3. Introduction
It is developmental condition leading to a high
or descended scapula ,is rare but most common
congenital deformity of shoulder complex.
Mainly shoulder abduction decreases, and
shoulder function also decreases. In this
condition, scapular muscles are poorly
developed or are replaced by fibrous band.
4. Definition
Rare congenital abnormality which arises from
interruption of normal caudal migration of
scapula and is characterized by elevation and
medial rotation of scapula.
5. Incidence
Most common congenital malformation of the
shoulder girdle.
• Mostly noticed at birth.
• Equally affected in both gender.
• Left side is most common than right, bilateral
only in 10%.
6. Embryology
The scapula is a cervical appendage that
normally differentiates opposite the C4,C5,C6
vertebrae at 5 weeks of gestation.
Normally descends to thorax by the end of third
month of intrauterine life.
Interruption in the normal caudal migration of
scapula results in hypoplastic, elevated scapula
known as sprengel’s deformity.
7. Pathophysiology
Occur between 9th &12th week of gestation.
An arrest in the development of bone, cartilage,
muscles also occur.
The trapezius, rhomboid, or levator scapulae
muscle may be absent or hypoplastic.
Serratus anterior muscle may be weak, leading
to winging of scapula.
8. Changes seen in scapula
Dysplastic
• Smaller in the vertical plane and larger
horizontally
• Inferior angle is rotated medially, causing
the glenoid fossa to face inferiorly
• Convexity of the upper portion of the
scapula is increased and curvature of the
clavicular shaft is decreased, forming a
narrower scapuloclavicular space, may
contribute to brachial plexus compression.
9. Clinical Features
Deformity is the only symptom & it may be noticed
at birth.
The shoulder on the affected side is elevated, the
scapula looks& feels abnormally high, smaller than
usual & somewhat prominent.
Occasionally both scapulae are affected
The neck appears shorter than usual & there may
be kyphosis or scoliosis of the thoracic spine.
10. Shoulder movements are
painless but abduction and
elevation may be limited by
fixation of the scapula.
• Torticollis
• Facial asymmetry
• Crania bifida or spina bifida
may present
18. Radiological criteria
Elevated scapula
With short vertebral border. The
scapula resembles equilateral
triangle
Rotation of inferior angle
Either towards the spine or less
commonly to the opposite direction
Omovertebral bone
Connecting the superior angle to the
cervical spine
19. Surgical Treatment
Factors to be assessed- severity of the deformity
functional impairment age , associated contributed
condition
Surgery is best advisable foe patient – between 3& 8
years of age, with moderate or severe cosmetic/
functional deformity.
Surgical intervention before the age of 2 years is
extensive & is technically more difficult. Best result are
obtained if surgery is performed below the age of 5
20. Green’s scapuloplasty
Resection of the prominent superior scapular
border and extra periosteal division of muscular
attachment of the scapula to allow the scapula
to be displaced inferiorly and muscular
reattachments at the newer corrected level at
the scapula.
21.
22. Modified woodward’s procedure
Detachment of attachment of trapezius and rhomboids
from spinous process
Release of omovertebral band
Excision of superomedial angle of scapula
Relocation of scapula to new position
Suturing of trapezius to inferior spinous process closure
in layers.
25. Physiotherapy
Gradual relaxed passive mobilization of the shoulder & scapula
Suitable pain relief modality TENS, IFT, hot packs used to induce
relaxation
Special attention is given to achieve early mobility of the scapula
and the shoulder abduction, elevation.
Overall mobilization and strengthening of shoulder girdle muscles
Emphasize maximum possible correction of the posture and its
maintenance is important.
29. Short term goal
• Pain relief- TENS
• Stiffness- hot pack
• Enhance movement- electrical stimulation
• Adhesion break- US
• Mobility- paraffin wax, mobilization
• Exercises for 1 week- passive/active assisted
shoulder movements
30. Long term goals
• Strength –strengthening exercises include
resistance exercises, gripping exercises,
shoulder wheel, pulley, wall ladder
• Gross movements- wall cleaning, functional
reach, gripping exercises, stretching exercises
• Fine skills- dressing up, picking up the small
things, use of pen or pencil, reaching exercises
32. Introduction
It is a congenital deformity characterized by unilateral
shortening of sternocleidomastoid muscle resulting in
lateral inclination of the neck associated with
contralateral torsion.
Incidence varies from 0.3% to 2.0% live births.
It is recorded as the third most common congenital
musculoskeletal anomaly after dislocation of hip and
clubfoot.
33. It is often associated with other congenital
deformities such as DDH with a coexistence
rate estimated as high as 14.9%
Other associations – Tibial torsion, club foot,
calcaneovalgus foot, hallux valgus
If torticollis persists, child will develop scoliosis
and facial/head asymmetry known as
plagiocephaly.
34. Aetiology
Main causes include fetal position abnormalities,
Intrauterine or perinatal compartment syndrome
and birth trauma.
Other possible causes encountered are
hereditary and venous or arterial occlusion which
may create fibrous tissue within the
sternocleidomastoid.
It is caused due to fibromatosis within SCM.
35.
36. Clinical features
It may involve the muscle diffusely, but often it is localized
near the clavicular attachment of the muscle.
A mass either is palpable at birth or becomes so usually
during first 2 weeks.
The mass attains maximal size within 1 or 2 months and
may remain the same size or become smaller, usually it
diminishes and disappears within 1 year.
If it fails to disappear, the muscle becomes permanently
fibrotic and contracted, and causes tortiocollis.
37. It is more common on the right side
than on the left side.
A palpable nodule is typically present
in the affected SCM at birth or within
first 2 weeks of life.
The head becomes inclined towards
the affected side and face towards
the opposite side thus producing the
COCK ROBIN APPEARANCE.
If the deformity is severe, the
ipsilateral shoulder becomes elevated
and the fronto occipital diameter of
the skull becomes less than normal.
38. Flattening of face on ipsilateral side
of the SCM lesion can be worsened
by prone position during sleep.
The infant may also have a bat ear
as a result of folding inutero. If
infants are placed supine for
sleeping, reverse modeling of
contralateral side of skull can occur.
39. Diagnosis
Diagnosis is mainly based on past medical
history and clinical examination of the infant.
A meticulous prenatal history record is
essential and detects complicated labour and
a previous birth trauma such as clavicle
fracture.
Cervical spine radiographs are appropriate
for diagnosis.
Lin and Chou reported that ultrasonography
was useful in predicting which infants would
require surgical treatment.
40. Treatment
Only conservative treatment is indicated during infancy.
Home stretching exercises during the first year of life
Surgery is delayed until evolution of fibromatosis is
complete, and the if necessary, the muscle can be released
at one or both ends.
Ideally surgery is done just before school age sufficient
growth remains for remodeling of facial asymmetry while
giving enough time for the growth of the structures to make
surgical dissection and release easier.
