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Anterior deltopectoral
- Internervous – axillary and lateral pec nerve
- Danger (4) –
- Musculocutaneous nerve
- Axillary nerve
- Anterior humeral circumflex artery
- Brachial plexus
- Position - Beach Chair
- Incision – Coracoid down deltopectoral groove
- Dissection – Incise deltopectoral fascia, retract cephalic vein laterally (Reason: tributaries come from the lateral side) → identify coracoid process and conjoint tendon → incise clavipectoral fascia lateral to conjoint (protect musculocutaneous nerve, avoid over-medial retraction) → down to subscapularis → identify "3 sisters" (anterior humeral circumflex artery and 2 venae comitantes) [Lower limit of incision]; ligate them → incise subscapularis in external rotation position, adduct arm (protect brachial plexus) and do not go beyond that (to avoid axillary nerve) → joint capsule
- Extension – anterolateral OR anterior approach to humerus
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- Posterior circumflex humeral artery goes through quadrilateral space.
- Upper margin of quadrilateral space is the lower margin of the subscapularis. That's why the 3 sisters is a very important landmark.
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- Consider coracoid osteotomy. Drill and tap before osteotomy.
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- 3 tendons - pectoralis minor, coracobrachialis, and short head of the biceps brachii muscles
- 4 ligaments - coracoclavicular, coracohumeral, coracoacromial ligaments, transverse scapular ligament
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- 5-8cm distal to coracoid process
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- Likely the anterior circumflex artery is injured
- I will need to extend proximally, may need a midclavicle osteotomy to assess the axillary artery
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Deltoid Split Approach (McKenzie Approach)
- Danger – Axillary nerve
- Incision – 5cm longitudinal from tip of acromion down lateral arm
- Dissection – Split deltoid muscle – avoid >5cm to protect axillary nerve → reach the Supraspinatus attachment and GT
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Posterior Judet Approach
- InterNervous plane – Infraspinatus (SS nerve) and Teres minor (axillary)
- Dangers (2) – SS nerve in suprascapular notch, axillary nerve and posterior circumflex artery in quadrangular space
- Position – Lateral
- Incision – Along scapular spine and curved inferior medially
- Dissection – Expose and sharp dissect deltoid off scapular spine → Identify ISP (superior) and TM (inferior) → retract TM inferiorly together with the quadrangular and triangular space away → joint capsule
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Shoulder Arthroscopy
- Position – Beach chair, aware of padding, face padding, slow inclination
- Portals
- Posterior - 2cm inferior and medial to posterior corner of acromion; aim towards coracoid process
- Plane is within INFRASPINATUS
- Anterior portal just above subscapularis in rotator interval
- Superior portal
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- Skin, subcutaneous tissue, DELTOID, subdeltoid BURSA, INFRASPINATUS, joint capsule
- Medially by lateral coracoid base, superiorly by inferior edge of supraspinatus, inferiorly by the superior border of the subscapularis
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Clavicle Anterior Approach
- Position - Supine, sand bag between medial border of scapula and spine
- Incision - Along the subcutaneous clavicle
- Dissection - Skin, fascia, platysma muscle, try to preserve supraclavicular nerves
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When you walk, they will lead you; when you lie down, they will watch over you; and when you awake, they will talk with you. Proverbs 6:22