Surgical Approaches to the Shoulder and Elbow
High-yield overview
Choose the exposure that reaches the pathology while protecting function
Targetpathology determines the exposure
Nervename the danger nerve before incision
Repairclosure protects stability and power
Approach Families
Shoulder joint
PatternDeltopectoral, superior or posterior exposures depending on pathology.
TreatmentCommon targets include arthroplasty, instability, proximal humerus fracture and posterior glenoid work.
Proximal humerus
PatternDeltopectoral, deltoid-splitting, anterolateral or posterior humeral extensions.
TreatmentChosen by tuberosity involvement, head access, implant plan and axillary nerve safety.
Lateral elbow
PatternKocher, Kaplan and extensile lateral exposures.
TreatmentUsed for radial head, capitellum, lateral column, instability and selected fracture-dislocation patterns.
Distal humerus and medial elbow
PatternPosterior, medial, paratricipital, triceps-splitting, triceps-reflecting and olecranon osteotomy exposures.
TreatmentChosen by articular visualisation requirement, ulnar nerve status, triceps management and fixation plan.
Critical Must-Knows
- Do not describe an approach as a skin incision only. A safe answer includes position, landmarks, interval, danger structures, exposure target and repair.
- Deltopectoral shoulder exposure is a true internervous plane between deltoid and pectoralis major, but cephalic vein, musculocutaneous nerve and axillary nerve still matter.
- Deltoid-splitting exposure is limited by the axillary nerve on the deep surface of deltoid; excessive distal extension risks deltoid paralysis.
- Lateral elbow exposure requires deliberate choice between Kocher and Kaplan, with specific attention to the posterior interosseous nerve and lateral ligament complex.
- Posterior distal humerus exposure is a triceps-management decision: triceps-sparing, triceps split, triceps reflection or olecranon osteotomy.
Clinical Pearls
- "A named approach is not enough. Explain why that approach reaches the specific target better than the alternatives.
- "For shoulder surgery, loss of deltoid, cuff or subscapularis function can be more disabling than the scar.
- "For elbow surgery, the approach must preserve stability and allow early motion; stiffness is a major enemy.
- "If a ligament or tendon insertion is divided for exposure, the repair is part of the operation, not an optional closing step.
The approach can create the complication
Wrong exposure, excessive retraction, missed nerve baseline, poor soft-tissue repair or inadequate articular visualisation can cause the failure. The safest approach is the one that gives enough access without sacrificing the structures needed for postoperative function.
At a Glance Table
Shoulder and Elbow Approach Selection
| Problem | Common target | Approach options | Main danger |
|---|---|---|---|
| Shoulder arthroplasty | Glenohumeral joint and proximal humerus | Deltopectoral most common; superior or posterior in selected cases | Subscapularis failure, axillary nerve injury, instability |
| Anterior instability surgery | Capsulolabral complex and subscapularis interval | Deltopectoral open exposure or arthroscopic portals | Musculocutaneous nerve, axillary nerve, subscapularis management |
| Greater tuberosity or selected proximal humerus fixation | Lateral proximal humerus and rotator cuff insertion | Deltoid-splitting or deltopectoral depending fracture pattern | Axillary nerve and deltoid dysfunction |
| Radial head or capitellum fracture | Radiocapitellar joint | Kocher or Kaplan lateral elbow approach | Posterior interosseous nerve and LUCL |
| Coronoid or medial elbow pathology | Medial trochlea, coronoid, sublime tubercle, MCL | Medial approach through or around flexor-pronator mass | Ulnar nerve and medial antebrachial cutaneous nerve |
| Complex distal humerus fracture | Articular surface and both columns | Posterior approach with triceps-sparing, triceps split, triceps reflection or olecranon osteotomy | Ulnar nerve, triceps dysfunction, osteotomy complications and stiffness |
Mnemonic
SAFERDescribe Any Upper Limb Approach
| S | Set-up Position, table, arm support, tourniquet, imaging and access for reduction. |
| A | Anatomy Landmarks, interval, nerve supply and structures at risk. |
| F | Field What part of the joint or bone must be seen and why. |
| E | Extension How to safely extend exposure or change plan if the target is not reached. |
| R | Repair Capsule, tendon, ligament, triceps, subscapularis or deltoid closure. |
| S | Set-up Position, table, arm support, tourniquet, imaging and access for reduction. | E | Extension How to safely extend exposure or change plan if the target is not reached. |
| A | Anatomy Landmarks, interval, nerve supply and structures at risk. | R | Repair Capsule, tendon, ligament, triceps, subscapularis or deltoid closure. |
| F | Field What part of the joint or bone must be seen and why. |
Hook:A good approach answer should be safe before it is detailed.
Mnemonic
AMURUpper Limb Nerve Check
| A | Axillary Shoulder and deltoid-splitting approaches. |
| M | Musculocutaneous Deep medial retraction in anterior shoulder exposure. |
| U | Ulnar Medial and posterior elbow exposure. |
| R | Radial/PIN Lateral elbow, humeral shaft and distal extension. |
| A | Axillary Shoulder and deltoid-splitting approaches. | U | Ulnar Medial and posterior elbow exposure. |
| M | Musculocutaneous Deep medial retraction in anterior shoulder exposure. | R | Radial/PIN Lateral elbow, humeral shaft and distal extension. |
Hook:Before shoulder and elbow surgery, know the nerve at risk.
Overview/Epidemiology
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 exposure should match the operation
Do not choose an approach because it is familiar. Choose it because it gives direct access to the reduction, implant, reconstruction or debridement target with acceptable risk.
Anatomy/Biomechanics
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.
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.
Function is part of the anatomy
The deltoid, subscapularis, LUCL, MCL and triceps are not simply structures crossed during exposure. They are functional stabilisers and power units. If they are divided, their repair must be planned before they are divided.
Internervous Plane
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.
Intervals and Planes
| Approach | Plane | Practical consequence |
|---|---|---|
| Deltopectoral shoulder | Deltoid supplied by axillary nerve; pectoralis major supplied by pectoral nerves | True internervous interval, but deep retraction still risks musculocutaneous and axillary nerves |
| Deltoid-splitting proximal humerus | Muscle split through deltoid fibres | Not a full internervous plane; distal split is limited by axillary nerve |
| Posterior shoulder | Deltoid/cuff split or interval depending technique | Useful for posterior glenoid and scapular work; protect axillary and suprascapular nerve regions |
| Kocher elbow | Anconeus and ECU | Common lateral elbow interval; protect PIN and preserve or repair LUCL |
| Kaplan elbow | ECRB and EDC | More anterior radiocapitellar access; PIN risk increases with distal/anterior dissection |
| Posterior elbow | Triceps management strategy rather than a single internervous plane | Exposure depends on triceps-sparing, triceps split, reflection or olecranon osteotomy |
An interval is not a permission slip
Even a true internervous plane can become unsafe if retraction is aggressive, the incision is extended in the wrong direction, or the surgeon forgets the deep nerve course.
Clinical Assessment
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.
Investigations
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.
Use imaging to prove the approach
If the plan is a lateral elbow approach, imaging should show that the target is lateral or radiocapitellar. If the plan is posterior distal humerus exposure, CT should justify the need for articular visualisation and column fixation.
Approach Selection
Shoulder approach selection
Shoulder and Proximal Humerus Choices
| Target | Preferred exposure | Why | Avoid if |
|---|---|---|---|
| Primary shoulder arthroplasty | Deltopectoral | Reliable anterior access to humeral head, glenoid and subscapularis management | Severe anterior scarring or unusual pathology requiring posterior access |
| Open anterior instability | Deltopectoral | Access to subscapularis, capsule and anterior glenoid | Poor soft tissues or arthroscopic procedure preferred |
| Isolated greater tuberosity fixation | Deltoid-splitting or deltopectoral | Lateral split gives direct tuberosity access; deltopectoral is more extensile | Complex fracture requiring head, lesser tuberosity or arthroplasty access |
| Three-part or four-part proximal humerus fracture | Usually deltopectoral | Better anterior access to tuberosities, head, bicipital groove and conversion options | Poor soft tissue may require staged or alternative strategy |
| Posterior glenoid or scapular pathology | Posterior shoulder or Judet-type exposure | Direct posterior access | Anterior pathology alone |
Elbow approach selection
Elbow Approach Choices
| Target | Preferred exposure | Why | Key risk |
|---|---|---|---|
| Radial head | Kocher or Kaplan | Direct radiocapitellar access | PIN injury, LUCL injury |
| Capitellum | Kaplan or extensile lateral | More anterior radiocapitellar visualisation | PIN with distal anterior dissection |
| Coronoid anteromedial facet | Medial approach through or around FCU/flexor-pronator mass | Direct access to medial coronoid and sublime tubercle | Ulnar nerve and MCL |
| Distal humerus articular surface | Posterior approach with chosen triceps strategy | Bicolumnar fixation and articular reduction | Ulnar nerve, triceps morbidity, stiffness |
| Simple olecranon fracture | Posterior subcutaneous approach | Direct access to olecranon | Prominent metalwork and wound problems |
Patient Positioning
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.
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.
Position before prepping
Check fluoroscopy, tourniquet access, reduction manoeuvres, plate trajectory and the planned extension of exposure before the limb is prepared and draped.
Surgical Technique
Universal approach steps
- Confirm the procedure, side, imaging and implants.
- Review baseline nerve function.
- Position the patient and confirm fluoroscopy before preparing the limb.
- Mark landmarks and planned extension lines.
- Incise through safe skin and subcutaneous planes.
- Identify the planned interval before deep dissection.
- Protect named nerves and vessels deliberately.
- Confirm the exposure reaches the target before committing to fixation or reconstruction.
- Repair divided stabilisers, tendons, capsule or osteotomy.
- Document the approach, structures protected and repair performed.
The bailout plan should exist before the incision
If a deltoid split is inadequate, do not extend distally into the axillary nerve zone. Convert or extend safely. If a posterior elbow exposure is inadequate, change the triceps strategy deliberately rather than tearing through the interval.
Complications
Complications by Approach Family
| Approach | Key complications | Prevention |
|---|---|---|
| Deltopectoral shoulder | Cephalic vein bleeding, musculocutaneous traction, axillary nerve injury, subscapularis failure, stiffness | Gentle retraction, know nerve course, reliable subscapularis repair, rehabilitation plan |
| Deltoid split | Axillary nerve injury, deltoid weakness, inadequate exposure, cuff injury | Limit distal split, blunt dissection, convert if inadequate |
| Posterior shoulder | Axillary or suprascapular nerve risk, deltoid/cuff morbidity, stiffness | Precise anatomy, avoid aggressive medial retraction, repair cuff/deltoid |
| Lateral elbow | PIN palsy, LUCL insufficiency, radiocapitellar stiffness, heterotopic ossification | Controlled distal dissection, ligament repair, early safe motion |
| Medial elbow | Ulnar neuropathy, MABCN neuroma, valgus instability, stiffness | Document baseline, protect cutaneous nerves, plan ulnar nerve handling, repair MCL/flexor-pronator |
| Posterior elbow | Ulnar neuropathy, triceps weakness, olecranon nonunion, prominent metalwork, stiffness | Secure nerve strategy, robust triceps/osteotomy repair, early motion when safe |
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.
Differential of New Postoperative Upper Limb Nerve Deficit
| Nerve | Approach most associated | Typical motor sign | Sensory sign | Usual cause and action |
|---|---|---|---|---|
| Axillary | Deltoid split, inferior shoulder dissection | Weak shoulder abduction, deltoid wasting | Numb lateral upper arm (regimental badge) | Traction or split too distal; if no recovery on serial review, image and consider exploration |
| Posterior interosseous | Lateral elbow (Kocher / Kaplan) | Weak finger and thumb extension, wrist drifts radially (wrist extension preserved) | No sensory loss (motor nerve) | Distal or supinated dissection; observe a neurapraxia, explore if division suspected |
| Ulnar | Medial and posterior elbow | Weak intrinsics, weak FDP to ring/little finger, clawing | Numb little and ulnar ring finger | Mobilisation, tight transposition or kinking; check construct, may settle by 12 months |
| Musculocutaneous | Deltopectoral with deep medial retraction | Weak elbow flexion and supination | Numb lateral forearm | Conjoint-tendon over-retraction; usually traction neurapraxia, relieve retraction |
| Radial (main trunk) | Distal humeral extension / shaft | Wrist drop, weak finger and thumb extension | Numb dorsal first web space | Spiral-groove handling; protect and document, explore if iatrogenic division suspected |
Postoperative Care
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.
The elbow hates immobilisation
The elbow stiffens quickly. A good operation includes a realistic motion plan that protects fixation and repair while avoiding unnecessary prolonged immobilisation.
Outcomes/Prognosis
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.
Evidence Base
Surgical Exposures of the Shoulder
Chalmers PN, Van Thiel GS, Trenhaile SW • Journal of the American Academy of Orthopaedic Surgeons (2016)
Key Findings:
- Open shoulder surgery is challenging because the deltoid and rotator cuff envelop the joint, and in most approaches exposure is limited by the proximity and importance of the axillary nerve.
- Deltopectoral, deltoid-splitting and posterior approaches each have distinct advantages, disadvantages and risks, with variations and extensions of each.
- Mastery of all three exposures gives the surgeon flexibility to address the widest variety of pathology.
Clinical Implication: Shoulder approach teaching should focus on pathology-specific exposure and protection of deltoid, cuff and axillary nerve function.
Surgical Exposures of the Humerus
Zlotolow DA, Catalano LW 3rd, Barron OA, Glickel SZ • Journal of the American Academy of Orthopaedic Surgeons (2006)
Key Findings:
- No truly safe fully extensile approach to the humerus exists because the spiralling radial nerve crosses the posterior midshaft; the nerve must be mobilised at the spiral groove for maximal exposure.
- The anterolateral approach uses an internervous plane between axillary and deltoid nerves proximally and radial and musculocutaneous nerves distally; deltopectoral remains the most widely used proximal exposure.
- Distal intra-articular exposure depends on triceps mobilisation by olecranon osteotomy or triceps release, coupled with triceps-splitting or paratricipital extension.
Clinical Implication: When extending shoulder exposure into the humerus, the radial and axillary nerve courses must be considered before any distal extension.
Subscapularis tenotomy versus lesser tuberosity osteotomy in TSA (RCT)
Levine WN, Munoz J, Hsu S, Byram IR, Bigliani LU, Ahmad CS, et al. • Journal of Shoulder and Elbow Surgery (2019)
Key Findings:
- 60 shoulders randomised to subscapularis tenotomy or lesser tuberosity osteotomy during anatomic total shoulder arthroplasty for primary osteoarthritis.
- No significant difference in range of motion or clinical outcome scores at one year between the two techniques.
- Lesser tuberosity osteotomy healed more reliably (bone-to-bone union in 93.1%) than tenotomy (no full-thickness tear in 86.7% on ultrasound), but added operative and repair time.
Clinical Implication: Subscapularis management during the deltopectoral approach is a deliberate decision: both tenotomy and lesser tuberosity osteotomy give comparable function, but the chosen technique must be repaired securely and protected in rehabilitation.
Acromion-axillary nerve distance: safe zone for the deltoid-splitting approach
Yildirim C, Demirel M, Bayram E, Ekinci M, Yilmaz M • Journal of Orthopaedic Surgery and Research (2022)
Key Findings:
- In 37 patients undergoing proximal humerus fixation, mean acromion-axillary nerve distance was 6 cm (range 5.5-6.6 cm) and the axillary nerve index (nerve distance / arm length) averaged 0.18.
- The axillary nerve position was predictable from anatomy in only 18% of patients, underlining wide individual variation.
- A zone of 5.5 cm distal to the anterolateral edge of the acromion can be regarded as the safe limit for an anterolateral deltoid-splitting incision.
Clinical Implication: Keep the deltoid split within roughly 5 cm of the acromion; beyond this, deliberately identify and protect the axillary nerve rather than relying on a fixed measurement.
Clinical Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
Scenario 1: Deltopectoral approach for shoulder arthroplasty
CLINICAL PROMPT
"You are asked to describe a deltopectoral approach for shoulder arthroplasty."
PRACTICAL APPROACH
I would position the patient in beach-chair or supine with the shoulder accessible and confirm imaging if needed. I would mark the coracoid, deltopectoral groove, clavicle and acromion. The incision follows the deltopectoral interval. I identify the cephalic vein and preserve it with either the deltoid or pectoral side. I develop the interval between deltoid and pectoralis major, release clavipectoral fascia as required, protect the conjoint tendon and avoid excessive medial retraction because of the musculocutaneous nerve. I manage the biceps and rotator interval, expose subscapularis by the chosen technique, protect the axillary nerve inferiorly, perform the arthroplasty, then repair subscapularis and soft tissues securely. I would document nerve function and protect subscapularis repair during rehabilitation.
KEY CLINICAL POINTS
Position and landmarks first.
True internervous plane between deltoid and pectoralis major.
Cephalic vein, musculocutaneous nerve and axillary nerve are key risks.
Subscapularis management and repair are part of the approach.
COMMON PITFALLS
Only describing the skin incision.
Forgetting musculocutaneous nerve risk with medial retraction.
Treating subscapularis repair as optional.
FURTHER QUESTIONS
"How would you manage the subscapularis?"
"How would you test axillary nerve function postoperatively?"
CLINICAL SCENARIOChallenging
Scenario 2: Radial head fracture through a lateral elbow approach
CLINICAL PROMPT
"A patient has a displaced radial head fracture requiring fixation or replacement. Describe the lateral elbow exposure and the structures at risk."
PRACTICAL APPROACH
I would choose a lateral elbow approach because the target is the radiocapitellar joint. I would position the patient supine, lateral or prone depending associated injuries, with the elbow accessible and fluoroscopy available. I would mark the lateral epicondyle, radial head and olecranon. I would choose Kocher between anconeus and ECU or Kaplan between ECRB and EDC depending the required anterior access. The key danger structure is the posterior interosseous nerve, particularly with distal and anterior dissection. I would keep dissection controlled, avoid unnecessary distal extension and protect the lateral ligament complex. If the LUCL, annular ligament or capsule is divided for exposure, I would repair them at closure to avoid posterolateral rotatory instability.
KEY CLINICAL POINTS
Target is radial head or capitellum.
Kocher and Kaplan are different lateral intervals.
PIN protection is central.
LUCL preservation or repair prevents instability.
COMMON PITFALLS
Confusing Kocher and Kaplan intervals.
Ignoring the lateral ligament complex.
Extending distally without a PIN strategy.
FURTHER QUESTIONS
"When would Kaplan be preferred?"
"What happens if the LUCL is not repaired?"
CLINICAL SCENARIOAdvanced
Scenario 3: Complex distal humerus fracture
CLINICAL PROMPT
"CT shows a comminuted intra-articular distal humerus fracture requiring bicolumnar fixation. How do you choose the posterior exposure?"
PRACTICAL APPROACH
I would first define how much articular visualisation is required and whether the fracture can be reduced through triceps-sparing windows. The posterior skin incision is only the superficial exposure; the critical decision is triceps management. If the articular surface can be reduced indirectly, a paratricipital or triceps-sparing approach may reduce extensor mechanism morbidity. If visualisation is inadequate, a triceps split or triceps-reflecting approach may be used. For highly comminuted articular fractures requiring direct visualisation, a chevron olecranon osteotomy may be justified, but it creates an osteotomy that must be fixed securely. I would identify and protect the ulnar nerve as required, obtain stable bicolumnar fixation, repair triceps or osteotomy reliably and start controlled motion as early as safe.
KEY CLINICAL POINTS
Posterior elbow exposure requires a triceps strategy.
Articular visualisation must be balanced against triceps and osteotomy morbidity.
Ulnar nerve strategy should be planned.
Postoperative motion plan is part of the operation.
COMMON PITFALLS
Automatically choosing olecranon osteotomy for every distal humerus fracture.
Not mentioning ulnar nerve handling.
Forgetting triceps or osteotomy repair.
FURTHER QUESTIONS
"What are the complications of olecranon osteotomy?"
"How do you reduce elbow stiffness risk?"
Guidelines, Registries & Global Practice
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
Guideline, Trial and Registry Signals Relevant to Approach Selection
| Body / source | Domain | Signal | Evidence level |
|---|---|---|---|
| PROFHER trial (UK, Rangan et al. 2015, PMID 25756440) | Displaced proximal humerus fracture | No benefit of surgery over non-operative care for most displaced fractures; fewer patients need an open shoulder approach than historically performed | Level I RCT |
| AAOS / shoulder & elbow literature | Subscapularis management in TSA | Tenotomy and lesser tuberosity osteotomy give equivalent function; LTO heals more reliably (Levine RCT, PMID 30771825) | Level I RCT |
| BOA / BOAST (UK) open fracture and trauma standards | Open injuries and trauma pathways | Emphasise early senior decision-making, soft-tissue assessment and orthoplastic input before definitive exposure | Guideline / consensus |
| AO Foundation principles | Distal humerus and elbow trauma | Posterior approaches with a deliberate triceps strategy give bicolumnar access; preserve and protect the ulnar nerve | Expert consensus / technique |
| NICE (UK) non-complex fracture guidance (NG38) | Fracture care pathways | Focus on shared decision-making, imaging and rehabilitation rather than mandating a specific exposure | Guideline |
| National arthroplasty registries (AOANJRR, NJR, Nordic) | Shoulder arthroplasty | Track implant survival and revision; the deltopectoral exposure underpins most anatomic and reverse arthroplasty volume | Registry observational |
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.
Shoulder and Elbow Approach Summary
Clinical summary
Approach Answer
- •Position, imaging and landmarks.
- •Interval or muscle strategy.
- •Danger structures.
- •Exposure target.
- •Repair and rehabilitation.
Shoulder
- •Deltopectoral: deltoid and pectoralis major interval.
- •Protect cephalic vein, musculocutaneous nerve and axillary nerve.
- •Subscapularis repair matters.
- •Deltoid split is limited by axillary nerve safety.
Elbow
- •Kocher: anconeus and ECU.
- •Kaplan: ECRB and EDC.
- •Medial approach: ulnar nerve and MABCN.
- •Posterior approach: choose triceps strategy.
Do Not Miss
- •Baseline nerve function.
- •PIN in lateral elbow exposure.
- •LUCL repair if released.
- •Ulnar nerve in posterior or medial elbow surgery.
- •Early safe motion after elbow surgery.
"Shoulder and elbow approaches should be described as functional exposures: choose the target, use the correct interval, protect the named nerves, repair stabilisers and plan rehabilitation."
References
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