Scapulothoracic Burscoscopy

CHAPTER 29 Scapulothoracic Burscoscopy

The scapulothoracic articulation plays a crucial role in the motion of the upper extremity. There are multiple disorders that affect this articulation and cause snapping scapula. Snapping scapula may be secondary to scapulothoracic bursitis, scapular osteochondromas or elastofibromas, scapular winging, scapulothoracic dyskinesia, and/or Sprengel’s deformity. The term snapping scapula is somewhat of a misnomer because not all disorders of the scapulothoracic joint make a characteristic snapping sound. As the understanding of snapping scapula improves, more cases are being diagnosed and treated. In most cases, conservative management is successful.1 However, patients who fail conservative management may be treated with open or arthroscopic surgery. Historically, surgical procedures described were open procedures28 or a combined open and arthroscopic procedure.4 An all-arthroscopic procedure was initially described by Cuillo in 1992 and the first series was later published by Harper and colleagues.2,10 Scapulothoracic burscoscopy provides a safe alternative to open superomedial angle resection, bursectomy, and excision of an elastofibroma or osteochondroma.


Disorders of the scapulothoracic joint are infrequently treated. The surgeon must have a good understanding of the anatomy and pathoanatomy of the shoulder, specifically the scapulothoracic joint.11


The scapula is a triangular-shaped bone that articulates with the humerus and clavicle laterally and thorax ventrally. Its only attachment to the axial skeleton is the acromioclavicular joint. The scapula is integral to motion of the shoulder because it provides a congruous joint for humeral articulation, glides on the thorax to position the glenoid in space,12 and serves as a stable base for the origin and insertion of multiple muscles that control scapular and humeral motion.

Seventeen muscles have their origins or insertions on the scapula (Box 29-1). The subscapularis muscle covers the anterior surface of the scapula and the supraspinatus and infraspinatus cover the posterior surface in the supraspinatus and infraspinatus fossa, respectively. The scapular spine and acromion provide the origin of the deltoid muscle and an insertion for the trapezius muscle. On the medial border, the serratus anterior, levator scapulae, and rhomboid major and minor muscles attach to the scapula. The lateral border is the origin of the triceps, teres major, and teres minor muscles. Inferiorly, the latissimus dorsi muscles attaches to the inferior angle of the scapula. Other muscle attachments include the omohyoid, long head of the biceps, coracobrachialis, short head of the biceps, and pectoralis minor muscles (Figs. 29-1 and 29-2).

The neurovascular structures that are in proximity to the scapula include the suprascapular nerve and artery, dorsal scapular nerve and artery, transverse cervical artery, spinal accessory nerve, and long thoracic nerve. The suprascapular nerve travels through the suprascapular notch and suprascapular artery over the transverse scapular artery to continue laterally around the spine of the scapula and through the spinoglenoid notch into the infraspinatus fossa. The dorsal scapular nerve dorsal scapular artery,13 and spinal accessory nerve (cranial nerve IX) travel parallel to the medial border of the scapula. Understanding these relationships will allow safe portal placement and minimize the risk of injury to important neurovascular structures when performing scapulothoracic burscoscopy (Fig. 29-3).

There are two major anatomic bursa and four minor adventitial bursae of clinical significance. The anatomic bursae are the supraserratus bursa, which is located between the subscapularis and serratus anterior muscles, and the infraserratus bursa, which is located between the serratus anterior muscle and chest wall.1,3,6,11,14 These bursae have been consistently located in both cadaveric specimens and during arthroscopic procedures (Table 29-1; Figs. 29-4 and 29-5).

TABLE 29-1 Bursae of the Scapulothoracic Joint

Bursae Location
Supraserratus bursa Between serratus anterior and subscapularis muscles
Infraserratus bursa Between chest wall and serratus anterior muscle
Supraserratus bursa (superomedial angle) Between serratus anterior and subscapularis muscles
Infraserratus bursa (superomedial angle) Between chest wall and serratus anterior muscle
Infraserratus bursa (inferior angle of scapula) Between chest wall and serratus anterior muscle
Trapezoid bursa Between spine of the scapula and trapezius muscle

In addition, four adventitial bursae have been described. These are thought to develop as a result of scapulothoracic dyskinesia and are not consistently seen. The supraserratus and infraserratus bursae (minor) are located ventral to the superomedial angle of the scapula. A second infraserratus bursa is located anterior to the inferior angle of the scapula. The trapezoid bursa is located dorsal to the spine of the scapula.14


The patient with a symptomatic snapping scapula often gives a history of a traumatic event or a repetitive upper extremity activity.4,10,2328 The traumatic event may involve a protraction or retraction movement of the scapula, direct blow to the scapula, fracture of the scapula, or fracture of the underlying rib cage. Sports requiring repetitive or forceful shoulder activities including baseball pitching, swimming, weight training, gymnastics, football, and fencing may produce the symptoms of snapping scapula.

Regardless of the underlying pathology, most patients report having crepitus—grinding, grating, clicking, or crunching with shoulder motion.5,6,17,30 The audible snap may or may not be painful.31 We have noted that the crepitus associated with bursitis is less severe than crepitus or snapping caused by bony lesions.20 Pain is often localized to the superomedial angle or medial border of the scapula, but pain at the inferior angle of the scapula is more typical in overhead athletes.28 Patients commonly report pain that is worsened with overhead activities, irrespective of the location of the inflamed bursa. Some patients may report a family history of similar symptoms.23

In most studies, the period of time from the onset of symptoms to treatment varies widely. Most patients have a prolonged course of pain and limitation of activities, with symptom duration for many reports averaging longer than 2 years and some cases longer than 10 years prior to treatment.4,10,16,26,27,30 This delay is often to the result of a prolonged course of conservative treatment, delayed recognition of the diagnosis, incorrect initial diagnosis, and evaluation by multiple physicians.

Physical examination findings associated with disorders of the scapulothoracic articulation can vary from near-normal to severe scapular winging and crepitus. Inspection of the posterior aspect of the shoulders may reveal subtle asymmetry. The dominant shoulder is frequently slightly depressed compared with the contralateral shoulder.32 This is a normal finding in many active individuals and athletes and is not directly related to a snapping scapula (Fig. 29-6).

Jun 19, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Scapulothoracic Burscoscopy
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