Surgical Approaches to the Shoulder and Elbow

Shoulder and elbow approaches are common in trauma, arthroplasty, instability, sports surgery, reconstruction and infection surgery. They are high-yield because a small technical error can produce a large functional problem: deltoid weakness, subscapularis failure, elbow instability, ulnar neuropathy, posterior interosseous nerve palsy, triceps insufficiency or disabling stiffness.

The approach must be chosen from the problem, not from habit. A deltopectoral shoulder exposure is versatile, but it is not the best answer for every proximal humerus target. A lateral elbow approach is logical for radial head and capitellar work, but a complex distal humerus fracture may need posterior articular visualisation. A posterior elbow incision can be combined with several different triceps strategies, each with different exposure and morbidity.

Good approach planning answers three questions:

• What must be exposed? Joint, column, tuberosity, glenoid, coronoid, radial head, humeral shaft or implant.
• What must be protected? Nerve, vessel, tendon, ligament, cuff, deltoid, triceps and skin envelope.
• What must be repaired? Subscapularis, capsule, rotator interval, LUCL, MCL, triceps or olecranon osteotomy.

The shoulder and elbow are soft-tissue dependent joints. The shoulder depends on the deltoid, rotator cuff, subscapularis, capsule and glenoid version; the elbow depends on congruent articular anatomy, collateral ligaments, capsule, triceps and early motion. An approach that damages these structures can compromise the reconstruction.

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Shoulder region

Key structures:

• Cephalic vein: marks the deltopectoral interval; it may be taken medially or laterally depending preference and exposure.
• Deltoid: primary power muscle for elevation; denervation or detachment failure is disabling.
• Pectoralis major: medial boundary of the deltopectoral interval.
• Conjoint tendon: landmark for deep anterior shoulder exposure; excessive medial retraction risks musculocutaneous nerve traction.
• Subscapularis: must be managed carefully in arthroplasty and instability surgery; failure causes weakness, pain and anterior instability.
• Axillary nerve: at risk with inferior shoulder dissection, deltoid splitting and aggressive retraction.
• Rotator cuff footprint: critical during tuberosity fixation, cuff repair and proximal humerus surgery.

Elbow region

Key structures:

• Ulnar nerve: vulnerable in medial and posterior elbow exposure; preoperative symptoms must be documented.
• Posterior interosseous nerve: vulnerable during lateral elbow approaches, radial neck work and distal extension.
• Lateral ulnar collateral ligament: protects against posterolateral rotatory instability; if released, it must be repaired.
• Medial collateral ligament: primary valgus stabiliser; important in medial elbow exposure and coronoid work.
• Triceps: posterior exposure strategy determines articular visualisation and postoperative extension strength.
• Capsule: release improves exposure but can destabilise the elbow if collateral structures are not repaired.

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Internervous planes matter because they allow exposure without denervating a muscle group. Some approaches use true internervous intervals; others are muscle-splitting or tendon-reflecting approaches that are safe only if the split is limited and the repair is reliable.

The preoperative assessment should decide whether the planned approach is safe and adequate.

History

• Previous operations, scars, infection, instability surgery, arthroplasty or fracture fixation.
• Current pathology: trauma, arthritis, instability, cuff disease, infection, tumour or nonunion.
• Neurological symptoms: deltoid weakness, lateral arm numbness, ulnar nerve paraesthesia, radial/PIN weakness.
• Functional requirements: overhead work, sport, manual labour, transfers, walking aid use.
• Anticoagulation, diabetes, smoking, inflammatory disease and wound-healing risk.

Examination

• Shoulder: deltoid function, axillary sensation, cuff strength, subscapularis tests, active and passive range, instability signs and skin condition.
• Elbow: range of motion, ulnar nerve symptoms, intrinsic hand function, PIN function, collateral stability, swelling, open wounds and soft-tissue envelope.
• Trauma: vascular status, compartments, open wounds, contamination, associated fractures and reduction urgency.

What must be documented

• Baseline nerve function before surgery.
• Skin scars and intended incision relationship.
• Vascular status.
• Open-wound location and whether it conflicts with definitive exposure.
• Active motion and stiffness, especially at the elbow.

Imaging should answer the exposure question, not just confirm the diagnosis.

Radiographs

• Shoulder trauma series: AP, scapular Y and axillary or modified axillary view.
• Elbow AP and lateral views, with radiocapitellar and ulnohumeral alignment.
• True lateral elbow radiographs for dislocation, coronoid, olecranon and distal humerus work.
• Long humerus views when shaft extension or radial nerve risk is relevant.

CT

CT is especially useful for:

• proximal humerus fracture pattern and tuberosity involvement
• glenoid bone loss or posterior glenoid deformity
• scapula and glenoid fractures
• distal humerus articular comminution
• radial head and capitellar fractures
• coronoid fracture morphology
• preoperative planning for osteotomy or revision implants

MRI and ultrasound

MRI is useful when rotator cuff, subscapularis, labrum, capsule, infection extension or muscle quality changes the operation. Ultrasound can assess cuff integrity in selected patients but does not replace CT for fracture morphology.

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Shoulder approach selection

Elbow approach selection

Positioning must allow exposure, reduction, imaging, implant insertion and safe anaesthesia access. A perfect incision is not enough if fluoroscopy, reduction tools or the assistant cannot work.

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Shoulder positioning

• Beach-chair: common for arthroplasty, instability and cuff surgery; check head, neck, blood pressure and arm access.
• Supine with bump: useful for deltopectoral exposure and fracture work when fluoroscopy is needed.
• Lateral decubitus: common for arthroscopy and some posterior work; protect pressure points and brachial plexus traction.
• Prone or floating shoulder setups: selected scapula and posterior shoulder exposures.

Elbow positioning

• Supine with arm across chest: useful for lateral elbow, radial head and selected distal humerus work.
• Lateral decubitus: common for posterior distal humerus exposure; arm supported over bolster.
• Prone: useful for posterior elbow and distal humerus exposure; confirm anaesthetic and airway access.
• Hand table or arm board: useful for medial/lateral elbow approaches and fluoroscopy.

Red flags after surgery

• New deltoid paralysis or lateral arm numbness.
• New PIN palsy with finger/thumb extension weakness.
• Worsening ulnar nerve symptoms.
• Loss of elbow stability after lateral approach.
• Inability to actively extend elbow after posterior approach.
• Wound breakdown over olecranon or shoulder incision.
• Increasing pain, fever, drainage or acute stiffness suggesting infection or haematoma.

Differentiating a new postoperative nerve deficit

A new motor or sensory deficit after an upper limb approach must be localised quickly, because the differential ranges from a recoverable traction neurapraxia to a divided nerve needing exploration. The pattern of weakness usually points to the nerve at risk for that specific approach.

Postoperative care depends on what was repaired, not only on the skin approach.

Shoulder

• Protect subscapularis repair after arthroplasty or instability surgery according to repair method.
• Monitor axillary nerve and deltoid function.
• Start passive and active-assisted motion according to reconstruction stability.
• Avoid early resisted internal rotation after subscapularis repair.
• Follow fracture fixation or arthroplasty radiographs when indicated.

Elbow

• Balance soft-tissue healing against the high risk of stiffness.
• Check ulnar, radial/PIN and median nerve function after surgery.
• Use a hinged brace when stability or ligament repair requires protection.
• Begin controlled motion as early as fixation and soft-tissue repair permit.
• Monitor olecranon osteotomy fixation, triceps repair and wound pressure points.

Outcomes are determined by pathology, patient factors, surgical execution and rehabilitation. The approach contributes by enabling reduction or reconstruction while minimising additional morbidity.

Shoulder outcomes depend on restoration of stable arthroplasty mechanics, tuberosity/cuff healing, subscapularis function, deltoid function and avoidance of nerve injury. A well-executed deltopectoral approach is repeatable and versatile, but poor subscapularis management can create pain, weakness and instability. A deltoid split can be efficient for lateral targets, but nerve injury is a major failure.

Elbow outcomes depend on articular reduction, stability, ulnar nerve status, triceps function and early motion. For distal humerus fractures, an exposure that gives inadequate articular visualisation can compromise reduction; an exposure that gives excellent visualisation but creates triceps or osteotomy morbidity must be justified and repaired well.

There is no single international guideline that prescribes a specific shoulder or elbow approach; exposure choice is a surgeon-led decision governed by anatomy, pathology and the registry-level evidence on the underlying operation. The unifying principles are universal: document preoperative nerve status, position safely, choose exposure from imaging, protect named structures and plan early rehabilitation.

Global epidemiology and burden

Proximal humerus fractures are among the most common fragility fractures, typically third behind hip and distal radius fractures in older adults, and most are managed without an open approach at all. Distal humerus fractures show a bimodal distribution (high-energy young men, low-energy elderly women) and are rising with population ageing. This epidemiology drives the global debate over when an operative exposure is even warranted, which is the backdrop to approach selection.

Side-by-side guidance and registry evidence

Practice variation

• When to expose at all: PROFHER and related trials shifted many displaced proximal humerus fractures towards non-operative care, reducing deltopectoral exposures in elderly patients while reverse shoulder arthroplasty (deltopectoral) has grown for selected complex patterns.
• Subscapularis strategy: practice varies between tenotomy, peel and lesser tuberosity osteotomy; the evidence supports any well-executed and well-repaired technique.
• Triceps and ulnar nerve handling in the elbow: olecranon osteotomy versus triceps-sparing exposures, and in situ versus transposed ulnar nerve, remain surgeon-preference decisions supported by Level I and IV evidence rather than mandated by guideline.
• System factors: implant availability, trauma network maturity, orthoplastic support and rehabilitation access drive much of the international variation in exposure and timing.

Local practice reminders

• Document neurological findings clearly before shoulder and elbow trauma surgery.
• Discuss complex elbow trauma early with surgeons experienced in elbow reconstruction when available.
• Plan rehabilitation access before procedures that need early supervised motion.
• In arthroplasty, use the approach and implant system that the treating team can perform reliably and revise safely.