Updated: 6/5/2021

Scapulothoracic Crepitus

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  • summary
    • Scapulothoracic crepitus, or snapping scapula syndrome, manifests as pain at the scapulothoracic junction with overhead activity.
    • Diagnosis is made clinically with painful crepitus of the scapulothoracic joint with forward flexion and improvement of pain with stabilization of the scapula.
    • Treatment is mainly nonoperative with NSAIDs, scapular strenghthening exercises, postural training and activity modifications.  
  • Etiology
    • Pathophysiology
      • predisposing abnormal anatomy
        • 6% of scapulae have some superomedial hooking
        • malunion of scapula or rib fractures
        • history of resection of 1st rib for thoracic outlet syndrome
      • overuse with normal anatomy
      • inflammation from overuse results in chronic inflammation, causing bursal fibrosis, bursitis, snapping
      • bony or soft tissue masses
        • osteochondroma
        • elastofibroma dorsi
          • a benign soft tissue tumor
        • scapular chondrosarcoma
    • Associated conditions
      • Scoliosis, kyphosis
      • scapulothoracic dyskinesis
  • Anatomy
    • Osteology - Scapula
      • spans ribs 2 to 7
      • three borders (superior, lateral, medial)
      • three angles (superomedial, inferomedial, lateral)
      • no direct bony articulation
      • no true synovial articulation
    • Muscles
      • trapezius
      • serratus anterior
      • subscapularis
      • levator scapulae
      • rhomboids
      • supraspinatus
      • infraspinatus
      • teres minor
      • teres major
      • triceps brachii (long head)
      • biceps brachii
      • coracobracialis
      • deltoid
      • pectoralis minor
      • latissimus dorsi (small slip of origin)
      • omohyoid
    • Ligaments
      • transverse scapular ligament - separates suprascapular artery (above) from suprascapular nerve (below, in suprascapular notch)
    • Blood Supply
      • dorsal scapular artery runs deep to rhomboids and levator 1 to 2 cm medial to scapula
    • Bursae
      • Anatomic
        • infraserratus
        • supraserratus
      • Adventitial (pathologic)
        • near superior or inferior angles
        • inconsistently identified
  • Presentation
    • History
      • presentation ranges from mild discomfort to significant disability
      • trauma and overuse have both been reported
    • Symptoms
      • patient complains of "popping" of scapula
      • painful crepitus with elevation of arm
      • pain relieved with stabilization of scapula
    • Physical exam
      • fixed or postural kyphosis may be present
      • tenderness or fullness of symptomatic bursa
      • ask patient to demonstrate symptomatic motions
      • passive scapulothoracic motion by examiner may also reproduce crepitus
      • scapulothoracic dyskinesis may be present
        • evaluate for winging
        • test muscle strength
          • trapezius
          • serratus
          • rhomboids
          • levator
          • latissimus
  • Imaging
    • Radiographs
      • recommended
        • AP, lateral and axillary
      • findings
        • look for osseous abnormalities
    • CT scan
      • indications
        • osseous lesion on plain radiographs
    • MRI
      • indications
        • soft tissue masses
        • inflamed bursae
  • Studies
    • Diagnostic injections
      • selective injection of local anesthetic and/or corticosteroid to point of maximal tenderness can be diagnostic and therapeutic
  • Differential
    • Cervical pathology
      • can be referred to shoulder girdle
  • Treatment
    • Nonoperative
      • NSAIDs, scapular strengthening exercises, postural training, activity modification
        • indications
          • first line of treatment
          • no mass or aggressive lesion
      • local corticosteroid injections
        • indications
          • second line of treatment
    • Operative
      • bursectomy (open or arthroscopic), resection of osseous lesion, resection of scapular border
        • indications
          • cases refractory to nonoperative treatment
        • outcomes
          • improvement in symptoms reported with both open and arthroscopic
          • better results in patients who responded well to injection
          • incomplete resolution of symptoms common despite improvement
          • better results with addition of partial scapulectomy (vs bursectomy alone)
  • Techniques
    • Open
      • position
        • prone, extremity draped free
      • approach
        • vertical incision over medial border of scapula, centered on symptomatic bursa
        • trapezius split in line with fibers
        • rhomboids and levator elevated subperiosteally
      • technique
        • bursa excised
        • angle of scapula can be excised
        • detached muscles repaired through drill holes
      • postoperative care
        • sling immediate post op
        • must protect repaired muscle attachments
          • immobilize x 4 weeks
          • active motion at 8 weeks
          • strengthening at 12 weeks
      • pros and cons
        • pros: wide exposure
        • cons: morbid
    • Arthroscopic
      • position
        • prone, extremity draped free, arm in maximum internal rotation with hand over lumbar spine
      • approach
        • portals: 3 cm medial to medial border of scapula (avoids dorsal scapular nerve and vessels) and below scapular spine (avoids spinal accessory nerve)
          • superior (Bell's) portal: junction of medial one third and lateral two thirds of superior border of scapula
        • trochar as parallel to chest wall as possible
      • technique
        • skeletonize superomedial angle with cautery
        • resect superomedial angle if desired using burr
        • can place spinal needle at superior scapular border to mark lateral limit of resection
      • postoperative care
        • sling immediate post op used for comfort x 1 week
        • active motion and strengthening based on tolerance
      • pros and cons
        • pros: no muscle detachment
        • cons: technically demanding
  • Complications
    • Neurovascular injury
      • suprascapular nerve and vessels
      • dorsal scapular nerve and vessels
      • spinal accessory nerve
    • Chest wall penetration
      • pneumothorax
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