 SHOULDER AND ELBOW
Anatomy of the terminal branch of the
C. D. Smith,
S. J. Booker,
H. S. Uppal,
J. Kitson,
T. D. Bunker
From Royal Devon
and Exeter Hospital,
Exeter, United
Kingdom
 C. D. Smith, FRCS (T&O), MD,
MSc, Consultant Orthopaedic
Surgeon, Princess Elizabeth
Orthopaedic Centre
 S. J. Booker, FRCS (Tr&Orth),
Shoulder Fellow, Princess
Elizabeth Orthopaedic Centre
 J. Kitson, FRCS(Tr&Orth),
Consultant Orthopaedic
Surgeon
 T. D. Bunker, MD, MCh, FRCS,
Consultant Orthopaedic
Surgeon, Princess Elizabeth
Orthopaedic Centre,
Royal Devon and Exeter
Hospital, Exeter, Devon, UK.
 H. S. Uppal, FRCS(Tr&Orth),
MSc, Consultant Orthopaedic
Surgeon, Shoulder and Elbow
Unit
Lister Hospital, Stevenage,
Hertfordshire, UK.
Correspondence should be sent
to Mr S. J. Booker; e-mail:
simonbooker@doctors.net.uk
©2016 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.98B10.
38011 $2.00
Bone Joint J
2016;98-B:1395–8.
Received 3 February 2016;
Accepted after revision 29 June
2016
VOL. 98-B, No. 10, OCTOBER 2016
posterior circumflex humeral artery
RELEVANCE TO THE DELTOPECTORAL APPROACH TO THE
SHOULDER
Aims
Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral
approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder.
The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has
not been described before. We undertook an investigation to correct this omission.
Patients and Methods
The vascular anatomy encountered during 100 consecutive elective deltopectoral
approaches was recorded, and the common variants of the terminal branches of the PCHA
are described.
Results
In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid
and the proximal humerus and which was therefore vulnerable to tearing or avulsion during
the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In
75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple
vessel.
Conclusion
The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis
major into the proximal humerus is described. Damage to these previously undocumented
branches can cause persistent bleeding leading to prolonged surgery and post-operative
haematoma and infection, as well as poor visualisation during the procedure.
Cite this article: Bone Joint J 2016;98-B:1395–8.
The deltopectoral approach is the standard will commonly be torn either by the blade of
approach for most operations involving the the retractor or by blunt dissection.
shoulder, both in elective and trauma cases. It The aim of this study was to document the
is extensile and sited on an inter-neural plane anatomical variations of the terminal branches
between the axillary nerve and the musculocu- of the PCHA in relation to the pectoralis major
taneous nerve. However, this exposure is some- tendon. The insertion of pectoralis major is a
times accompanied by unexpected bleeding.1 standard reference point which is encountered
One source of this can be the deltoid artery and during the approach.
its branches.2 Another potential source is the
terminal branch of the posterior circumflex Patients and Methods
humeral artery (PCHA),3 the anatomy of A prospective observational study was under-
which has not been well described, making it taken between January 2011 and June 2012
susceptible to damage during this approach. involving consecutive patients undergoing a
Damage to this vessel can result in poor visual- deltopectoral approach to the shoulder.
isation and risks post-operative haematoma The inclusion criterion was any patient aged
formation and possible infection.4 > 18 years undergoing this approach. Exclu-
The terminal branch of this vessel is found in sion criteria were revision surgery, acute frac-
the subdeltoid recess as the PCHA travels ante- ture surgery, because there is often a large
riorly. This space is exposed in order to allow haematoma, and previous local radiotherapy.
the insertion of retractors (Fig. 1) with one This group of patients have been described in a
blade usually in the space between the deep previous study, detailing the anatomy of the
surface of the deltoid muscle and the humerus. deltoid artery.2 A total of 100 patients, 51
The terminal branch crosses this plane, and women and 49 men, were enrolled. The mean
1395
1396 C. D. SMITH, S. J. BOOKER, H. S. UPPAL, J. KITSON, T. D. BUNKER

Fig. 2a

Fig. 1

Illustration showing 1) terminal branch of the

posterior circumflex humeral artery (PCHA)
crosses the interneural plane and enters the
humerus, just lateral to the insertion of pecto-
rals major and 2) the PCHA and the axillary
nerve traverse the quadrilateral space to travel
around the back of the humerus and emerge on
the deep surface of deltoid (Co, coracoid; D, del-
toid; PM, pectoralis major).

Table I. Indications for surgery

Cases (n) Surgery

52 Total shoulder arthroplasty
26 Reverse shoulder arthroplasty
7 Subscapularis repairs
6 Laterjet procedures
4 Capsular shift operations for instability
Fig. 2b
3 Eden Hybinette procedures
1 Humeral avulsion glenohumeral ligament repair a) Clinical photograph showing the position of the retractors. b)
Angiogram demonstrating the posterior circumflex humeral artery
1 Hemiarthroplasty for osteonecrosis (PCHA). TBPC, terminal branch of the PCHA; H, humerus; PM, pec-
toralis major.

age of the patients was 65 years (standard deviation (SD)
17; 23 to 87). The right shoulder was involved in 54
patients and the left shoulder in 46. The indications for sur-
gery are shown in Table I.
A standard approach was used with the patient in the
supine position and the table in 10˚ of head-up tilt. The
incision was made between the coracoid superiorly and
about 2 cm lateral to the axillary crease distally. The inter-
val between the deltoid and pectoralis major was carefully
dissected and the superior border of the insertion of the ten-
don of pectoralis major was exposed. A retractor was
inserted between the lateral shaft of the humerus and
deltoid in the subdeltoid space, 1 cm above a line projected
from the superior border of the insertion of pectoralis
major. A second retractor was placed in a similar position,
but 3 cm below the line projected from the superior border
of the insertion of pectoralis major (Fig. 2a). The subdeltoid
fascia was dissected from the lateral humeral shaft to
expose the terminal branch of the PCHA as it entered the
humerus. Any variations in the pattern of the terminal
branches and their relationship to the superior border of
the pectoralis major tendon were recorded, with the dis-
tance from the superior border being measured in millime-
tres using a sterile ruler.
Results
No patient developed a post-operative haematoma requir-
ing drainage and none is known to have had any
subsequent problems with perfusion of the humeral head.
In total, four main variations were discovered with sub-
divisions depending on whether the terminal branch was
superior (group A) or inferior (group B) to the insertion of

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 ANATOMY OF THE TERMINAL BRANCH OF THE POSTERIOR CIRCUMFLEX HUMERAL ARTERY
Table II. Results: a summary of the findings
Type Cases (n)
Type 0 8/100
Type 1a 45/100
Type 1b 30/100
Type 2 16/100
Type 3 1/100
pectoralis major. Type 0 variants had no terminal branch
and comprised 8% of patients.
Type 1 variants (Fig. 2) had a single terminal branch and
comprised 75% of patients; 45% had a type 1A terminal
branch which was superior to the superior border of the
insertion of pectoralis major and 30% had a type 1B termi-
nal branch below the superior border of the tendon. Type
1B branches were a mean of 4.5 mm (SD 2.9, 0 to 12) below
the insertion.
In total, 16% of patients had a type 2 variant with two
terminal branches, superior and inferior. Of these variants
most (63%, ten dissections) were type 2A with a superior
terminal branch superior to the tendon and the remainder
(37%, six disssections) were type 2B variants with a supe-
rior terminal branch inferior to the tendon (mean 4.4 mm,
SD 3.1mm, 0 to 10). The inferior branches of all the type 2
variants were well below the superior border of the tendon
(mean 9.3 mm, SD 5.3mm, 3 to 18).
There was one type 3 variant (1%) with three terminal
divisions. The most superior branch was 8mm below the
tendon and the most inferior branch was 16 mm below it
(Table II).
Discussion
The anatomy of the PCHA has been described many
times.5-7 However, to our knowledge, the terminal branches
crossing the space deep to deltoid to enter a nutrient pit in
the humerus just lateral to the superior border of the inser-
tion of the tendon of pectoralis major, have not been
described. This vessel is important because of its vulnerabil-
ity to the position of the blade of self-retaining retractors
during the deltopectoral approach to the shoulder. Tearing
a terminal branch with retractor blades rather than cauter-
ising it is a potential source of post-operative haematoma.
The classic studies on the anatomy of the PCHA5-7 are
concerned with the perfusion of the humeral head follow-
ing fracture and the sequelae of avascular necrosis. These
studies highlight the perforating branches within the quad-
rilateral space and how they enter the calcar of the humerus
and perfuse the head. Another study8 examines the passage
of the artery through the quadrilateral space and how it can
be compressed by fibrous bands.
The anatomy of the PCHA as it passes with the axillary
nerve through the substance of the deltoid muscle has been
examined and how it is vulnerable to percutaneous pinning
during surgery for fracture,9 but did not identify the termi-
nal branch. Nor did the work of Gardner et al10 concerning
VOL. 98-B, No. 10, OCTOBER 2016
1397
Outcome
No vessel present
Single vessel; superior to pectoralis major
Single vessel; inferior to pectoralis major
Double vessel
Triple vessel
the vulnerability of the axillary neurovascular bundle to
minimally-invasive plating of proximal humeral fractures,
identify the terminal branch.
Pakonstantinou et al11 looked at the vasculature of the
proximal humerus, but considered the intraosseous blood
supply, rather than the extra-osseous vulnerability of the
nutrient vessels. Chen et al12 also performed an anatomical
study of the origins of the circumflex humeral arteries, but
did not discuss their insertions.
We found that the PCHA usually has either one or two
terminal branches and that a third of these will be distal to
the insertion of the tendon of pectoralis major. Careful
exposure of the subdeltoid space with reference to this ten-
don allows visualisation of the terminal branches as they
run into the lateral humeral periosteum. Cauterising these
vessels close to the humeral shaft is safe and does not risk
injury to the distal section of the axillary nerve, which is
intimately related to the inner surface of the exposed del-
toid muscle.
In conclusion, we have identified and classified varia-
tions in the anatomy of the terminal branches of the PCHA,
and their relationships to the tendon of the insertion of pec-
toralis major, one of the primary landmarks for the delto-
pectoral approach. This knowledge will help surgeons
avoid unnecessary bleeding when using this approach in
operations on the shoulder.
Take home message:
Surgeons should identify and cauterise the terminal branches
of the PCHA as described to prevent intra- and post-operative
complications.
Author contributions:
C. D. Smith: Data Collection, Data analysis, Writing the paper.
S. J. Booker: Writing the paper.
H. S. Uppal: Writing the paper.
T. D. Bunker: Concept, Performed surgeries, Data collection, Editing the paper.
J. Kitson: Performed surgeries.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by J. Scott and first proof edited by G. Scott.
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