Surgical Approaches to the Scapula and Shoulder

By Dr. Zubair Khalid, DVM, MS, PhD · 2026-08-11

Key Takeaways

• Surgical approaches to the scapula and shoulder in dogs and cats are dictated by the specific anatomical location of the lesion, prioritizing adequate exposure for fracture repair or joint stabilization while minimizing iatrogenic trauma. Key considerations include fracture pattern for scapular approaches (body, spine, acromion, neck) and joint pathology for shoulder approaches (instability, osteochondritis dissecans).
• The choice of surgical approach is guided by anatomical landmarks and muscular intervals, with lateral approaches utilizing the scapular spine and acromion, and medial approaches relying on the serratus ventralis and subscapularis muscles. Nerve proximity, particularly the suprascapular nerve near the scapular notch and the axillary nerve caudal to the joint, necessitates careful dissection and retractor placement to prevent injury.
• Implant placement for scapular fractures requires biomechanical consideration; plates are contoured to the lateral surface, particularly along the spine and neck, with screws directed away from the joint. Shoulder stabilization procedures depend on the approach's ability to facilitate accurate implant positioning for the specific instability.
• Common complications include iatrogenic suprascapular nerve injury, characterized by subtle proprioceptive deficits and later muscle atrophy, and avascular necrosis of the scapular spine or acromion due to excessive periosteal stripping. Early detection involves serial postoperative radiographic and clinical assessments.
• The evidence base for optimal fixation methods and rehabilitation protocols for scapular fractures is largely derived from retrospective studies and expert opinion, with limited prospective comparative trials. Referral to a surgical specialist is warranted for comminuted intra-articular glenoid fractures, significant articular surface involvement, or brachial plexus deficits.

This article details the surgical approaches to the scapula and shoulder joint in dogs and cats, with emphasis on the dissection planes, muscular intervals, and implant placement considerations relevant to fracture repair and joint-stabilizing procedures. The content serves the practising veterinarian who performs or assists in these procedures, and it answers the practical question of which exposure is appropriate for a given lesion and how to achieve that exposure safely. The approaches are described in a sequence that follows the regional anatomy from superficial to deep, and from the scapular spine to the joint capsule.

The scapula is an uncommon fracture site in small animals, but when it occurs, the fracture pattern dictates the approach. The shoulder joint, by contrast, is approached frequently for conditions ranging from instability to osteochondritis dissecans. The surgeon must balance exposure against iatrogenic trauma to the surrounding musculature, and the choice of approach often determines whether adequate implant placement is possible. The following sections provide the anatomical foundation, the specific approaches, and the clinical decision points for each exposure.

At a Glance

Anatomical Foundations of Scapular and Shoulder Exposure

The scapula is a flat, triangular bone with a prominent spine on its lateral surface. The spine divides the lateral aspect into the supraspinous and infraspinous fossae, which house the corresponding muscles. The medial surface is covered by the subscapularis muscle and provides attachment for the serratus ventralis. The scapular neck is the narrow region distal to the supra- and infraspinous fossae, and it is a common fracture location. The acromion projects distally from the spine and serves as the origin for the acromial part of the deltoideus muscle.

The shoulder joint is a simple hinge joint with a wide range of motion, stabilized primarily by the surrounding musculature instead of by ligamentous constraints. The joint capsule is thin and capacious, and it attaches proximal to the glenoid rim and distal to the humeral head. The biceps brachii tendon runs through the intertubercular groove and is an important intra-articular structure. The suprascapular nerve passes through the scapular notch on the cranial border of the scapula, and the axillary nerve courses caudomedial to the joint before innervating the deltoideus and teres muscles. Both nerves are at risk during surgical approaches, and their positions must be considered when placing retractors or implants.

The muscular anatomy dictates the surgical intervals. The lateral surface of the scapula is covered by the supraspinatus cranially and the infraspinatus caudally, with the deltoideus overlying the distal portion of both. The teres major and the long head of the triceps lie caudal to the joint. The medial surface is covered by the subscapularis, with the serratus ventralis attaching along the dorsal border. The omotransversarius and trapezius muscles attach to the spine and provide superficial landmarks for skin incisions.

Biomechanical Considerations for Implant Placement

The scapula is subjected to bending and torsional loads during weight bearing, and the thin nature of the scapular body limits the options for implant placement. Screws placed in the scapular body have limited purchase, and plates must be contoured to the lateral surface, where the bone is thickest along the spine and the neck. The scapular neck is the strongest region and is the preferred site for screw placement when the fracture involves the body or the neck itself. For fractures of the acromion or the spine, tension band fixation is often appropriate, and the approach must expose the dorsal border to allow accurate reduction.

The shoulder joint is a low-friction joint with a large range of motion, and the goal of surgical exposure is to allow visualization of the articular surfaces without destabilising the joint. The lateral approaches provide good access to the cranial and lateral aspects of the joint, while the medial approach is reserved for specific lesions of the medial compartment. The choice of approach also affects the ability to place implants for stabilization procedures, such as those used for medial or lateral shoulder instability. The surgeon must plan the approach based on the preoperative imaging and the intended procedure, instead of adapting the procedure to the exposure.

The regenerative and tissue-engineering literature has explored the use of bone marrow derived mesenchymal stem cells for skeletal repair, including in the context of fracture healing. While these approaches are not yet standard for scapular fractures, the principles of biological fixation and preservation of the soft tissue envelope remain relevant to the choice of surgical approach. The clinical application of bone marrow mesenchymal stem cells for skeletal tissue repair summarizes the current state of these therapies, and the surgeon should be aware that preserving the muscular attachments and blood supply to the scapula is a prerequisite for any biological healing response. The global burden of fractures, as documented in the systematic analysis from the Global Burden of Disease Study 2019, underscores the clinical importance of fracture management across species, although the specific epidemiology of scapular fractures in dogs and cats is not well characterized.

Patient Positioning and Preparation

The patient is positioned in lateral recumbency with the affected limb uppermost for most approaches to the lateral scapula and shoulder. The limb is draped free to allow manipulation during the procedure, and the forelimb is suspended or held by an assistant to provide traction and rotation. For medial approaches, the patient is positioned in dorsal recumbency with the limb abducted, or in lateral recumbency with the limb elevated and externally rotated. The draping must include the entire scapular region, extending from the dorsal midline to the elbow, to allow extension of the incision if needed.

The skin incision is planned along the scapular spine for lateral approaches, curving distally toward the acromion and the shoulder joint. For medial approaches, the incision is made along the cranial border of the scapula or directly over the joint, depending on the target structure. The surgeon must identify the superficial muscles before deepening the dissection, and the use of a periosteal elevator is often necessary to reflect the trapezius and omotransversarius from the scapular spine. The positioning and preparation steps are consistent with the specialist summaries of surgical conditions and procedures provided by the American College of Veterinary Surgeons, which emphasize the importance of adequate exposure and atraumatic technique.

Approach Selection by Procedure

The choice of surgical approach depends on the target structure, the planned implant, and the fracture configuration. Table 1 summarizes the standard indications for each approach.

For most scapular body fractures, a lateral approach with elevation of the supraspinatus and infraspinatus from the scapular spine provides adequate exposure for plate application. Fractures of the scapular neck require a craniolateral approach with partial tenotomy of the supraspinatus insertion. Glenoid fractures involving the articular surface demand an arthrotomy, and the specific quadrant of the glenoid dictates whether a craniolateral, caudal, or medial approach is preferred.

Patient size and body condition alter the practical execution of these approaches. In small-breed dogs and cats, the entire scapula can be exposed through a single lateral incision. In large-breed dogs, the scapular spine and the supraspinous fossa may require separate fascial incisions to avoid excessive tension on the skin retractors. Obese patients obscure the acromion and the scapular spine as palpable landmarks, and fluoroscopic guidance or a larger incision is advisable.

Lateral Approach to the Scapular Body and Spine

This approach is the workhorse for scapular body fractures and for plate application along the scapular spine. The patient is positioned in lateral recumbency with the affected limb uppermost and the forelimb draped free to allow manipulation.

The skin incision begins over the dorsal third of the scapular spine and extends distally to the acromion, then curves slightly cranially over the shoulder joint. The subcutaneous fascia is incised along the same line. The superficial pectoral and omotransversarius muscles are identified at the cranial border of the scapula and retracted cranially. The trapezius muscle is incised along its attachment to the scapular spine, leaving a small cuff of tendon on the bone for closure. The underlying rhomboideus muscle is elevated from the dorsal border of the scapula.

The supraspinatus and infraspinatus muscles are then elevated subperiosteally from their respective fossae. Elevation begins at the scapular spine and proceeds toward the cranial and caudal borders. The suprascapular nerve runs through the supraspinous fossa and must be identified and protected. The nerve is most vulnerable where it passes around the cranial border of the scapular neck.

For plate application along the scapular spine, the spine itself provides a thick, strong anchor for screws. The plate is contoured to the spine, and screws are placed through the plate into the spine and the adjacent fossae. The scapular body is thin centrally, and screws placed there have poor purchase. The thicker regions are the spine, the cranial and caudal borders, and the supraglenoid tubercle.

The incision is closed by reapposing the trapezius and rhomboideus muscles to the scapular spine with interrupted sutures. The subcutaneous tissue and skin are closed routinely. The supraspinatus and infraspinatus muscles are not sutured to each other, they are held in position by the overlying fascia and the closure of the trapezius.

Craniolateral Approach to the Shoulder Joint

The craniolateral approach provides access to the cranial and lateral aspects of the glenoid, the biceps tendon origin, and the cranial joint capsule. It is used for cranial glenoid fractures, biceps tenodesis, and arthrotomy for joint exploration.

The skin incision is centerd over the acromion and extends proximally along the scapular spine and distally along the cranial border of the humerus. The subcutaneous fascia is incised. The acromial head of the deltoideus muscle is identified and retracted caudally. The supraspinatus muscle is retracted cranially. The infraspinatus tendon is identified caudal to the joint and may be retracted caudally or partially tenotomised for greater exposure.

The joint capsule is incised parallel to the glenoid rim, starting at the supraglenoid tubercle and extending caudally. The biceps tendon is identified within the joint as it courses over the cranial glenoid rim. The tendon of origin is evaluated for fraying or partial avulsion.

For supraglenoid tubercle avulsion fractures, the supraspinatus tenotomy approach is preferred. The supraspinatus tendon is incised transversely near its insertion on the tubercle, and the tubercle fragment is exposed. The fragment is reduced and fixed with a tension band wire or a small screw. The supraspinatus tendon is repaired with a locking loop or three-loop pulley pattern.

The craniolateral approach can be extended proximally by elevating the supraspinatus from the scapular neck, which converts it into a craniolateral approach to the scapular neck. This extension is useful for scapular neck fractures that extend into the glenoid.

Caudal Approach to the Shoulder Joint

The caudal approach exposes the caudal glenoid rim, the teres minor origin, and the caudal joint capsule. It is used for caudal glenoid fractures and for procedures addressing caudal shoulder instability.

The skin incision is centerd over the acromion and extends distally along the caudal border of the humerus. The acromial head of the deltoideus is incised at its origin on the acromion and reflected distally. The infraspinatus tendon is identified and retracted cranially. The teres minor muscle is identified caudal to the joint and retracted caudally.

The joint capsule is incised parallel to the caudal glenoid rim. The caudal glenoid rim and the origin of the long head of the triceps are visualized. The axillary nerve runs caudal to the joint and must be protected during deep dissection.

Closure requires reattachment of the acromial head of the deltoideus to the acromion. This is accomplished with bone tunnels through the acromion or with a suture anchor. The infraspinatus and teres minor are not sutured to each other.

Medial Approach to the Shoulder Joint

The medial approach is technically demanding and is reserved for medial glenoid fractures, subscapularis tendon repair, and medial shoulder instability. The patient is positioned in lateral recumbency with the affected limb dependent and the contralateral limb retracted dorsally.

The skin incision is centerd over the medial aspect of the shoulder joint, extending from the cranial border of the scapula to the proximal humerus. The superficial pectoral muscle is identified and retracted cranially. The deep pectoral muscle is incised at its insertion on the humerus and reflected caudally. The brachial plexus and the axillary artery and vein are identified and retracted caudally with a blunt retractor.

The subscapularis tendon is identified crossing the medial joint capsule. The tendon is incised near its insertion on the lesser tubercle, and the joint capsule is opened. The medial glenoid rim and the medial joint capsule are exposed.

The neurovascular bundle is at significant risk during this approach. The musculocutaneous nerve and the axillary nerve pass close to the operative field. Retraction must be gentle and intermittent to avoid traction injury.

Closure involves repair of the subscapularis tendon with a locking loop pattern. The deep pectoral muscle is reapposed to its insertion with bone tunnels or suture anchors. The superficial pectoral muscle is closed routinely.

Approach Selection Checklist

The following sequence guides approach selection for a given fracture or procedure.

1. Confirm the fracture location with orthogonal radiographs or CT. Classify the fracture as scapular body, scapular neck, glenoid, acromial, or supraglenoid tubercle.
2. Determine whether the articular surface is involved. Articular fractures require an arthrotomy and anatomic reduction.
3. Identify the specific quadrant of the glenoid involved. Cranial and lateral quadrants are accessed craniolaterally. Caudal quadrants require a caudal approach. Medial quadrants require a medial approach.
4. Assess the planned implant. Plates require exposure of the scapular spine or the thick borders. Tension band wires require exposure of the acromion or supraglenoid tubercle.
5. Evaluate patient size and body condition. Small patients may be adequately exposed with a single incision. Obese patients may require a larger incision or additional retraction.
6. Consider concurrent soft tissue injury. Biceps tendon pathology is addressed through a craniolateral approach. Medial instability requires a medial approach.
7. Select the approach that provides the most direct access to the fracture with the least soft tissue dissection. When two approaches provide equivalent access, choose the one with which the surgeon is most experienced.

The medial approach carries the highest risk of iatrogenic neurovascular injury and should be undertaken only when the target structure cannot be reached through another approach. The craniolateral approach is the most versatile and is the default choice for most shoulder arthrotomies. The lateral approach to the scapular body is the default for scapular body fractures. The caudal approach is used selectively for caudal glenoid pathology. The supraspinatus tenotomy approach is specific to supraglenoid tubercle avulsions.

Postoperative radiographs are obtained to confirm reduction and implant position. The limb is supported in a sling for 2 to 4 weeks after procedures involving tendon repair or osteotomy. Passive range of motion exercises begin after the first recheck examination. Return to full activity is guided by radiographic evidence of healing, typically at 6 to 8 weeks for scapular body fractures and 8 to 12 weeks for glenoid fractures.

Recognized Complications and Early Detection

Scapular and shoulder surgery carries specific failure modes that differ from appendicular long bone work. The most consequential is iatrogenic injury to the suprascapular nerve, which courses around the scapular notch and can be compressed by malpositioned screws or retractors. Early detection relies on serial postoperative assessment of shoulder extension and weightbearing, since suprascapular denervation produces subtle proprioceptive deficits before overt muscle atrophy appears at 2 to 3 weeks.

Avascular necrosis of the scapular spine or acromion occurs when dissection strips the periosteum beyond the fracture zone. The clinical sign is delayed union with progressive lameness beyond 8 weeks. Radiographic monitoring at 4 and 8 weeks should compare callus formation against the expected timeline for the specific fracture configuration.

Infection after open shoulder arthrotomy presents with persistent incisional drainage, heat, and worsening lameness after initial improvement. Synovial fluid analysis and culture are indicated when these signs appear, since septic arthritis can destroy articular cartilage within days. The ACVS small animal surgical resources emphasize that postoperative swelling that increases beyond day 3 warrants aspiration instead of observation.

Implant failure, particularly screw pullout from the thin scapular body, manifests as acute recurrence of lameness after a period of improvement. Radiographs with orthogonal views and a skyline projection of the scapula are required to detect subtle implant migration that oblique views may obscure.

Common Errors and Corrective Actions

The most frequent error in scapular fracture repair is inadequate exposure of the caudal scapular border, leading to screw placement outside the bone or into the glenoid. Corrective action is to extend the incision proximally and elevate the teres major and subscapularis as a single muscular unit, which provides visual confirmation of the caudal border before drilling.

Less experienced surgeons often misidentify the acromial branch of the omocervical artery during the lateral approach. The vessel crosses the surgical field at the level of the acromion and, when transected, retracts into the surrounding muscle and can bleed persistently. The corrective step is to identify and ligate this vessel before osteotomy of the acromion, instead of attempting to control hemorrhage after transection.

Overzealous retraction during the craniolateral shoulder approach can stretch the axillary nerve, which passes deep to the subscapularis. The resulting sign is postoperative knuckling of the distal limb. Prevention requires periodic release of retraction during the procedure and confirmation that the nerve is not trapped between retractor blades.

A common error in medial approaches is failure to identify and protect the median and musculocutaneous nerves as they cross the surgical field. Students should be taught to palpate the neurovascular bundle before sharp dissection and to use blunt dissection parallel to the nerve orientation.

Limitations of Current Evidence

The evidence base for scapular surgical approaches in small animals is largely derived from cadaveric studies and retrospective case series instead of prospective comparative trials. Expert opinion differs on whether acromial osteotomy is necessary for adequate glenoid exposure, with some surgeons advocating routine osteotomy and others reserving it for fractures involving the supraglenoid tubercle.

There is genuine uncertainty regarding the optimal fixation method for scapular body fractures. Some authorities favour plate fixation along the spine, while others recommend a combination of lag screws and neutralisation plates. The choice currently depends on fracture configuration and surgeon preference instead of high-quality comparative data. The broader orthopedic literature on bone healing, including work on bone marrow mesenchymal stem cell applications in skeletal repair, suggests that biological augmentation may eventually influence decision-making, but clinical translation in veterinary scapular fractures remains investigational.

Postoperative rehabilitation protocols for shoulder surgery are similarly understudied. The MSD Veterinary Manual provides general guidance on controlled exercise and physiotherapy, but specific timelines for return to full activity after scapular fracture repair are not evidence based.

Referral and Escalation Criteria

Referral to a surgical specialist is warranted for comminuted intra-articular fractures of the glenoid, fractures with more than 50 percent articular surface involvement, and fractures associated with brachial plexus deficits. These cases require arthrotomy with direct visualization of the articular surface and often benefit from advanced imaging that is not available in general practice.

Specialist consultation is also appropriate when a previously repaired fracture fails to unite by 12 weeks, when implant loosening is identified on follow-up radiographs, or when a second surgical procedure is contemplated. Revision surgery on the scapula carries higher morbidity than primary repair, and the margin for error is reduced by prior scar tissue.

Laboratory involvement is indicated when postoperative infection is suspected. Aerobic and anaerobic culture of synovial fluid or deep tissue samples, with antimicrobial susceptibility testing, should guide therapy. The AVMA professional practice resources provide guidance on antimicrobial stewardship that is relevant to perioperative prophylaxis and treatment of confirmed infections.

Regulatory reporting is rarely required for scapular surgery in companion animals. However, if an implant failure is traced to a manufacturing defect, reporting to the relevant national adverse event system is appropriate. For practices in jurisdictions that follow WOAH terrestrial animal health standards, any unusual clustering of surgical site infections should be investigated and reported according to local requirements.

Troubleshooting Table

Frequently Asked Questions

How Do I Choose Between a Lateral and Medial Approach for Scapular Fracture Repair?

The fracture configuration dictates the approach. Lateral exposure of the scapular body and spine suits most diaphyseal and spinal fractures, as it permits plate application along the tension surface. Medial approaches are reserved for fractures involving the subscapular fossa or when the medial cortex requires direct visualization for reduction. Commit to the approach that exposes the entire fracture length, since inadequate exposure is a leading cause of malreduction. Preoperative computed tomography, when available, clarifies the fracture plane and helps you select the side of implant placement. If the fracture extends into the supraglenoid tubercle or glenoid, combine the lateral approach with a craniolateral arthrotomy to address articular involvement in the same field.

What Can I Do When Locking Plates Are Unavailable?

Conventional plates remain serviceable when applied with attention to contouring. A reconstruction plate or a cuttable plate can be bent to match the scapular spine and body, but contouring must be precise because the bone is thin and the plate will not maintain reduction if it stands proud. Use cortical screws placed in the thicker regions of the scapula, namely the spine, the supraglenoid tubercle, and the caudal angle. If the bone is too thin for screw purchase, consider cerclage wire or a tension band construct for avulsion fractures of the supraglenoid tubercle. External coaptation is rarely sufficient for scapular fractures and should be reserved for non-displaced, stable injuries in small patients.

How Does the Approach Differ in Cats Compared with Dogs?

The same surgical planes exist in cats, but the smaller dimensions demand scaled instruments and finer implants. Retraction force must be gentler because the supraspinatus and infraspinatus muscles are thin and tear easily. The scapular spine is less prominent in cats, which makes plate contouring more challenging and increases the appeal of smaller cuttable plates or wire fixation. The shoulder joint capsule is proportionally tighter, so a craniolateral approach may require a more generous tenotomy of the supraspinatus tendon to achieve adequate joint visualization. Postoperative activity restriction is shorter in cats, but the same staged physiotherapy protocol applies. Always confirm implant size against the patient's body weight and bone dimensions before committing to a construct.

What Should I Document in the Surgical Record for These Procedures?

Record the approach used, the muscles incised or retracted, and the method of closure for each layer. Note the implant type, size, and position, including the number of screws placed on each side of the fracture. Document the range of motion achieved at the shoulder after fixation, as this guides postoperative physiotherapy. Include a description of any iatrogenic trauma, such as partial muscle tearing or neuropraxia of the suprascapular nerve, and the steps taken to address it. Photographs of the exposure and final construct are valuable for client communication and for review if complications arise. The American College of Veterinary Surgeons practice resources emphasize clear operative documentation as part of standard surgical care.

How Do I Explain the Need for Surgery to a Client Who Is Hesitant?

Focus on the functional consequences of non-operative management. Scapular fractures that are displaced or involve the joint surface will not heal in an acceptable alignment, and the result is chronic lameness, muscle atrophy, and shoulder stiffness. Explain that the goal of surgery is to restore the normal alignment so the muscles of the shoulder can work effectively again. Describe the recovery timeline honestly, including the period of strict confinement and the gradual return to activity. Mention that complications such as implant loosening or infection are uncommon but possible, and that follow-up radiographs are part of the protocol. The MSD Veterinary Manual provides client-facing summaries that can reinforce your explanation.

When Should I Refer a Scapular Fracture Case instead of Operate Myself?

Refer when the fracture involves the glenoid or supraglenoid tubercle with articular displacement, because these require precise reduction and specialised implants. Refer also when the fracture is comminuted and extends into the scapular neck, where the margin for error is small and the risk of iatrogenic injury to the suprascapular nerve is high. If you lack locking plates or a full set of small fragment instruments, referral is appropriate for any fracture that cannot be stabilized with the equipment you have. Consider your own caseload and experience honestly. A stable, non-displaced fracture in a small patient may be managed conservatively, but a displaced fracture that you cannot fix well is better referred early than revised later.

Related Clinical & Scientific Guides

• Perioperative Antibiotic Prophylaxis: Timing and Selection
• Surgical Approaches to the Femur and Stifle
• Fracture Healing Assessment: Radiographic and Clinical Evaluation

References and Further Reading

• Clinical Application of Bone Marrow Mesenchymal Stem/Stromal Cells to Repair Skeletal Tissue.. 2020.
• Global, regional, and national burden of bone fractures in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019.. 2021.
• Animal Models of Bone Metastasis.. 2015.
• Reconstruction of segmental mandibular defects: Current procedures and perspectives.. 2019.
• American College of Veterinary Surgeons Animal Health Resources. American College of Veterinary Surgeons.
• MSD Veterinary Manual, Professional Edition. MSD Veterinary Manual.
• American Veterinary Medical Association Practice Resources. American Veterinary Medical Association.
• WOAH Terrestrial Animal Health Code. WOAH.

Related Articles

• Surgical Approaches to the Femur and Stifle
• Surgical Approaches to the Humerus and Elbow
• Surgical Approaches to the Mandible and Maxilla
• Surgical Approaches to the Pelvis and Acetabulum
• Surgical Approaches to the Long Bones: Radius and Tibia

This article is educational professional reference material for veterinary audiences. It is not a substitute for veterinary diagnosis, individual clinical judgment, current product labeling, or applicable regulatory requirements.