1.    What are the indications for the deltopectoral approach?

The deltopectoral approach affords excellent anterior access to the glenohumoral joint and is used for:

• • Proximal humerus ORIF
  • Arthroplasty
  • Open washout septic glenohumeral joint
  • Open reduction of irreducible anterior dislocations

2.    What is the internervous plane utilised by this approach?

Deltoid (axillary nerve) laterally

Pectoralis major (medial and lateral pectoral nerves) medially

3.    How would you position the patient?

I would utilise the beach chair position. This would include sitting the patient up at 45 degrees, placing two pillows under the knees, and formal head support/head ring reinforced with a crepe bandage.

4.    Where would you make your incision?

An incision is made in the line of the deltopectoral groove, from the coracoid pro- cess, along the deltopectoral groove to the lateral arm.

5.    Talk me through the superficial dissection.

After making my skin incision (as above) I would achieve haemostasis due to the bleeding that can occur from superficial skin vessels and identify the deltopectoral fascia. The cephalic vein lies in a layer of fat and is used to identify the interval between the deltoid and pec major. I would retract the cephalic vein (usually later- ally as the tributaries come from the lateral side) and divide the deltopectoral fascia of the arm.

6.    What about the deep dissection?

• • Identify the coracoid process.
  • Divide the clavipectoral fascia from the coracoid process down along the lateral border of conjoint tendon.
  • Retract conjoint tendon medially, with care taken to avoid overzealous retraction and damage to the musculocutaneous nerve, and retract the deltoid laterally.
  • This will allow for identification of the subscapularis tendon. Externally rotate the arm to put the subscapularis under tension.
  • Place stay sutures in the lateral part of the subscapularis tendon and divide in tendinous portion and take off capsule under tension.
  • Perform a vertical capsulotomy to enter the joint.

7.   What are the dangers of this approach?

• • Musculocutaneous nerve: This enters the coracobrachialis muscle as close as

2.5 cm distal to the tip of the coracoid. Vigorous retraction can lead to damage to this nerve.

7. • Axillary nerve: This is at risk during the incision in the subscapularis tendon, where it lies just distal to the tendon as it wraps around the humerus from lateral to medial.
   • Cephalic vein: This can cause bleeding if damaged intraoperatively, and will increase surgical oedema if damaged and ligated.
8.    How would you extend this approach?

This can be extended distally into an anterior (brachialis splitting) approach to the humerus (see Chapter 65).