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Scapular area

The scapular region is bounded above by a line connecting the clavicular-acromial articulation with the spinous process of the VII cervical vertebra, from below by a horizontal line through the lower angle of the scapula; the inner border is the vertical line running through the inner edge of the scapula, the outer border is the posterior edge of the deltoid muscle and the middle axillary line. On palpation in the scapular region, the upper, inner and outer edges, the lower angle of the scapula (at the level of VII — VIII ribs) and scapular awn are determined. Under the skin, fiber, and superficial fascia own surface layer of muscles (trapezius muscle and broad muscle of the back).

The innervation of the scapular region is carried out by the branches of the suprascapular nerve, the intercostal nerves; blood supply - deep branch of the transverse artery of the neck. Lymphatic drainage from the scapular region goes outwards and in depth to the axillary and subscapularis lymph nodes.

Anomalies: high standing of the scapula (Sprengel's disease) with its location in the horizontal plane, combined with malformations of the spine (cleft of the arches and curvature); the pterygoid scapula with its inner edge standing out and the restriction of the function (impossibility of raising and rotating the arm). Treatment is prompt.

In case of injuries of the scapular region, closed fractures of the scapula are observed.

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Among the diseases found bursitis (the so-called crisp antescapular bursitis). Treatment - puncture or removal of the mucous bag. Abscesses and cellulitis may develop within the limits of the pre-lobe fat. Osteomyelitis is often a complication of the gunshot wounds of the scapula.

Benign tumors of the scapular region — fibromas ; osteomas and osteochondromas — are rare; malignant (osteochondrosarcoma) - usually observed in the body of the scapula.

Scapular region (regio scapularis) - the back surface of the shoulder girdle, limited by the location of the shoulder blade and the muscles attached to it.

Scapula (scapula) - a flat triangular bone adjacent to the posterior-lateral surface of the chest wall, along the vertical axis occupies a space from II to VII ribs.

There is a medial edge of the scapula (margo medialis), lateral (margo lateralis), upper (margo superior) with a notch in which vessels pass (incisura scapulae), and three angles — medial (angulus medialis), lower (angulus inferior) and outer ( angulus externus); the latter has an oval-shaped articular cavity (cavitas glenoidalis) for articulation with the head of the humerus (see shoulder joint).

The articular surface passes through the neck of the scapula (collum scapulae) into the body of the scapula (corpus scapulae). Above and below the articular cavity are tuberosities for attaching the muscles of the shoulder (triceps and biceps). The scapular spine (spina scapulae) passes in the oblique direction along the posterior surface of the scapula, which ends at the humeral process (acromion), which has an articular area for articulation with the clavicle. At the outer angle of the scapula there is a coracoid process (processus coracoideus) to which are attached: a short head of the biceps of the shoulder (m. Biceps brachii), a small pectoral (m. Pectoralis minor) and a coraco-brachial (m. Coracobrachialis) muscles (Fig. 1 and 2).

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In the scapular region, anterior (costal) and posterior (dorsal) surfaces are distinguished. The dorsal surface is divided into two pits: supraspinatus and subosseous, performed by the corresponding muscles.

Under the skin and its own fascia of the back, along the posterior surface of the scapular region, without covering the outer part of the fossa, there are trapezoid and wide back muscles (m. Trapezius et m. Latissimus dorsi). Under these muscles there are dense aponeurotic leaves of the supraspinous and subacute fascia (fascia supraspinata et fascia infraspinata), which form bone fibrous beds filled with the same name muscles and a small amount of fiber with the posterior surface of the scapula.

From the outer edge of the scapula begins a large round muscle (m. Teres major), and from its lower corner - a small (m. Teres minor). Closed spaces of bone-fibrous lodges in the presence of an inflammatory process create great difficulties for the outflow of pus. Outflow is possible only along the tendons of the muscles that attach to the large humproot of the humerus, as well as along the neurovascular bundle into the axillary region.

More superficially lies; the muscle lifting the scapula (m. levator scapulae) and starting from the transverse processes of the four upper cervical vertebrae is attached to its medial angle. Below is a diamond-shaped muscle, starting from C VI – VII and Th I – IV , attached to the spinal edge of the scapula below its spine.

The front (costal) surface of the scapula has a concavity, made by the subscapularis muscle (m. Subscapularis), which is attached to the small tubercle of the humerus.

The scapula is tightened to the rib cage by a rhomboid muscle, and especially by the front serratus (m. Serratus ant.), Which starts from the ribs and attaches to the medial edge from the inside.

In the scapular region there are two neurovascular bundle. One of them is: the suprascapular artery (a. Suprascapularis), accompanying its eponymous veins and nerve innervating the supraspinatus and hypostatic muscles. The neurovascular bundle passes into the sub-axial fossa under the acromial process. In the subarticular bed, the suprascapular artery forms numerous anastomoses with branches of the artery that surrounds the scapula (a. Circumflexa scapulae).

The other neurovascular bundle consists of the descending branch of the transverse artery of the neck (a. Transversa colli), the veins of the same name and the dorsal scapular nerve (n. Dorsalis scapulae), which run along the medial edge of the scapula. The descending branch of the transverse artery of the neck is also involved in the formation of the scapular arterial circle (Fig. 3), which plays an important role in the development of the circumferential circulation when bandaging the axillary and brachial arteries.

Impaired movement of the upper limb in the shoulder joint and changes in the position of the scapula depend on the state of the function of the muscles of the scapular region. In this regard, the disease or injury of the scapula often causes sharp movement disorders in the shoulder joint.

There are various deviations from the normal position and shape of the scapula. The high standing of the scapula (Sprengel's disease) is reflected in the fact that one of the shoulder blades is located 4-5 cm above the other, the lower angle is attracted to the spine, and the lateral edge is turned outwards. Sometimes the deformation is significant. High standing of the scapula causes not only a cosmetic defect, but also leads to significant functional impairment - restriction of movements in the shoulder joint and atrophy of the muscles of the shoulder girdle.

Conservative treatment - massage, gymnastics, the use of bandages - does not work. Surgical treatment methods consist in mobilizing the scapula, bringing it down and fixing it in a new place (Fig. 4).


Fig. 4. The operation of the reduction of the scapula: 1 - skin incision; 2 - osteotomy of the coracoid process, the reduction of the scapula and its fixation with a silk suture to the VII rib.

The pterygoid (navicular) scapula (scapula alata) is a congenital deformity consisting in the deviation of the medial edge of the scapula from the posterior surface of the chest. Often this deformity is bilateral and is often combined with Sprengel disease. Sometimes the posterior deviation of the scapula develops on the basis of childhood paralysis (when the rhomboid and trapezius muscles are affected).

The treatment is conservative - a long massage and therapeutic exercises.

Heavy unilateral deformations are treated promptly - they fix the edge of the scapula in the notches made in VI and VII ribs.

Fig. 5. Typical fractures of the scapula: 1 - fracture of the anatomical neck; 2 - fracture of the surgical neck; 3 - fracture of the lower corner; 4 - fracture of the upper inner corner; 5 - longitudinal fracture.

Fractures of the scapula are observed in the area of ​​the neck, body and acromial process (Fig. 5). The diagnosis of acromion and coracoid process fractures is determined by local tenderness and crepitus. In case of fractures of the neck of the scapula, the shoulder hangs downwards instead of with the articular cavity, and the limb of the injured side becomes longer than healthy. Fractures of the neck of the scapula are often complicated by damage to the suprascapular artery (A. suprascapularis) - hematoma, as well as compression of the suprascapular nerve (n. Suprascapularis), as a result of which contracture develops in the shoulder joint and a sharp soreness with active shoulder abduction.

Fractures of the body of the scapula grow well together and have little effect on the function of the limb.

Treatment of fractures of the coracoid and acromion processes is carried out by immobilizing the shoulder joint for 20-25 days in an abduction splint with a 90 ° hand abduction. For cervical fractures, inpatient treatment is recommended with a traction in the position of the limb abduction. Immobilization in these cases is carried out with a Deso-type dressing, which after 5–6 days is replaced with a kerchief and a consistent therapeutic gymnastics is started.

Purulent processes of the scapular region develop predominantly in the cellular tissue spaces located between the scapula and the chest wall; they can extend to the cellulose of the subdeltoid space, and through the latter to the fiber of the armpit. Of particular importance in the spread of purulent processes is the pre-blade gap (Fig. 6).


Fig. 6. Fascia of the scapular region and pre-blade gaps (frontal cut): 1 - m. trapezius; 2 - neurovascular bundle of the armpit; 3 - clavicle and m. subclavius; 4 - m. pectoralis major; 5 - m. pectoralis minor; 6 - bridge between the third and fourth fascia; 7 - VIII rib; 8 - bridge between the fourth and fifth fascia; 9 - front pre-blade gap; 10 - the fifth fascia; 11 - the third fascia; 12 - m. serratus ant. and his fascia (fourth); 13 - m. infraspinatus; 14 - m. subscapularis; 15 - scapula; 16 - rear pre-blade gap; 17 - the second fascia; 18 - the first fascia (fascia superficialis); 19 - m. supraspinatus.

From inflammatory processes in the scapular region, phlegmons are observed that develop in the tissues between the scapula and the chest wall.

A. Yu. Sozon-Yaroshevich recommends opening cellulitis in the pre-blade region by a cross-section above the lower angle of the scapula.

From the same incision, trepanation or partial resection of the scapula can be made to remove foreign bodies. With extensive phlegmon of the scapular area with involvement of the axillary fossa, the pre-fissure gap can be drained through a three-sided opening (foramen trilaterum). The incision is made on the edge m. teres minor and further bluntly penetrate the fiber that performs the foramen trilaterum, as well as into the purulent cavity of the intermuscular spaces of the scapula.

When diffuse osteomyelitis of the scapula produces its subperiosteal resection. For this purpose, conduct a horizontal incision along the upper edge m. latissimus dorsi, crossing the bottom corner of the scapula; the second incision — from the middle of the first, is directed upwards to the neck of the scapula. The muscles and the periosteum are removed from the scapula by a raspator. After subperiosteal resection, the scapula regenerates completely in 4-6 weeks at the expense of the periosteum, but does not reach its original size.