Scapulothoracic pathology: review of anatomy, pathophysiology, imaging findings, and an approach to management

Shoulder girdle muscle abscess: Potential routes of spread and surgical management by a dual anterior approach

BACKGROUND

Spontaneous infections involving muscles in the shoulder girdle are uncommon conditions rarely reported in the literature. The large musculature of shoulder girdle, complex communicating spaces into the periscapular region, and late glenohumeral joint involvement can cause delay in diagnosis of infections involving muscular portion of rotator cuff. The method of surgical drainage with involvement of scapulothoracic and subscapular spaces and prognosis can be challenging.

METHODOLOGY

In this descriptive study, we included patients with shoulder girdle muscle abscess and analyzed the spread in the shoulder girdle and arm through various pathways radiologically. Debridement of the abscess in the subscapular muscle and adnexa was done through the dual approach, one with deltopectoral approach for the shoulder girdle and another incision anterior to the latissimus dorsi muscle for inferior subscapular spaces and gravity-dependent drainage of collection.

RESULTS

The causative organism Staphylococcus aureus was isolated only in two patients out of four cases. In repeated collections, axillary and suprascapular nerve palsies were commonly encountered. Adequate debridement, antibiotic cover with vancomycin and clindamycin for six weeks, and rehabilitation restored normal functions of the shoulder in three patients.

CONCLUSION

Unsuspecting nature of the subscapular abscess and similarities with common shoulder conditions at initial presentation often led to extensive shoulder girdle involvement via subscapular space, subcoracoid recess, and scapulothoracic space to adjacent areas. The dual approach provides adequate access to drain the collections in subscapularis muscle, subscapular spaces, and shoulder girdle.

LEVEL OF STUDY

V.

Ultrasound Evaluation and Guided Injection of the Subscapularis and Serratus Anterior Muscles Between the Scapula and the Thoracic Cage: A Technical Note

Most subscapularis and serratus anterior muscles lie between the scapula and the thoracic cage. Evaluation of this area in patients with scapulothoracic dyskinesis, snapping scapular syndrome, or interscapular pain can provide valuable information to clinicians. However, ultrasound scanning of pathologies in this area is hindered by anatomical limitations. In this study, we described a simple patient setup position and scanning method for ultrasound evaluation and guided intervention of the subscapularis and serratus anterior muscles between the scapula and thoracic cage.

Regarding a human costoscapular joint by Prof. Dr. H. von Luschka (1870): A translation

Knowledge of variant anatomy was important during the time of Dr. Hubert von Luschka (1820-1875) and continues to be of relevance in current practice to prevent medical and surgical errors and to improve patient outcomes. Dr. H. von Luschka described an anatomical variant observed in the left scapula of a 40-year-old male: a connection between the medial superior angle of the scapula, piercing through the serratus posterior muscle to connect via a synovial capsule to the articular surface of the thoracic wall. The clinical relevance of this so-called "Luschka's tubercle" of the shoulder continues to be discussed. This translation is intended to broaden access to this hallmark manuscript to a wide audience of English readers. The introduction places the manuscript in the context of historical and current discussions. Three authors, all proficient in the German and English languages and educated in the anatomy of the shoulder, conducted the translation. The skeletal process that is part of the described joint structure appears similar to what is now called Luschka's tubercle. The full structure, including its connecting parts, are not currently included in anatomical nomenclature. In conclusion, Luschka's text and named tubercle continue to contribute to the discussion of scapulothoracic joint disorders.

Arthroscopic scapulothoracic bursectomy with and without superomedial angle scapuloplasty: a comparison of patient-reported outcomes

BACKGROUND

Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding whether or when scapuloplasty should be performed. Prior studies are limited to small case series, and optimal surgical indications are not yet established. The purposes of this study were (1) to retrospectively review patient-reported outcomes of arthroscopic treatment of scapulothoracic bursitis and (2) to compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. We hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement.

MATERIALS AND METHODS

All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through August 2020 were reviewed. Patient demographic characteristics, symptomatology data, physical examination findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores were collected. Comparisons between the group undergoing bursectomy alone and the group undergoing bursectomy with scapuloplasty were made using the Student t test for continuous variables and the Fisher exact test for categorical variables.

RESULTS

Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data were available for 56 of 68 cases (82%). Final postoperative visual analog scale pain scores (3.4 ± 2.2 and 2.8 ± 2.2, respectively; P = .351), American Shoulder and Elbow Surgeons scores (75.8 ± 17.7 and 76.5 ± 22.5, respectively; P = .895), and Simple Shoulder Test scores (8.8 ± 2.3 and 9.5 ± 2.8, respectively; P = .340) were similar between the bursectomy-alone and bursectomy-with-scapuloplasty groups.

CONCLUSION

Both arthroscopic scapulothoracic bursectomy alone and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures showed similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus on 3-dimensional scapular morphology may help optimize patient selection for each of these procedures.

Scapulothoracic separation: A severe injury to the upper extremity

INTRODUCTION AND IMPORTANCE

Scapulothoracic separation is an infrequent ailment marked by the detachment of the upper limb bones from the chest wall, resulting in a range of symptoms. In this report, we present a collection of instances of Scapulothoracic separation.

CASE PRESENTATION

A female patient, aged 35, was referred to our emergency department from a primary healthcare center for treatment following a high-energy motor vehicle accident that occurred two days prior. Upon examination, no vascular damage was detected. Following the critical period, the patient underwent surgery to repair a clavicle fracture. Despite the passage of three months since the surgery, the patient continues to experience functional limitations in the affected limb.

CLINICAL DISCUSSION

The incidence of Scapulothoracic separation.is uncommon and stems from forceful injuries, predominantly resulting from vehicular mishaps. In managing this condition, it is imperative to prioritize the individual's safety and prioritize targeted treatment thereafter.

CONCLUSIONS

The presence or absence of vascular injury determines the need for emergency surgical treatment, while the presence or absence of neurological injury affects the recovery of limb function.

CT-guided scapulothoracic bursal injection-technical considerations in planning needle trajectory and confirming bursal distribution

OBJECTIVE

To describe a technique of targeted CT-guided scapulothoracic bursal injections in an illustrated and step-wise manner.

MATERIALS AND METHODS

This technical report describes the authors' experience in using CT guidance for targeted scapulothoracic bursal injections in 8 patients with suspected scapulothoracic bursitis over an 18-month period.

RESULTS

The outcome of the image-guided injection was retrospectively assessed in 8 patients. None of the patients had any complications related to the procedure. Symptomatic improvement was achieved in 62.5% of the patients while 25% of patients did not report any benefit from the injection.

CONCLUSION

In providing a record of needle tip position and contrast distribution, CT-guided scapulothoracic bursal injections provide an objective record of the procedure, which may assist in further treatment planning.

Ultrasound-guided bursal injections

The native bursa is a structure lined by synovium located adjacent to a joint which may serve to decrease friction between the tendons and overlying bone or skin. This extra-articular structure can become inflamed resulting in bursitis. Steroid injections have proven to be an effective method of treating bursal pathology in various anatomic locations. Performing these procedures requires a thorough understanding of relevant anatomy, proper technique, and expected outcomes. Ultrasound is a useful tool for pre procedure diagnostic evaluation and optimizing needle position during these procedures while avoiding adjacent structures. The purpose of this article is to review core principles of ultrasound-guided musculoskeletal procedures involving bursae throughout the upper and lower extremities.

Fluoroscopy-guided injections of the upper extremity: pearls and pitfalls

Fluoroscopy guidance is commonly utilized for injections in the upper extremity, with increased accuracy for injection placement compared to blind injection. Injection of the glenohumeral joint is the most commonly performed upper extremity procedure. However, there are a number of other sites which can be easily injected under fluoroscopy including the acromioclavicular joint, subacromial subdeltoid bursa, biceps tendon sheath, scapulothoracic bursa, elbow, wrist, first CMC joint, and pisotriquetral joint. Fluoroscopy can be used to guide injections into the glenohumeral, elbow, or wrist joints preceding MR arthrography. While there are technique similarities when injecting any of these sites, some particular approaches and pitfalls are unique to each anatomic site.

Scapulothoracic Arthroscopy for Snapping Scapula Syndrome

Background:

Snapping scapula syndrome (SSS) is a disruption of the normal smooth motion of the scapulothoracic joint leading to clicking or “snapping” which can be painful or painless. There are a variety of etiologies with first-line treatment being conservative. If patients fail extensive nonoperative treatments, then surgery may be considered. Although technically challenging, arthroscopic treatment is recommended due to its decreased morbidity and improved cosmesis.

Indications:

We present a 21-year-old man with a 2-year history of mechanical popping and crepitus with overhead and scapulothoracic motion of his left arm. After failing an extensive trial of conservative therapy, the patient underwent scapulothoracic arthroscopy with bursectomy and partial resection of the superomedial border of the scapula.

Technique Description:

The patient is positioned prone with the operative arm behind the back to elevate the medial border off the chest wall. The scapula is outlined. Two arthroscopic portals are used; the superior portal is 3 cm medial to the medial border of the scapula at the level of the scapular spine and the inferior portal is 4 cm inferior to this at the inferomedial angle of the scapula. Viewing is typically done from the inferior portal, and the superior portal is used for resection of the bursa and superomedial border of the scapula. A shaver and ablator are used to perform a bursectomy and expose the superomedial border of the scapula. An arthroscopic bur is used to partially resect the superomedial border of the scapula at approximately 3.5 cm wide and 2 cm deep.

Results:

Although there are limited studies examining outcomes after scapulothoracic arthroscopy, the current literature suggests that scapulothoracic arthroscopy is effective in improving crepitus, pain, and clinical outcome scores.

Discussion/Conclusion:

In cases of SSS which have failed exhaustive conservative therapy, arthroscopic bursectomy and partial bony resection can be an effective treatment option with minimal invasiveness, improved cosmesis, and early return to activities. Proper patient positioning and careful portal placement are critical to avoid iatrogenic injury, particularly to neurologic structures.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

A rare case of chest wall tuberculosis: Tuberculous scapulothoracic bursitis

Chest wall tuberculosis is a relatively rare extrapulmonary tuberculosis, and is often difficult to diagnose and treat because of the lack of symptoms. The scapulothoracic joint is a special joint that does not have a joint capsule, cartilage, or synovial membrane but consists of muscle and bursa. Tuberculosis infection of the scapulothoracic joint is an extremely rare musculoskeletal tuberculosis of the chest wall. Herein, we present the diagnosis and treatment strategy for tuberculous scapulothoracic bursitis in an 82-year-old man who was successfully treated.

Scapulothoracic Articulation Disorders on 99mTc-MDP Bone Scintigraphy

ABSTRACT

Disorders of the scapulothoracic articulation can cause significant pain, as well as an audible "snapping" or crepitus in advanced cases. Although radiography, CT, and MRI are used in the diagnosis of these conditions, little is known about their manifestations on nuclear imaging. We present a case of symmetric uptake at the inferior scapulothoracic articulations mimicking metastatic disease on a staging bone scan. Recognition of this pattern of activity is not only important to accurately exclude malignancy, but also to aid referring providers in addressing potential causes of patient morbidity.

Arthroscopic Management of Scapulothoracic Bursitis: Clinical Outcomes and Assessment of Novel Bony Parameters on Magnetic Resonance Imaging

Background

Scapulothoracic bursitis is a significant clinical condition that limits day-to-day function. Arthroscopic scapular debridement and resection have provided satisfactory outcomes; however, techniques, approaches, and recommendations remain varied. Novel bony parameters have also gained increasing interest owing to their value in preoperative planning.

Purpose

To assess midterm clinical outcomes after the arthroscopic management of scapulothoracic bursitis and to identify and measure novel bony parameters on preoperative magnetic resonance imaging.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 8 patients underwent arthroscopic scapular debridement and bursectomy; 5 of the 8 patients underwent additional medial scapulectomy. There were 5 male (62.5%) and 3 female (37.5%) patients with a mean age of 30.1 ± 12.3 years (range, 19-58 years). Inclusion criteria for surgery were patients with symptomatic scapulothoracic bursitis for whom extensive nonoperative modalities had been utilized for at least 6 months but failed. Outcome measures included the Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) shoulder rating scale, Constant Shoulder Score (CSS), and visual analog scale (VAS) for pain. The bony parameters included scapular shape, anterior offset, costomedial angle, and medial scapular corpus angle (MSCA).

Results

The follow-up duration was at least 2 years for all patients (mean follow-up, 25.0 ± 4.1 months [range, 24-35 months]). The majority of patients had a concave-shaped scapula (62.5%). The mean anterior offset was 24.3 ± 3.4 mm, and the mean costomedial angle was 132.3° ± 9.6°. Half the patients had a positive MSCA, while the other half had a negative MSCA. A statistically significant improvement was observed in the OSS, UCLA, CSS, and VAS scores from preoperatively to 2-year follow-up (P < .001 for all). No complications were observed.

Conclusion

Arthroscopic scapular debridement and resection provided satisfactory midterm clinical outcomes for the treatment of scapulothoracic bursitis.

Scapular Dyskinesis: From Basic Science to Ultimate Treatment

Background: This study intends to summarize the causes, clinical examination, and treatments of scapular dyskinesis (SD) and to briefly investigate whether alteration can be managed by a precision rehabilitation protocol planned on the basis of features derived from clinical tests. Methods: We performed a comprehensive search of PubMed, Cochrane, CINAHL and EMBASE databases using various combinations of the keywords “Rotator cuff”, “Scapula”, “Scapular Dyskinesis”, “Shoulder”, “Biomechanics” and “Arthroscopy”. Results: SD incidence is growing in patients with shoulder pathologies, even if it is not a specific injury or directly related to a particular injury. SD can be caused by multiple factors or can be the trigger of shoulder-degenerative pathologies. In both cases, SD results in a protracted scapula with the arm at rest or in motion. Conclusions: A clinical evaluation of altered shoulder kinematics is still complicated. Limitations in observing scapular motion are mainly related to the anatomical position and function of the scapula itself and the absence of a tool for quantitative SD clinical assessment. High-quality clinical trials are needed to establish whether there is a possible correlation between SD patterns and the specific findings of shoulder pathologies with altered scapular kinematics.

Huge Bursitis and Bursal Synovial Osteochondromatosis Associated With Scapular Osteochondroma Mimicking a Giant Calcific Mass of the Chest Wall

Osteochondroma is the most common benign bone tumor, but it rarely arises from the scapula. Scapulothoracic bursitis is quite rare and osteochondroma is one of the unusual causes of this condition. Synovial chondromatosis may occur extremely uncommonly in this bursa. We reported an unusual case of scapulothoracic bursitis with synovial chondromatosis, which is caused by osteochondroma. To the best of our knowledge, there is no defined chondromatosis in the scapulothoracic bursa secondary to scapular osteochondroma in the literature.

Ultrasound-Guided Therapeutic Scapulothoracic Interval Injections

Scapulothoracic pain is a common ailment, but the underlying cause can be difficult to diagnose in a timely manner, and treatment options are limited. We retrospectively review our experience using ultrasound-guided therapeutic scapulothoracic interval steroid injections to treat scapulothoracic pain and review correlative magnetic resonance imaging findings over a 5-year period. Although a variety of structural causes are known to cause scapulothoracic pain, in our experience, most cases lack correlative imaging findings. Ultrasound-guided scapulothoracic interval injections provide a safe, easily performed diagnostic and therapeutic tool for treating patients with periscapular pain, providing at least short-term symptom relief.

Scapulothoracic dissociation

Scapulothoracic dissociation is a rare and potentially limb- and life-threatening injury, that results from high-energy trauma. Scapulothoracic dissociation has the potential to be overlooked in the acute setting, especially in the setting of polytrauma. Therefore, a careful search for this condition should be performed in all patients with high-energy shoulder girdle injuries. The goals of this article are to review the anatomy of the scapulothoracic articulation as well as the spectrum, imaging evaluation, differential diagnosis and management of scapulothoracic dissociations.