Introduction Overview This approach can be a fairly extensile exposure, allowing access to the anterior, medial, and lateral aspects of the shoulder. Can be extended distally to incorporate the anterior approach to the humerus Indications shoulder arthroplasty proximal humerus fractures (especially 3 and 4 part fractures) reconstruction of recurrent dislocations long head of the biceps injury septic glenohumeral joint Internervous plane Internervous plane deltoid muscle (axillary nerve.) pectoralis major (medial and lateral pectoral nerve) Position Beach chair position or supine with an ipsilateral scapular bump Approach Incision an incision is made following the line of the deltopectoral groove In obese patients, this may be difficult to palpate; the incision starts at the coracoid process, which is usually more easily palpable a 10-15 cm incision is usually utilized, but is sized according to surgical need and size of patient Superficial dissection attention must be paid to superficial skin vessels, as these can bleed significantly the deltopectoral fascia is encountered first ; the cephalic vein is surrounded in a layer of fat and is used to identify the interval the cephalic vein can be mobilized either medially or laterally, depending on patient factors and surgeon preference. fibers of the deltoid are retracted laterally and the pectoralis major is retracted medially Deep dissection the short head of the biceps and coracobrachialis arise from the coracoid process and are retracted medially. The musculocutaneous nerve enters the biceps 5-8cm distal to the coracoid process; retraction of the conjoint tendon must be done with care. the fascia on the lateral side of the conjoint tendon is incised to reveal the subscapularis External rotation puts the subscapularis fibers on stretch the subscapularis may be released from its insertion on the lesser tuberosity through the tendon or via an osteotomy the capsule is then incised (as needed) to enter the joint Dangers Musculocutaneous nerve renters medial side of biceps muscle 5-8 cm distal to coracoid (stay lateral) can have neurapraxia if retraction is too vigorous Cephalic vein should be preserved if possible; if injured, can ligate Helpful to be preserved as anatomical landmark in case of revision cases needing same approach Axillary nerve at risk with release of subscapularis tendon (runs distal and medial to) or with incision of teres major tendon or latissimus dorsi tendon (runs proximal to) Anterior circumflex humeral artery runs anteriorly around the proximal humerus cephalad to pectoralis major tendon