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The features of congenital elevation of the scapula are described for a group of 16 children. Fibrous bands which tether the scapula and limit its movements were discovered in most children. Vertical displacement osteotomy of the medial border of the scapula and division of the fibrous attachments have provided a reliable and safe treatment for 12 children during the past 10 years.
We studied the position and rotational changes associated with elevation of the glenohumeral joint, using a three-dimensional magnetic-field tracking system on nine fresh cadaveric shoulders. The plane of maximal arm elevation was shown to occur 23 degrees anterior to the plane of the scapula. Elevation in any plane anterior to the scapula required external humeral rotation, and maximal elevation was associated with approximately 35 degrees of external humeral rotation. Conversely, internal rotation was necessary for increased elevation posterior to the plane of the scapula. The observed effects of this rotation were to clear the humeral tuberosity from abutting beneath the acromion and to relax the inferior capsular ligamentous constraints. Measurement of the obligatory humeral rotation required for maximal elevation helps to explain the relationship of the limited elevation seen in adhesive capsulitis and after operations which limit external rotation.
Our aim was to determine the most repeatable three-dimensional measurement of glenoid orientation and to compare it between shoulders with intact and torn rotator cuffs. Our null hypothesis was that glenoid orientation in the scapulae of shoulders with a full-thickness tear of the rotator cuff was the same as that in shoulders with an intact rotator cuff. We studied 24 shoulders in cadavers, 12 with an intact rotator cuff and 12 with a full-thickness tear. Two different observers used a three-dimensional digitising system to measure glenoid orientation in the scapular plane (ie glenoid inclination) using six different techniques. Glenoid version was also measured. The overall precision of the measurements revealed an error of less than 0.6 degrees. Intraobserver reliability (correlation coefficients of 0.990 and 0.984 for each observer) and interobserver reliability (correlation coefficient of 0.985) were highest for measurement of glenoid inclination based on the angle obtained from a line connecting the superior and inferior points of the glenoid and that connecting the most superior point of the glenoid and the most superior point on the body of the scapula. There were no differences in glenoid inclination (p = 0.34) or glenoid version (p = 0.12) in scapulae from shoulders with an intact rotator cuff and those with a full-thickness tear. Abnormal glenoid orientation was not present in shoulders with a torn rotator cuff.
BACKGROUND: Scapulothoracic dissociation is an infrequent injury that is often accompanied by neurovascular injuries with a potentially devastating outcome. The aim of this study was to evaluate the functional outcome following scapulothoracic dissociation. METHODS: During a twenty-four-year period, we treated twenty-five patients with a scapulothoracic dissociation. The average age was 32.5 years. The average Injury Severity Score was 22 points. Nine patients had a complete brachial plexus avulsion, and ten had an incomplete brachial plexus avulsion. Three patients died from their associated injuries, and six patients required an above-the-elbow amputation. The outcome was assessed with use of the Short-Form 36-Item Health Survey, and the shoulder function of the patients who had not had an amputation was evaluated with use of the Subjective Shoulder Rating System. The degree of initial scapular lateralization was quantified with the scapula index. RESULTS: The average duration of follow-up was 12.6 years. The physical and mental component summary scores and the scores on the role-physical, general health, vitality, and mental health subscales of the Short-Form 36-Item Health Survey were significantly lower for patients with a complete brachial plexus avulsion (p < 0.05). The Subjective Shoulder Rating System score was also significantly lower in patients with a complete brachial plexus avulsion (33.8 points compared with 72.5 points for the patients with no or an incomplete avulsion, p = 0.046). The average scapula index was 1.29 +/- 0.19. The scores on the Short-Form 36-Item Health Survey scales and the Subjective Shoulder Rating System score did not correlate with the initial scapula index (p > 0.05). CONCLUSIONS: The presence of a complete brachial plexus avulsion is predictive of a poor functional outcome in a patient with a scapulothoracic dissociation. Therefore, we suggest a modification of the classification of the severity of this injury, with complete brachial plexus avulsion considered to be the most severe injury type. LEVEL OF EVIDENCE: Prognostic study, Level II-1 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.
BACKGROUND: Facioscapulohumeral muscular dystrophy causes winging of the scapula and weakness and discomfort of the shoulder. Surgical stabilization of the scapula to the posterior part of the chest wall permits shoulder abduction and flexion by the deltoid muscle. In the present retrospective study, we describe our experience with eleven scapulothoracic fusion procedures that were performed for the treatment of the infantile and adolescent forms of the disease. METHODS: Eleven procedures were performed in eight patients, including four male patients (one of whom had bilateral involvement and three of whom had unilateral involvement) and four female patients (two of whom had bilateral involvement and two of whom had unilateral involvement). One of the female patients had the infantile variant, whereas all other patients had the adolescent form of the disease. The mean age at the time of the eleven operations was seventeen years. The scapula was fused to the thorax in 25 degrees of abduction with use of 16-gauge wires, a plate or washers on the posteromedial scapular surface to prevent wire pull-out, and iliac crest autograft. After a mean duration of follow-up of 6.3 years, all patients were assessed clinically and radiographically. RESULTS: In all cases, scapular winging and shoulder fatigue and pain were initially eliminated. In the first year after the operation, active abduction and flexion of the shoulder improved to a mean of 145 degrees (range, 110 degrees to 160 degrees ) and 144 degrees (range, 130 degrees to 160 degrees ), respectively, from a preoperative mean of 75 degrees (range, 70 degrees to 90 degrees ). At the time of the final assessment (mean, 6.3 years postoperatively), abduction and flexion were maintained at a mean of 139 degrees and 134 degrees , respectively, in seven shoulders; however, in the remaining four shoulders, both of these motions had decreased to a mean of 48 degrees because of progressive loss of deltoid muscle strength. In two cases, prominent subcutaneous wires required trimming. There were no other complications. CONCLUSIONS: Scapulothoracic fusion relieves shoulder fatigue and pain, allows for smooth functional abduction and flexion of the upper extremity, and improves the appearance of the neck and shoulder in patients who have symptomatic scapular winging due to facioscapulohumeral muscular dystrophy. The procedure is associated with a low risk of complications. Progression of the disease affecting the deltoid muscle can cause loss of abduction, but the other benefits of stabilization persist. LEVEL OF EVIDENCE: Therapeutic Level IV.
STUDY DESIGN: Two-group comparison. OBJECTIVE: To compare scapular kinematics during arm elevation between groups distinguished by pectoralis minor resting length. BACKGROUND: Studies have demonstrated that individuals with subacromial impingement have altered scapular kinematics, such as loss of posterior tipping and increased internal rotation. One proposed mechanism for these alterations is an adaptively short pectoralis minor. This anterior scapulothoracic muscle may impact normal scapular kinematics if adaptively short. METHODS AND MEASURES: Fifty volunteers without shoulder pain were divided into long or short groups according to normalized pectoralis minor resting length. An electromagnetic motion capture system determined the angular orientation of the scapula, humerus, and trunk during arm elevation in 3 separate planes. Groups were compared for 3-dimensional scapular orientation relative to the trunk at arm elevation angles of 30 degrees, 60 degrees, 90 degrees, and 120 degrees, using a mixed-model analysis of variance (ANOVA). RESULTS: There were statistically significant interaction effects between group and arm elevation angle for scapular tipping in all planes of arm elevation, with the scapula for the short group staying anteriorly tipped at higher angles. There was also a significant interaction for scapular internal rotation at lower arm elevation angles in the coronal plane only, with individuals with a shorter pectoralis minor demonstrating a more internally rotated scapula. CONCLUSIONS: The group distinguished by a short pectoralis minor demonstrated scapular kinematics similar to the kinematics exhibited in earlier studies by subjects with shoulder impingement. These results support the theory that an adaptively short pectoralis minor may influence scapular kinematics and is therefore a potential mechanism for subacromial impingement.
The kinematics of scapula and shoulder joint movements were analyzed in three species of arboreal quadrupedal primates using cineradiography. Our findings indicate that scapular movement is highly important for forelimb movement in primates with this ancestral mode of locomotion. Retroversion of the scapula (syn. caudal rotation or extension) during the stance phase contributes more than 40% to the stride length of the forelimb. Lateral forelimb excursions, a general feature for arboreal primates, are based on complex three-dimensional scapular movements guided by the clavicle. Humeral abduction is achieved by scapular abduction and transversal rotation of the scapula about its longitudinal axis, and is therefore strikingly different from humeral abduction in humans. At the same time, the movements of the shoulder joint are limited to flexion and extension only.
PURPOSE OF THE STUDY: The serratus anterior, innervated by the long thoracic nerve, participates in shoulder abduction and elevation, stabilizing the scapula on the rib cage. Paralysis of the serratus anterior prohibits shoulder abduction and elevation beyond 90 degrees and elevation of the spinal border of the scapula. We report our experience with traumatic serratus anterior palsy. MATERIAL AND METHODS: Our series included 16 patients with traumatic unique injury to the long thoracic nerve. Mean age of the patients at the time of the accident was 27.6 years. Seven patients were not operated on due to total or partial spontaneous recovery. Scapulothoracic arthrodesis or scapulopexy was performed in nine patients. RESULTS: For the non-operated patients, mean elevation was 125 degrees at diagnosis and 145 degrees at five years follow-up with a Constant score of 85 and muscle force reaching 83% (12 kg shoulder abduction) of the healthy side. Outcome was rated very good in 4 patients, and good, fair and poor in one each. For the operated patients, elevation was 95 degrees preoperatively and 104 degrees at last follow-up. At four years follow-up mean values were: elevation 104 degrees, Constant score 75, muscle force 72% (9 kg shoulder abduction) of the healthy side. An infection required a revision procedure in one patient who recovered successfully. Outcome was rated very good in six patients and good in three. DISCUSSION: Several types of treatment have been proposed for serratus anterior palsy: non-operative care, muscle transfers mainly with pectoralis major flaps, and scapulothoracic arthrodesis. Most of the series on scapulothoracic arthrodesis have concerned fascioscapulohumeral dystrophy and cannot be compared with our patients. Data in the literature on muscle transfers, which could be considered as comparable with our trauma injuries, have demonstrated good results for shoulder motion but a limited effect on overall muscle force. In our series, scapulothoracic arthrodesis provided good results for muscle force, pain relief, and overall shoulder function, with shoulder motion being limited by the position of the arthrodesed scapula. We propose this type of treatment for serratus anterior palsy mainly for manual laborers.
PURPOSE OF THE STUDY: The purpose of this work was to propose an objective radiographic evaluation of the antero-inferior gleno-humeral ligament for comparison with the clinical assessment proposed by Gagey. MATERIAL AND METHODS: A test radiogram was obtained from 32 healthy volunteers (15 men, 17 women, mean age, 29 years, age range 21-54 years) free of shoulder disease. The dynamic test image consisted in a strictly AP view of the shoulder in forced abduction in neutral rotation. The subjects were awake and in dorsal decubitus. Displacements of the scapulo-thoracic articulation were limited by a counter-force applied to the acromion, in accordance with the method described by Gagey. Bilateral images were obtained for comparison. Several angles were measured between the humeral shaft and the scapula to search for the most reliable and reproducible measurement. RESULTS: Three series of angles were measured between the axis of the humeral shaft and the scapula. The mean angle between the axis of the humeral shaft and line drawn from the lower rim of the glenoid cavity to the lateral border of the scapular tubercle was 130.3 degrees (range 110-148 degrees) on the dominant side and 131.5 degrees (108-148 degrees) on the non-dominant side; giving 38 degrees variability on the dominant side and 40 degrees variation on the non-dominant side and a standard deviation of 10.4 degrees on the dominant side and 11.5 degrees on the non-dominant side. The mean difference in gleno-humeral abduction was 3.8 degrees (range 0-14 degrees) between the dominant and non-dominant side. DISCUSSION: Among the different angles measured between the scapula and the humerus, the angle between the axis of the humeral shaft and the line drawn from the lower rim of the glenoid cavity to the lateral border of the scapular tubercle was the most reliable and reproducible. Inter-observer measurements were well correlated. We observed that the variability in the radiographic values of the scapulo-humeral angle was much greater than the clinical values described by Gagey who, finding very constant values during forced abduction, described "invariable" scapulo-humeral abduction of the shoulder. Our study demonstrates that scapulo-humeral abduction is not an invariable parameter. More interestingly, the difference in amplitude between the dominant and non-dominant sides showed very strong interindividual correlation. Interobserver variability was low and reproducibility was good. CONCLUSION: This dynamic radiographic test enables a precise quantified assessment of pure gleno-humeral abduction which depends on the antero-inferior gleno-humeral ligament. This test is reliable and reproducible. Variations in the length of the antero-inferior gleno-humeral ligament evaluated radiographically were greater than described clinically. We did not find any difference in pure gleno-humeral abduction greater than 14 degrees between the dominant and non-dominant sides in healthy subjects.
We report a case of complex reconstruction after traumatic loss of bone and muscle of the upper third of the humerus. A composite flap using the lateral border of the scapula and the pediculated latissimus dorsi muscle was used. The latissimus dorsi flap covered the bony reconstruction and enabled elbow flexion. Outcome was very satisfactory at three years follow-up. The lateral border of the scapula is rarely used for bony reconstruction of the humerus. Free composite flaps with the lateral portion of the scapula and the latissimus dorsi muscle have been used to reconstruct tissue loss of the lower limb. We were unable to find another published case where this composite pediculated flap was used for the upper limb.
Measurements on 319 macerated scapulae showed a size of the surface of the glenoid cavity between 3.5 and 9.7 cm2. We tried also to evaluate the size of this surface in living humans. This is principally possible, but in 10% of all scapulae there is an error range of more than +/- 1 cm2. The error range in small scapulae (greater than 5 cm2) can be reduced to +/- 0.58 cm2. The shoulder joint is not a ligament but a muscle dependent joint. Therefore the adhesion in this joint, relying on the smaller surface is very important. The small surface of cavitas glenoidalis in the context of habitual shoulder dislocation could be an important role.
The distal scapula and proximal humerus from each shoulder of nine adult dogs were slab-sectioned, cleaned of soft tissues, embedded in white plastic and stained black with a silver stain. These preparations were then photographed for automated, digital, morphometric analysis of subchondral bone structure. Comparison of transverse and coronal sections through the left and right shoulders demonstrated essential isometry of trabecular patterns within each bone. Comparison of the scapula and humerus revealed significant differences in bony architecture. The subchondral plate was an average of 5.6 times thicker under the glenoid fossa than in the opposing humeral head. Deeper trabecular structure also differed with the trabecular bone volume (density) in the humerus being greater than that in the scapula. This difference reflects a greater trabecular density in the humerus with comparable trabecular thickness in both bones. These structural differences are consistent with previous functional studies of the same two bones that revealed greater mechanical stiffness beneath the glenoid fossa and greater hydraulic resistance within the humeral head.
Elevation of the scapulohumeral joint can be executed by two different and distinct systems, both capable of separately performing this movement. The deltoid muscle is composed of several parts contracting independently, sometimes antagonistically between them and providing elevation in different directions. Parts two and three (Fick) of the deltoid are essential because they are lateral to the centers of rotation and work in the plane of the scapula. The supraspinatus and adjacent muscle system can produce compensatory movements with full elevation in the plane of the scapula. Lateral rotation is absolutely necessary for abduction in the coronal plane. Rotatory muscles inserted on the tuberosities of the proximal part of the humerus are more efficient than those inserted on the humeral diaphysis. Vertical and horizontal stabilization of the humeral head in the glenoid fossa is the result of a complex balance between several muscles and passive factors. Trapezius and serratus anterior are essential for the rotation of the scapula around its centers of rotation.
Two men, aged 68 and 77 years, had metastases of carcinoma in pagetic bones. These cases were initially diagnosed clinically as Paget's sarcoma. Roentgenograms, scintigrams, and bone puncture biopsy specimens (BPBs) of the right scapula and the sacrum, respectively, showed only Paget's disease. However, an additional BPB obtained with the aid of computed axial tomography (CAT) revealed the presence of metastases of lung carcinoma in the right scapula and of a carcinoma of probable prostatic origin in the pagetic sacrum in the other. The observations testify to the usefulness of CAT-directed BPB when Paget's sarcoma is suspected, especially in cases located in the scapula, pelvis, or spine.
Motion analyses by a NAC Selgraph, electromyographic examination and measurement of intraarticular pressure during shoulder elevation were done in this study. Abnormal patterns during shoulder motion were analysed and compared with normal patterns. Results are as follows; A "floating phenomenon" in which the scapula adducts as soon as the arm elevates and then begins to abduct disappears in cases with "rotator interval" lesion: the scapula abducts immediately when the arm elevates. Disappearance of the "floating phenomenon" depends on higher activity of the upper trapezius observed in EMG. Anterior and middle fibers of the deltoid are highly active in normal individuals. At arm elevation of 110 degrees the upper trapezius joins the activity. On the other hand, it is the upper trapezius that mainly acts in cases with "rotator interval" lesion. The intra-articular pressure in the early phase of arm elevation depends on the opening of the "rotator interval" and on the abduction of the scapula. Abnormal patterns of should movement in cases with "rotator interval" lesion are almost normalized after surgery.
The combined paresis of the musculus trapezius and musculus serratus anterior results in a positional change and major loss of active mobility of the shoulder girdle. This greatly disturbs the mechanics of movement of the upper arm. The individual signs include a lowering of the shoulder blade in ventro-caudal direction in accordance with the weight of the arm, as a result of the absence of muscular restraint. In this position, the scapula exercises so to say an adducting action on the upper arm, so that this will usually not exceed an abduction of about 40 degrees, in relation to the perpendicular line of C7, althoug it may be freely mobile in the glenohumeral joint. Increase of elevation of the upper arm and of the force exercised by the musculature acting on the glenohumeral joint can be achieved via a correction of the position of the shoulder girdle associated with simultaneous stabilization of the shoulder blade at the posterior thoracic wall. Using an actual case as basis, scapulothoracic arthrodesis in the modification according to Spira is described as a method to correct the position of the shoulder blade and to stabilize the scapula. Other possibilities of stabilization in the form of musculature transpositions and paresis operations are discussed. The article also comments on the indication of scapula fixation.
Searching for a muscle stretch reflex that is innervated by the high cervical cord, the authors discovered the scapulohumeral reflex (Shimizu)--SHR (Shimizu). The testing maneuver, localization of the reflex center, its clinical significance, and the designation of the SHR (Shimizu) are dealt with in this report. The SHR is elicited by tapping the tip of the spine of the scapula and acromion in a caudal direction. The SHR is classified as hyperactive only when an elevation of the scapula or an abduction of the humerus have been clearly defined after tapping at these points. Two hundred twenty-five patients with cervical spine disorders, 90 normal individuals, and 17 patients with cerebrovascular strokes were examined. The incidence of hyperactive SHR was highest among several neurologic abnormalities in spastic cases with craniovertebral or high cervical lesions, and all cases with hyperactive SHR in the cervical spine disorder group exhibited neural compressive factors at the high cervical region. The major muscles participating in the SHR are considered to be the upper portion of the trapezius, the levator scapulae, and the deltoid. According to the anatomic level of compressive factors and the postoperative course of the activity in hyperactive SHR cases, the reflex center of the SHR is clinically presumed to be located between the posterior arch of C1 and the caudal edge of the C3 body. Hyperactive SHR provides useful information about dysfunctions of the upper motor neurons cranial to the C3 vertebral body level.
Primary and secondary reconstruction of mandibular continuity defects with vascularized bone is currently the standard of care at many institutions. The most commonly utilized donor sites for such bone flaps include the scapula, iliac crest, fibula, and radius. Recently, interest has grown in the placement of osseointegrated implants into these flaps to facilitate functional dental rehabilitation. There are no studies comparing the bone available from each of these flaps into which osseointegrated implants can be placed. In this cadaver study, the dimensions of bone available for implant placement from the iliac crest, scapula, fibula, and radius osseous flaps were measured. The iliac crest and fibula flaps had bone dimensions consistently adequate for implant placement. Bone available for the safe placement of implants into the scapula flap was found in the majority of specimens. The radius flap group had the highest number of specimens that were inadequate for implant placement. The majority of the specimens with bone inadequate for implantation were from females. Clinical implications of this study regarding flap selection are discussed.