Name:
Deltoid Split (Mckenzie) Approach To The Shoulder
Description:
Deltoid Split (Mckenzie) Approach To The Shoulder
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/08a3450c-3503-4aa7-ad68-3266e0e52a92/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H07M44S
Embed URL:
https://stream.cadmore.media/player/08a3450c-3503-4aa7-ad68-3266e0e52a92
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/08a3450c-3503-4aa7-ad68-3266e0e52a92/Deltoid Split (Mckenzie) Approach to the Shoulder.mp4?sv=2019-02-02&sr=c&sig=jvlEIyYL0akGl9NLmae12EybutXVu4HCKZylFRFFYmA%3D&st=2024-12-04T19%3A03%3A47Z&se=2024-12-04T21%3A08%3A47Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. Today, I'm going to show the deltoid split approach which is, which I commonly use for fixation of proximal humerus fractures, but can also be used for doing shoulder replacement, especially the reverse shoulder. Patient is in a beach chair position and I always draw my, mark the anatomic landmarks, the acromion and where my incision is going to be.
BIJAYENDRA SINGH: And then roughly about 6 to 7cm from the lateral edge of the acromion to give an approximate idea of where the axillary nerve is likely to be. So as the skin and the fascia for about 8 to 10cm, almost at the entry of one third. The posterior to third junction or even a bit more anterior than that.
BIJAYENDRA SINGH: Getting adequate hemostasis is key, then you start to deeper dissection. I lift thick flaps off both the anterior and posterior skin folds right up to the deep fascia and because this skin and the soft tissue is fairly mobile, you can manipulate the arm and have access to deeper tissues with a relatively smaller incision.
BIJAYENDRA SINGH: Once I've done that, then I identify the bony edge of the lateral edge of the acromion, and the AC joint is also palpated. From there, I incise the fascia with the deltoid right up to the AC joint to allow me adequate exposure.
BIJAYENDRA SINGH: So now incising the deep fascia over the acromion to the full thickness and also to the deltoid. Normally just go to the facial part of the deltoid with the diathermy and then use my dissecting scissors to open up the muscle layer and normally if it's a fresh injury, we'll get the fracture hematoma drain through.
BIJAYENDRA SINGH: After that, I further split the deltoid with the scissors. The first five centimeters or so is fairly safe to do and then I would normally put a self retainer in this split to allow easy visualization. Make sure you get adequate hemostasis. Now I'm going to peel some of the fascia both on the front edge as well as on the posterior edge to get some exposure over the acromion
BIJAYENDRA SINGH: once I've done that. Sometimes you may find a thick bursa, which needs to be excised. After this, I use an osteotome. A charcot is often used to perform this osteotomy of the acromion. If I'm fixing, sometimes I take a small sliver of the acromium.
BIJAYENDRA SINGH: How to provide a bit more room at the anterior edge. At the end, I normally do the trans-osseos repair using non-absorbable suture. Once I've done the osteotomy, then I further split the deltoid. Now, this is quite an important step to identify the axillary nerve.
BIJAYENDRA SINGH: Start my finger posterior superiorly and try and feel, feel the band of the axilliary nerves. Comes out of the, the space from the posterior side of the arm running under the surface of the deltoid anteriorly. And this technique I've used, even in cases where either I've had to revise or to remove the metalwork occasionally, this easy identification of the axillary nerve as it's not stuck or fibrous in the posterior aspect of the arm. Then put my finger under the axillary nerve and dissect above my finger.
BIJAYENDRA SINGH: Take care not to completely skeletonize the nerve, but dissect enough muscle off so that will facilitate me my fixation and not obscure the fixation. I would then put a vasculus loop around to identify and protect the axillary nerve. Just tie this loop on itself, making a few knots. I never put any arthrotape or any other clip at the end of this loop as it has increased risk of getting tangled
BIJAYENDRA SINGH: and disrupting the axillary nerve. So you've done that, then you can go and do a subdeltoid dissection and you can start to see the fragments of the upper end of the humerus. Can use various ring handled spikes or Hoffman's retractors to provide more access. Once I've identified this, then the fracture is easy to be manipulated.
BIJAYENDRA SINGH: You can see here I'm starting to put some stay sutures in the tuberosities and in the cuff and putting the sutures is important to pass it through the tendon rather than the bony fragments. The number of sutures depends on the size and the number of fragments. I try and put at least three sutures, sometimes maybe four or five.
BIJAYENDRA SINGH: Again, you can see there's some thick bursa, which you must excise to provide adequate exposure. I'm now putting another suture on the posterior aspect of the cuff to control, get control over the fragments. This is a short video just on the approach to the proximal humerus
BIJAYENDRA SINGH: as you can see in this fracture. For more in depth technique for fixation, please look at my other videos. Thank you.
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