Rev. bras. ortop. vol.52 número2

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r e v b r a s o r t o p . 2017;52(2):220–223

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

report

Snapping

scapula.

Arthroscopic

resection

of

osteochondroma

of

the

subscapularis

superomedial

angle.

Case

report

and

literature

review

夽

Alexandre

Tadeu

do

Nascimento

∗

_,

_Gustavo

_Kogake

_Claudio

HospitalOrthoservice,SãoJosédosCampos,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received29March2016

Accepted10May2016

Availableonline5February2017

Keywords:

Arthroscopy

Boneneoplasms

Humerus Osteochondroma

a

b

s

t

r

a

c

t

Snappingscapulasyndromehasseveraletiologies,includingsubscapularosteochondroma.

Whenthistumorneedstoberemoved,thiscanbedonearthroscopically,aprocedurethat

hasrestrictedindications.Theauthorspresentacaseofapatientwithsuperomedial

sub-scapularosteochondromawhounderwentascapulothoracicarthroscopyforitsremoval.

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Ressalto

de

escápula.

Ressecc¸ão

artroscópica

de

osteocondroma

subescapular

da

região

superomedial.

Relato

de

caso

e

revisão

da

literatura

Palavras-chave:

Artroscopia

Neoplasiasósseas

Úmero Osteocondroma

r

e

s

u

m

o

Aescápulaem ressaltoéumasíndromecomdiversasetiologias,entreelaso

osteocon-dromasubescapular.Quandoessetumornecessitaserretirado,épossívelfazê-loporvia

artroscópica,umprocedimentoqueapresentaindicac¸õesrestritas.Osautoresapresentam

nesteartigoocasodeumapacientecomosteocondromadaregiãosuperomedialdaface

ventraldaescápula,submetidaaprocedimentocirúrgicoporartroscopiaescápulotorácica

parasuaretirada.

Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedattheHospitalOrthoservice,GrupodeOmbroeCotovelo,SãoJosédosCampos,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](A.T.Nascimento).

http://dx.doi.org/10.1016/j.rboe.2017.01.007

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rev bras ortop.2017;52(2):220–223

221 Introduction

Snapping scapula is a disorder that varies in its

clin-ical manifestations from a mild to a limiting disorder,

characterized byscapulothoracic movements that produce

an audible and/or palpable crackling, pain, and snapping

sensation.1

Manycauseshavebeensuggestedforthissyndrome.One

of them is repeated shoulder movement, which produce

microtraumasand alocalbursitisthatcangenerateabony

spuratthelevelofthemuscularinsertioninthescapulaand

subsequentcrepitus.2

Occasionally, there is no identifiable cause. Structural

abnormalitiesthatmayleadtothissyndromeinclude

scoli-osis,thoracickyphosis,bonyprominences(suchasLuschka’s

tubercle),abnormalcurvatureofthesuperiorscapularangle,

Sprengeldeformity,vertebralborderbulging,subscapularrib

irregularities,subscapularribexostosis,osteogenicsarcoma,

andosteochondroma.3

Osteochondromais the mostcommon benigntumor of

thebone,accountingforapproximately35%ofbenignbone

tumors and 9% of all bone tumors. This tumor is often

diagnosed incidentally, as most are asymptomatic, but it

maycausemechanicalsymptomsdependingonlocationand

size.4

In an extensive reviewof the literature, Carlson et al.3

identified89 casesofsnapping scapulasyndromereported

between1867and 1996.Scapularosteochondroma wasthe

causeof16%(14cases).

Scapulothoracicarthroscopyisa procedurewithlimited

indications. Few articles have been published on the

sub-ject, and they refer to case reports and series with a

reduced number of patients. The current indications for

thisprocedurearesnappingscapulasyndrome,

scapulotho-racicbursitis,foreignbodyresection,benigntumorresection,

and treatment of chronic pain refractory to conservative

treatment.5

Thearthroscopicanatomywasdescribedinthestudyby

Rulandetal.,6_stipulating_safe_portals_and_avoiding_injury_to

neurovascularstructures.Thescapulothoracicjointhastwo

triangular spaces,the serratusanterior spaceand the

sub-scapularspace,whichare dividedobliquelybytheanterior

serratusmuscle.Thelimitsofserratusanteriorspaceinclude

theanteriorserratusmuscleposteriorly,therhomboidmuscle

medially,andthethoracicwallanteriorly.Inthesubscapular

space,theanteriorserratusmuscleislocatedanteriorly,the

subscapularismuscleposteriorly,andtheaxillalaterally.

Inthearthroscopicprocedure,patientisplacedinprone

position,withthearminfullinternalrotationandshoulder

extension(chickenwingposition)toincreasethe

scapulotho-racicspace.Theinitialentranceportalislocatedmedialtothe

scapularangleimmediatelybelowthelevelofscapulothoracic

spine,3cmfromthemedialborderofthescapula;asecond

portalispositionedapproximately4cmbelowthefirstportal

topreventdamagetothenerve,thedorsalscapularartery,and

thespinalaccessorynerve,aswellastoallowaperpendicular

orientationrelativetothechestwall.Toaccessthesuperior

angleofthescapula,itmaybenecessarytocreateaportal

superiorlytothescapula.6

Case

report

A female patient, 21 years of age, university student and

horseracingpractitioner,complainedofpainandcrepitation

ofthescapulaforthreeyears.Shewasattendedtoatseveral

services,withadiagnosisofparaescapulardyskinesia;during

that time, sheunderwent physiotherapywithout

improve-mentofthecondition.

Atphysicalexamination,shepresentednormalrangeof

motion,butwithaudibleandpalpablecrepitus,evenin

pas-sivemovements.

Aradiographofthescapularregionshowedabonetumor

attheanteriorborderofthescapula(Fig.1).Theinvestigation

wascomplementedwithcomputedtomographyandmagnetic

resonanceimaging(MRI;Fig.2),andthediagnostichypothesis

ofosteochondromawasreached.

Then,patientunderwentasurgicalprocedurefor

arthro-scopicremovalofthetumor(Fig.3),accordingtothetechnique

describedbyRuland.6_One_portal_was_created_at_the_level_of

the scapular spineinthe spine ofthelevel ofthe scapula

and the other portal at 4cm below the first portal,

main-taining adistanceofat least3cm from the medialborder

ofthescapula.Therewasnoneedtousethesuperior

por-tal, whichis anoption when it is necessary toaccess the

superomedial regionofthescapula.Thetissuesamplewas

sentforanatomopathologicalanalysis,whichconfirmedthe

diagnosisofosteochondroma.Postoperativeradiographyand

tomographywereperformed(Fig.4),whichshowed

success-fulremovalofthetumor,withexcellentestheticappearance

(Fig. 5). Eight months postoperatively, patient presented a

Fig.1–Radiographinscapularprofileshowingabony

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222

rev bras ortop.2017;52(2):220–223

Fig.2–Tomographyshowingbonetumorinthesuperomedialregionofthescapula,inclosecontactwiththecoastal

arches,andmagneticresonanceimagingshowingosteochondroma“perforating”thesubscapularismuscle(whitearrow).

Fig.3–Intraoperativeimagesbeforeandafterthetumorremovalprocedure.

Fig.4–Postoperativeradiographandtomographyshowingsuccessfulremovaloftheentiretumor.

significantimprovementintheappliedscores.The

Disabili-tiesofArm,ShoulderandHand(Dash)scoredecreasedfrom

43.3preoperativelyto0.83postoperatively.TheUniversityof

CaliforniaatLosAngeles(UCLA)scoreincreasedfrom22

pre-operativelyto35postoperatively.Thevisualanalogscale(VAS)

decreasedfrom6inthepreoperativeperiodto0inthe

post-operativeperiod.

Discussion

Snappingscapulaisadisorderthatvariesinitsclinical

man-ifestations from a mild to limiting disorder. Many causes

havebeensuggestedforthissyndrome,andosteochondroma

accountsforapproximately15%ofcases.7_{Osteochondroma}_is

themostcommonbenignbonetumor,accountingfor

approx-imately35%ofthebenigntumorsand9%ofalltumors.This

tumorisoften diagnosedincidentally, asmostare

asymp-tomatic,butmaycausemechanicalsymptoms,dependingon

location andsize.4 _Despite_being_the_most_common_benign

tumorthat affectsthescapula, it israrelyobservedinthis

location.8_It_is_commonly_found_in_young_patients,_generally

agedbelow30years,withamale:femaleratioof1.5:1.9

When reviewing the cases described in the literature,

there was only one case retrieved in which the

loca-tion of the osteochondroma occurred in the superomedial

region ofthe scapula.10 _All _other _cases _were _located _at_or

belowthe equatorofthescapula. Thus,thiscasebecomes

of special presentation.11 _Tumors _of _the _inferior _scapular

region usually reach larger sizes, due to the space they

have to develop; depending on the size, they can

pre-cludearthroscopicresection.12_Although_technically_complex,

arthroscopic surgery forsnappingscapula syndromeoffers

several theoretical advantages over open surgery. These

includeminimizingthedissection,preservingmuscle

attach-ments,andtherebyeliminatingtheneedforimmobilization

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rev bras ortop.2017;52(2):220–223

223

Fig.5–Estheticaspectofthearthroscopicscapulothoracic

surgery.

Thepresentpatienthadanosteochondromawith

partic-ularcharacteristics,duetoitssuperomedialpositionandits

closecontactwiththesecondcostalarch.Asitispossibleto

observeinthetomography,itsgrowthtooktheformofahook,

probablyduetothemechanicaleffectofwearonitssurface,

whichwasinconstantfrictionwiththecostalarch.Another

peculiaritythatwas observedatthe MRIisthatthe tumor

advancedthroughthesubscapularismuscle,notrepellingit,

but insteadpuncturing it,which increasedthe difficulty of

localizationandresectionofthelesion.

Scapulothoracicarthroscopyisaprocedurethathasbeen

increasinglyperformedinorthopedicpractice,allowingthe

treatmentofpathologiesthataffectthescapulainaneffective

andminimallyinvasiveapproach.12_Similarly_to_the_present

report, many studies have demonstrated excellent results

inosteochondroma resections of the ventral region ofthe

scapulathroughscapulothoracicarthroscopy.14,15

Basedonthe reviewoftheliteratureand observationof

the present case,it can beconcluded that scapulothoracic

arthroscopyisanewprocedurewithlimitedindications,but

withgoodeffectivenessandgoodfinalestheticappearance.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.KuhneM,BoniquitN,GhodadraN,RomeoAA,Provencher MT.Thesnappingscapula:diagnosisandtreatment. Arthroscopy.2009;25(11):1298–311.

3.CarlsonHL,HaigAJ,StewartDC.Snappingscapulasyndrome: threecasereportsandananalysisoftheliterature.ArchPhys MedRehabil.1997;78(5):506–11.

4.Ermis¸MN,AykutUS,Durakbas¸aMO,OzelMS,Bozkus¸FS, Karakas¸ES.Snappingscapulasyndromecausedby subscapularosteochondroma.EklemHastalikCerrahisi. 2012;23(1):40–3.

5.PavlikA,AngK,CoghlanJ,BellS.Arthroscopictreatmentof painfulsnappingofthescapulabyusinganewsuperior portal.Arthroscopy.2003;19(6):608–12.

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osteochondroma.ActaOrthopScand.1999;70(4):394–6.

8.GalateJF,BlueJM,GainesRW.Osteochondromaofthe scapula.MoMed.1995;92(2):95–7.

9.SivanandaP,RaoBK,KumarPV,RamGS.Osteochondromaof theventralscapulacausingscapularstaticwingingand secondaryriberosion.JClinDiagnRes.2014;8(5).LD03-5.

10.SureshSS.Superomedialangleosteochondromaofthe scapulaasacauseofsnappingscapula.KeralaJOrthop. 2011;25(1):37–42.

11.FukunagaS,FutaniH,YoshiyaS.Endoscopicallyassisted resectionofascapularosteochondromacausingsnapping scapulasyndrome.WorldJSurgOncol.2007;5:37.

12.AndreoliCV,EjnismanB,PochiniAC,MonteiroHC,CohenM, FaloppaF.Artroscopiadaarticulac¸ãoescapulotorácica:relato decasos.RevBrasOrtop.2009;44(4):351–6.

13.HarperGD,McIlroyS,BayleyJI,CalvertPT.Arthroscopic partialresectionofthescapulaforsnappingscapula:anew technique.JShoulderElbowSurg.1999;8(1):53–7.

14.FrecheS,JuchF,NusseltT,DelankKS,HagelA.Arthroscopic treatmentofbilateralsnappingscapulasyndrome:acase reportandreviewoftheliterature.ActaOrthopTraumatol Turc.2015;49(1):91–6.

15.SarikayaB,SuluovaF,CetinBV,SarikayaZB.Endoscopically assistedresectionofararemass:intra-articular