Scapular Dyskinesis. Orthopaedic Update 2018 April 15, Peter Tang, MD, MPH, FAOA

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1 Scapular Dyskinesis Orthopaedic Update 2018 April 15, 2018 Peter Tang, MD, MPH, FAOA Director Center for Brachial Plexus and Nerve Injury Program Director Hand, Upper Extremity & Microvascular Surgery Fellowship Associate Professor Drexel University College of Medicine Allegheny General Hospital

2 Outline Scapular Mechanics Anatomy Cases

3 Scapular Mechanics Scapula is unique because it is only connected to clavicle and otherwise only stabilized by muscles It has to support large loads generated by long lever arm of the upper extremity as well as position the glenohumeral joint in space The shoulder complex consists of 14 muscles: 8 cross the glenohumeral joint and 6 stabilize the scapulothoracic articulation (trapezius, serratus anterior, levator scapulae, rhomboid major and minor, pectoralis minor) (Martin, Curr Rev Musculoskelet Med 2008)

4 Scapular Mechanics Translation along the chest wall: mediolateral and superior-inferior Rotation: 1. Upward or downward rotation in coronal plane of scapular (clockwise or counterclockwise); 2. Internal or external rotation about the medial scapular border; 3. Rotation in the sagittal plane about the scapular spine (Crowe, JHS 2016)

5 Scapulohumeral Rhythm Describes the ratio and coordination of scapulothoracic and glenohumeral motion Some studies show 30 to 60 deg of upward scapular rotation when the arm is maximally raised Glenohumeral to scapulothoracic motion (scapulohumeral rhythm) is routinely reported at 2:1 Giphart found the ratio to be 1.1:1 for elevation, 1.6:1 for scaption, and 2:1 for abduction (JBJS 2013) Other studies with simulated lifting activities found wide range of values from 2.6 to 4.6 (Forte, Phys Ther Sport 2009; Yoshizaki, JSES 2009)

6 The Scapular and the Shoulder The composite scapular motion of rotation, abduction and tilting is necessary for proper shoulder function Loss of normal scapular mechanics leads scapular winging and difficulties with arm elevation.

7 Trapezius Anatomy Originates in the occiput and ligamentum nuchae in the cervical spine as well as spinous processes of C7 to T12 Superior, middle and lower components Inserts on acromion and lateral scapular spine (superior), superior scapular spine (middle), and inferomedial scapular spine (lower) Innervation is the spinal accessory nerve (cranial nerve XI) (Crowe, JHS 2016)

8 Trapezius Anatomy (Crowe, JHS 2016)

9 Lateral Winging (Srikumaran, JBJS 2014)

10 Serratus Anterior Anatomy Superior segment originates from the first and second ribs and attaches to the anterior border of the superomedial angle of the scapula Middle segment originates from the second through fourth ribs and inserts on the anteromedial scapular border Inferior segment (more clinically relevant) comes from the fifth through ninth ribs and inserts on the anterior aspect of the inferomedial scapula (Crowe, JHS 2016)

11 Serratus Anterior Anatomy The 3 slips hold the medial scapula to the chest wall and counteract scapular internal rotation caused by the weight of the arm in front of the body Inferior serratus pulls laterally on the inferomedial scapular border to allow upward and external rotation of the scapular for full frontal plane motion The combination of the upper and lower trapezius and inferior serratus is analogous to 3 arms pulling on propeller blades to rotate the scapular upwardly Innervation is long thoracic nerve which is from anterior rami of C5, C6, and C7 (anterior and middle scalene muscles) This nerve may be at risk because of tight fascial band on the chest wall (Martin, Curr Rev Musculoskelet Med 2008)

12 Medial Winging (Srikumaran, JBJS 2014) (Gooding, Shoulder & Elbow 2013)

13 Serratus Anterior Testing Active forward flexion Wall push-up test Forward flexion against resistance at 40 to 60 degrees (load against lower serratus is greatest) Protraction against resistance examiner s hand is on anterior shoulder, pt s arm is at the side and pt is to push shoulder into examiner s hand Scapular compression test medial scapula is held down to chest wall and pt is to elevate and abduct the arm (Gooding, Shoulder & Elbow 2013)

14 Rhomboid Anatomy Rhomboid minor originates from C7 and T1 and inserts on the posteromedial border of the scapula at the base of the scapular spine Rhomboid major comes from the T2 to T5 and inserts from inferior aspect of the minor to the inferomedial border of the scapula The rhomboids aid the middle trapezius with scapular retraction and elevate the medial scapular border Innervation is dorsal scapular nerve (C5) (Crowe, JHS 2016)

15 Causes of Winging Most common causes is probably neurogenic (laceration, neuropraxia) - confirm with nerve study (serratus anterior palsy % to 0.21%) Another cause is muscle/tendon rupture (this is not well taught) - Traumatic history; nerve study is normal

16 Case 28 year-old male bread maker who was moving a 50 lb pail of dough from a top shelf to the ground. He felt a pop and pain in his left, posterior scapular area.

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29 Case Study 18 year-old female who was playing basketball and running up the court when her teammate tripped her up from behind and she fell forward. Her teammate fell on top of her and her teammate s flexed elbow hit her left scapula.

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36 Case Study Findings: Tear of the origin of the inferior trapezius from the spinous processes (but no tendon was found) Tear of the origin of the latissimus dorsi from the spinous processes (2 cm from origin) Tear superior and middle trapezius from the scapular spine (1 cm from insertion)

37 Case Study Plan: To provide a static restraint I decided to use an achilles allograft to connect the medial scapular spine to the spinous processes To provide a dynamic restraint I transferred the rhomboid major and minor to the medial scapular spine (the rhomboids had already been initially taken down to evaluate them)

38 Eden-Lange Procedure

39 Triple Transfer Procedure

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46 Thank You! Peter Tang, MD, MPH, FAOA Cell

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