DefinitionCongenital anomaly with undescended scapula.
- Most common congenital anomaly of the shoulder in children.
- The scapula is attached to the cervical spine (in 30% of patients) by an omovertebral bone, cartilage, or fibrous tissue.
EtiologyArises from interruption of normal caudal migration of the scapula.
SymptomsThe deformity is painless and many patients are not diagnosed until adolescence.
- Often winging of the scapula, hypoplasia, and omovertebral connections (30% of cases) that can severely limit the scapulothoracic motion.
- The affected scapulae are usually small, relatively wide, medially rotated and more cephalad than normal.
- There is elevation and medial rotation of inferior scapula.
- Due to scapular asymmetry, some patients are mistakenly thought to have scoliosis.
- Klippel-Feil syndrome (one third have Sprengel deformity)
- Cervical ribs
- Kidney disease/renal abnormalities
- Muscular hypoplasia (especially the trapezius)
X-rayWill show elevation of the scapula.
OverviewIf the patient needs treatment, it is primarily surgical.
Nonoperative TreatmentPassive stretching exercises that was advocated in the past are not successful.
Operative TreatmentIndication: Children between 3-8 years of age with significant deformities, both functional (decreased abduction) and cosmetic. Patients older than 8 years of age are not good candidates for scapular displacement procedures.
- Woodward procedure: Distal advancement of associated muscles and scapula.
- The procedure has 80% satisfactory functional and cosmetic results.
- Can improve abduction ollowing surgery by 40-50° (from 34-60°).
- The child’s age at operation and differing methods of measurement play largest role in accounting for these differences.
- Younger patients obtain better motion and postoperative correction.
- Caudad displacement of scapula is reported to be 1.9 vertebra body heights in one series and 4 cm in another.
- Schrock and Green procedures: Detachment and movement of scapula. Can improve abduction by 40-50°.
- Clavicular osteotomy: Often needed to avoid brachial plexus injury caused by stretch och compression agains first rib.
Surgical TechniqueWoodward procedure:
- Resection of omovertebral bone and division of vertebral attachments of trapezius, rhomboids, and levator scapula.
- Scapula is subsequently rotated and translated caudally.
- The detached muscle origins are then sutured to more inferior vertebral spinous processes.
- Clavicular osteotomy is often needed to avoid brachial plexus injury caused by stretch and to prevent compression of neurovascular structures against first rib.
- Three weeks of postoperative immobilization is required. Postoperative improvement in shoulder abduction is maintained, although some loss of scapular translation can occur in first four months postoperatively.
- One third of patients will have widening of their surgical scars, which can be cosmetically disturbing.