THE SHOULDER

Anatomy & Approaches

Abdulaziz F. Ahmed, MBBS
PGY-2

HGI-02-PHY-P140
Outline
• Surface Anatomy

• Osteology

• Musculature

• Neurology

• Vasculature
Surface Anatomy
SC Joint

Clavicle
Trapezius
AC Spine of Scapula
Joint
Deltoid Serratus anterior

Cephalic vein
 Osteology

Acromion

Clavicle Scapula Glenoid Proximal

Coracoid Humerus
Osteology (Clavicle)
Osteology (Clavicle)
• The first bone to ossify.

• Only long bone to ossify by intramembranous ossification.

• Medial epiphysis is last ossification center to fuse (20-25 yrs).

• No true intramedullay canal.

• Middle third is the narrowest with no muscle insertions.

Osteology (Scapula)

Suprascapular
notch
Spinoglenoid
notch
Osteology (Scapula - Acromion)
• The acromion has three ossification centers
1. Meta-acromion (base)
2. Mesoacromion (middle)
3. Preacriomion (tip)

• Failure of fusion = Os acromiale

Osteology (Scapula Acromion)

Link to rotator cuff

pathology is
CONTROVERSIAL

POOR INTEROBSERVER
RELIABILITY
Osteology (Scapula - Glenoid)
• Subchondral bone of the glenoid is flat.

• Articular concavity is augmented by cartilage and labrum.

• Glenoid averages 5-7 degrees of retroversion; 5 degrees superior tilt.

Osteology (Superior Shoulder Suspensory Complex)

• Stable connection between

• Scapula
• Axial Skeleton
Osteology (Proximal Humerus)
• Three centers of ossification:
• Head; GT and LT.

• 80% of bone growth is from the

proximal humerus physis.

• Humeral head
• 35 degrees of retroversion
• 130 degrees neck-shaft angle

• Tuberosities are rotator cuff tendon

insertion sites.
Joints of the Shoulder
• Glenohumeral; Sternoclavicular; Acromioclavicular; Scapulothoracic.

• Inherently unstable, however, with unparalleled ROM.

• Flexion 0-170; Extension 0-60; Abduction 0-180;

• IR to thoracic spine; ER up to 70.

• 2:1 ratio of glenohumeral joint to scapulothoracic joint contributes to motion.

• Static: joint congruity, labrum, GH ligaments, -ve intraarticular pressure.

• Dynamic: Rotator cuff muscles, biceps tendon, periscapular muscles.

 Sternoclavicular (SC) Joint
• It is the only true articulation between the appendicular and axial
skeletons.

Sternoclavicular ligament (ant/post)

Costoclavicular
Ligament
Scapulothoracic Joint
• Not an actual joint.

• Scapula slides along the posterior ribs.

• Multiple muscles involved: e.g. trapezium and s.anterior.

• During flexion & abduction: this joint contributes to 1/3 of the

shoulder ROM.
Acromioclavicular (AC) Joint
• Very limited ROM.

• AC ligaments are primary stabilizers to:

- Anterior and posterior translations

• CC ligaments are the primary stabilizers to vertical stability:

• Conoid medially
• Trapezoid laterally
The Glenohumeral Joint
Glenohumeral (GH) Joint
• Capsule maintains -ve intracapsular pressure; thin posteriorly

• Glenohumeral ligaments:
• Discrete thickening of the anterior and inferior capsule.
• No ligaments superiorly and posteriorly.
Coracohumeral
Ligament

Superior GHL

Middle GHL

Inferior GHL
Superior GHL & Coracohumeral Ligaments
Resists inferior translation & ER in shoulder adduction
Resists posterior translation in 90° of forward flexion
Middle Glenohumeral Ligament
Resists anteroposterior translation in 45° of abduction
Buford complex: thickened MGHL & absent anterior/superior labrum
Inferior Glenohumeral Ligament
Resists anterior & inferior translation in abduction & ER;
Resists posterior translation in IR & 90° flexion
 Quadrangular space
-Axillary nerve
-Post. Circumflex A.
-Humeral A.

Triangular space
-Circumflex scapular A. Triangular interval
-Radial N.
-Deep A. of the arm
Dorsal Scapular (C5)

Suprascapular (C5-6) Lateral Pectoral (C5-7)

USS, TD, LSS

Medial Pectoral
Medial cutaneous nerve of the arm
Medial cutaneous nerve of the forearm
Approach Outline
• The Deltopectoral Approach

• The Deltoid-Splitting Approach

• The Posterior Approach

• Shoulder Arthroscopy Basics

The Deltopectoral Approach

• AKA (Anterior Approach)

• This is the workhorse approach to the shoulder.

• Indicated in:
• shoulder hemiarthroplasty, TSA, RTSA,
• open shoulder stabilization
• ORIF of PHFs and anterior glenoid fractures.
Put a sandbag in between the spine
and the scapula on the affected side!
The Deltopectoral Approach
• Landmarks:
• Coracoid process
• Deltopectoral groove

• A marker pen can be rolled to

locate the “valley” of this interval.

• Incision is usually 10-12 cm in

length.

• This incision obliquely crosses the

skin tension lines of Langer.
The Deltopectoral Approach
• Internervous Plane:
• Deltoid (Axillary N.)

• P. Major
(Lateral and medial pectoral N.)
The Deltopectoral Approach
• Superficial dissection
• Dissection through the well
vascularized subcutaneous adipose
tissue. Develop a groove in the fascia
the pecs major.

• The cephalic vein identified.

• The vein may be retracted

either medially or laterally.

• It is preferred to perform dissection

medial to the vein because
there are fewer medial branches than
there are lateral branches.
The Deltopectoral Approach
• Deep dissection

• Conjoint tendon identified.

• Drill the tip of the coracoid

process before cutting it.

• Incise the fascia on the lateral

aspect of the conjoint tendon.
Watch out for the Brachial Plexus.
The Deltopectoral Approach
• Deep dissection

• Cut through the predrilled coracoid.

• Retract the conjoint tendon medially

to give greater exposure to the
subscapularis tendon.

Overzealous retraction will put the

musculocutaneous nerve at risk.
The Deltopectoral Approach
The Deltopectoral Approach
• Dangers

• Nerves: musculocutaneous nerve

• Don’t be generous with the retraction of the conjoint tendon.

• Vessels: cephalic vein

• If traumatized then ligate; prevents DVT.
The Anterolateral Approach
• Not frequently used due to the development
of arthroscopy.

• Indicated in:
• Rotator cuff repair
• Repair of the long head of the biceps
• Acromioclavicular joint decompression
• Anterior shoulder decompression

• Internervous plane
• None (deltoid split proximally to the axillary nerve)
The Anterolateral Approach
• Landmarks:
• Coracoid process

• An incision is made along the anterolateral

edge of the shoulder.
The Anterolateral Approach
Superficial Dissection

• The deltoid is then sharply released

from the acromion or clavicle
depending on area of surgical need.

• This should be limited, as deltoid

repair is often difficult

• The acromial branch of the

thoracoacromial artery
• must be ligated when encountered
deep to the deltoid, near the
acromioclavicular joint
The Anterolateral Approach
Deep Dissection

• The coracoacromial ligament is then

released from the acromion.

• The ligament can be excised by

releasing it from the coracoid as well

• The subacromial bursa is now seen

and can be excised.
The Anterolateral Approach
The Anterolateral Approach
Dangers
• Axillary nerve
This nerve runs transversely across the surface of the
deltoid muscle approximately 7 cm distal to the acromion.

• Acromial branch of the thoracoacromial artery

Runs directly under the deltoid muscle
The Deltoid Splitting Approach
• AKA (Lateral Approach of the Shoulder)

• Indicated in:
• ORIF of PHFs.
• TSA, RTSA.
• Open rotator cuff repair.

• Avoids the significant retraction of the anterior deltoid that which may
impair recovery (vs. DP approach)
The Deltoid Splitting Approach
• Landmarks:
• The acromion

• 5-cm longitudinal incision from

the tip of the acromion
down the lateral aspect of the arm.

• No internervous plane.
The Deltoid Splitting Approach
Subdeltoid portion of
subacromial bursa
The Deltoid Splitting Approach
The Posterior Approach

• Indications:
• osseous augmentation of the posterior glenoid
• posterior glenoid fractures
• scapula fractures
• open decompression of the spinoglenoid notch.
The Posterior Approach
• Internervous Plane:
• Teres Minor

• Infraspinatus
The Posterior Approach
• Landmarks:
• The acromion
• The spine of the scapula

• Make a linear incision along the

entire length of the scapular spine
extending to the posterior corner
of the acromion.
The Posterior Approach
The Posterior Approach
The Posterior Approach
• Dangers

• Nerves:
• Axillary nerve
• runs through the quadrangular space beneath the teres minor

• Suprascapular nerve
• Passes around the base of the spine of the scapula as it runs from the supraspinous fossa to the
infraspinous fossa.
• Don’t overdo the retraction of the teres minor.

• Vessels: posterior circumflex artery

• Runs with the axillary nerve in the quadrangular space.
Shoulder Arthroscopy
• Indications:
• Diagnostic surgery
• Loose body removal
• Rotator cuff repair or debridement
• Labral/SLAP and instability repair
• Subacromial decompression
• AC joint pathology
• Distal clavicle resection
• Release of suprascapular nerve entrapment
• Release of scar tissue/contractures
• Synovectomy
• Biceps tenotomy/tenodesis
Shoulder Arthroscopy
• Patient Position

Advantage: joint distraction Advantages:

Disadvantage: can be associated with - No need to reposition/redrape to convert to open procedure
neuropraxia. -Reduces venous pressure and bleeding
Shoulder Arthroscopy
• Primary Portals

• Posterior portal (1)

• Primary viewing portal used for diagnostic arthroscopy
• 2 to 3 cm inferior and 1 to 2
cm medial to the posterolateral acromion
• First portal to be placed.
Post. Ant.

• Anterior “anterocentral” portal (2)

• viewing and subacromial decompression.
• Lateral to the coracoid and anterior to the AC joint.

• Lateral “anterolateral” portal (3)

• subacromial decompression
• 2-3cm distal to the lateral edge of acromion.
• It passes through the deltoid “AXILLARY N”
Shoulder Arthroscopy
• Secondary Portals

• Anteroinferior (5 o’clock) portal (5)

• placement of anchors for anterior labral repair

• Posteroinferior (7 o’clock) portal (7)

• placement of anchors for posterior labral repair Post. Ant.

• Nevasier (supraspinatus) portal (9)

• subacromial decompression

• Port of Wilmington (10)

• Used to evaluate/repair posterior SLAP and RTC lesions
Shoulder Arthroscopy
• Dangers
•Posterior portal
•axillary nerve
•suprascapular nerve

Post. Ant.
•Anterior portal
•cephalic vein
•musculocutaneous nerve

•Anesthesia
•phrenic nerve
•with intrascalence block (anesthesia)
Thank You