagged and cut approx. 1-2 cm lateral to its insertion on greater tuberosity
        • retract medially
      •  medial
        • dissection of infraspinatus off the medial border of scapula is extended superiorly to the scapular spine
Dangers
  • Suprascapular nerve  
    • anatomy 
      • passes around the base of the spine of the scapula as it runs from the supraspinous fossa to the infraspinous fossa
    • risk of injury
      • forceful medial and superior retraction of infraspinatus muscle 
  • Axillary nerve  
    • anatomy
      • passes through the quadrangular space beneath the teres minor
    • risk of injury
      • dissection carried out inferior to the teres minor 
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