Evolving Technique: Resect the Superomedial Angle John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Vanderbilt University Medical Center V A N D E R B I L T S P O R T S M E D I C I N E
Snapping Scapula • Snapping may not be pathologic • Snapping may lead to bursitis which is symptomatic • “sound about the room without the slightest pain” V A N D E R B I L T S P O R T S M E D I C I N E
IMPORTANT POINTS • Crepitus May NOT be Symptomatic • Crepitus and Bursitis MAY BE Related • Treatment – Nonoperative – Arthroscopic – Open Surgery V A N D E R B I L T S P O R T S M E D I C I N E
Snapping Scapula • Degrees (Mauclaire 1904) – Froissement- physiologic – Frottemont- louder grating sometimes pathologic – Craquemont- always pathologic V A N D E R B I L T S P O R T S M E D I C I N E
Causes of Snapping Scapula • Bone • Soft Tissue – Osteochondroma (Scapula and Rib) – Bursitis – Fracture (Scapula and Rib) – Tuberculosis – Hooked Superomedial Angle – Syphylitic – Luschka’s Tubercle • Muscle – Reactive Spurs-Muscle Avulsion – Atrophy • Congruence – Fibrosis – Scoliosis – Anatomic Variants – Kyphosis – Postural V A N D E R B I L T S P O R T S M E D I C I N E
Luschka’s Tubercle V A N D E R B I L T S P O R T S M E D I C I N E
Bursal Anatomy • Natural Bursae • Adventitial Bursae V A N D E R B I L T S P O R T S M E D I C I N E
Scapulothoracic Bursitis • History of Overuse • Swelling/Pain along Medial Border • May have Subtle Winging • May have Crepitus V A N D E R B I L T S P O R T S M E D I C I N E
Inferior Angle Bursitis in Throwers • Rare • Swelling/Pain in Cocking • May Require Surgical Excision V A N D E R B I L T S P O R T S M E D I C I N E
Clinical Assessment • History – Pain • Location • Aggravating Features – Popping • Physical Exam – Scapula Exam – Demonstrate Snapping? V A N D E R B I L T S P O R T S M E D I C I N E
Clinical Assessment Inferior Angle Bursitis V A N D E R B I L T S P O R T S M E D I C I N E
Snapping Scapula V A N D E R B I L T S P O R T S M E D I C I N E
Nonoperative Treatment • Postural Correction – Figure of 8 brace • Subscapularis/Serratus Muscle Strengthening • Injections into Bursa – Watch for Pneumothorax • Coaching V A N D E R B I L T S P O R T S M E D I C I N E
Surgical Treatment of Scapular Bursitis and Snapping Scapula • ARTHROSCOPIC • OPEN V A N D E R B I L T S P O R T S M E D I C I N E
Arthroscopic Treatment • Mark Landmarks V A N D E R B I L T S P O R T S M E D I C I N E
Portal Placement Avoid Neurovascular Structures V A N D E R B I L T S P O R T S M E D I C I N E
Inject the Bursa V A N D E R B I L T S P O R T S M E D I C I N E
Insert Scope Blunt Tools V A N D E R B I L T S P O R T S M E D I C I N E
Views NOT IN BURSA IN THE BURSA V A N D E R B I L T S P O R T S M E D I C I N E
Osteochondroma V A N D E R B I L T S P O R T S M E D I C I N E
Open Surgery Resection of the Superomedial Angle V A N D E R B I L T S P O R T S M E D I C I N E
Subperiosteal Resection • Window through Trapezius • Elevate Supraspinatus • Shell out SM Angle and Remove V A N D E R B I L T S P O R T S M E D I C I N E
V A N D E R B I L T S P O R T S M E D I C I N E
V A N D E R B I L T S P O R T S M E D I C I N E
V A N D E R B I L T S P O R T S M E D I C I N E
Surgical Treatment • Resect Abnormal Bone • Resect Bursa • Superomedial Angle Resection V A N D E R B I L T S P O R T S M E D I C I N E
Results of Surgery • All Case Series • 85-90% success • Allow return to unrestricted activity • PEARLS: – Shell Out the Bone in a Subperiosteal Plane – Meticulous Repair of Muscle Plane – Repair to Bone When Possible V A N D E R B I L T S P O R T S M E D I C I N E
Summary • Scapulothoracic Crepitus is NOT Uncommon • It may be ASYMPTOMATIC-Watch for Secondary Gain! • Crepitus and Bursitis May Occur together or May be Independent • Nonoperative Treatment is an Option • Surgery, If Required is usually successful V A N D E R B I L T S P O R T S M E D I C I N E
Thank You V A N D E R B I L T S P O R T S M E D I C I N E
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