Shoulder - Anterior Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The Anterior (Deltopectoral) Approach to the shoulder remains the gold standard for open shoulder procedures including fracture fixation, arthroplasty, and soft tissue repair. It offers excellent exposure of the glenohumeral joint while preserving deltoid function by utilizing the internervous plane between the deltoid and pectoralis major muscles. This approach is favored for its safety, extensibility, and reproducibility, although minimally invasive and arthroscopic techniques are increasingly preferred for select pathologies.

Applied Anatomy & Intervals

Internervous Interval

Between the Axillary nerve (deltoid innervation) laterally and the Medial and Lateral Pectoral nerves (pectoralis major innervation) medially.

Anatomic Landmarks

Coracoid process: palpable bony prominence
Deltopectoral groove: natural interval between deltoid and pectoralis major muscles

Patient Positioning & Setup

Table Type

Standard operating table with radiolucent capabilities for intraoperative imaging.

Patient Position

Supine with head elevated 30–45° (beach chair variant). A sandbag or bolster is placed beneath the thoracic spine and medial border of the scapula to optimize exposure.

Specialized Equipment

Arm draped free to allow manipulation (abduction, external rotation)
Limb positioner or assistant to maintain arm position
C-arm positioned for anteroposterior and axillary imaging as needed

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

Make a 10–15 cm incision along the deltopectoral groove, starting just superior to the coracoid process.
Identify and preserve the cephalic vein within the deltopectoral interval; retract medially with pectoralis major or laterally with deltoid depending on surgeon preference.

Deep Dissection & Exposure

Retract the short head of biceps (SHB) and coracobrachialis (CB) medially; protect the musculocutaneous nerve which enters the CB 5–8 cm distal to the coracoid on its medial side.
Keep the arm adducted to relax the neurovascular bundle and minimize tension.
Divide the fascia lateral to the CB to access the subscapularis tendon.
Externally rotate the arm to stretch the subscapularis, increasing the distance between the tendon and axillary nerve.
Identify and ligate small vessels along the inferior border of the subscapularis.
Perform a subscapularis tenotomy or peel approximately 1 inch from its insertion on the lesser tuberosity.
Incise the joint capsule longitudinally to expose the glenohumeral joint.

The “Danger Zone”

Structure	Location / Risk Area	Protection Strategy
Musculocutaneous nerve	Enters coracobrachialis 5–8 cm distal to coracoid, medial side	Avoid deep medial retraction; identify early
Cephalic vein	Within deltopectoral groove	Preserve and retract carefully to avoid bleeding
Axillary nerve	Runs close to inferior border of subscapularis	External rotation to increase distance; avoid deep dissection inferiorly

Post-Operative Pearl

Limit external rotation and abduction initially to protect the subscapularis repair. Early passive range of motion within safe limits is encouraged to prevent stiffness.

Classic Clinical Notes