Scapular region

Scapular region is bounded from above by a line connecting the clavicle-acrobaleno articulation with the spinous process of VII cervical vertebra below the horizontal line drawn across the bottom corner of the scapula; inner boundary is the vertical line passing through the inner border of the scapula, exterior rear edge of the deltoid muscle and mid-axillary line. At a palpation in the shoulder area are defined: the upper, inner and outer edges, lower the angle of the scapula (level VII-VIII edges) and blade guard. Under the skin, fiber, surface and own bands are superficial layer of muscles trapezius muscle and latissimus dorsi muscles).
Innervation of the shoulder region is carried out by branches nadopasana nerve, intercostal nerves, blood - deep cross branch artery neck. Lymph from the shoulder area goes outwards and in depth to the axillary and subscapularis lymph nodes.
Anomalies: high standing of the scapula (illness Sprengel) with its location in the horizontal plane, combined with malformations of the spine (cleft arches and curves); wing-shaped blade with vastanie its inner edge, and the restriction of the function (the impossibility of raising and rotation of the hand). Operative treatment.
With injuries of the shoulder area there are closed fractures of the shoulder blade.
The disease occurs bursitis (the so-called crispy antisymmetry bursitis). Treatment - puncture or destruction of mucous bag. Within predoplatnoy tissue can develop abscesses and phlegmons. Osteomyelitis often a complication of gunshot wounds blades.
Benign tumors of the shoulder area - fibroma, osteomas and osteochondroma - rare, malignant (osteochondropathy) is usually observed in the body of the blade.

Scapular region (regio scapularis) - rear surface of the shoulder girdle, limited by limits of the location of the blade and attached muscles.
The shoulder blade (scapula),- flat triangular bone adjacent to the rear-side surface of the chest wall, vertical axis occupies the space from II to VII ribs.
There are medial border of the scapula (margo medialis), lateral (margo la
teralis), top (margo superior) with the tenderloin, in which are vessels (incisura scapulae), and three angles - medial (angulus medialis), bottom (angulus inferior) and external (angulus externus); the latter has an oval form joint depression (cavitas glenoidalis) for articulation with the head of the humerus (see the Shoulder joint).
Articular surface through the neck, shoulder blade (the word " Collum " scapulae) enters the body of the blade (corpus scapulae). Above and below the glenoid have tuberosity to attach heads of muscles of the shoulder (triceps and biceps). On the rear surface of the blade in an oblique direction blade passes the spine (spina scapulae), which ends shoulder process (acromion)with a joint platform for the articulation with the collarbone. The external angle of the blades has coracoid process (processus coracoideus), to which are attached: short head of the biceps shoulder (m. biceps brachii), small breast (m. pectoralis minor) and kljuvovidno-shoulder (m. coracobrachialis) muscles (Fig. 1 and 2).
In blade region allocated front (rib) and back (spinal) surface. Dorsal surface is divided into two holes: fossae and are performed by the relevant muscles.
Under the skin and private fascia back on the back surface of the shoulder area, not covering the outer part are holes are trapezoidal and widest back muscles (m. trapezius et so latissimus dorsi). Under these muscles are tight aponeurotic sheets fossae and infraspinatus fascia (fascia supraspinata et
fascia infraspinata)that from the back of the blade surface form a bone-fibrous couch, filled with the same muscles and less dietary fiber.
From the outer edge of the shoulder blades, the big round muscle (m. teres major), and from the lower corner of her small (so teres minor). Confined spaces bone-fibrous lodges in the presence of inflammatory process create great difficulties for the drainage of pus. The outflow is possible only along the tendons of muscles that attach to a large mound of the humerus, and neurovascular bundle in the armpit.
More lies superficially; muscle, levator scapulae (m. levator scapulae) and starting from the transverse processes of the top four cervical vertebrae, is attached to the medial her corner. Below is rhomboid muscle, starting from CVI-VII and ThI-IV, is attached to the spinal edge of the blade below her spine.
Front (rib) the blade surface is convex, made subscapularis (m. subscapularis), is attached to a small mound of the humerus.
Shoulder tightened to the chest rhomboid muscle and particularly the front
gear (m. serratus ant.), starting from the edges and is attached to the medial edge of it on the inside.
In blade area there are two neurovascular bundle. One of them is: nadopasana artery (a. suprascapularis), the accompanying same veins and nerves that Innervate fossae and infraspinatus muscles. The neurovascular bundle are held in a hole under acromial process. In infraspinatus bed nadopasana artery forms numerous anastomoses with branches artery envelope spade (a. circumflexa scapulae).
Another neurovascular bundle consists of the descending branch of cross arteries in the neck (a. transversa colli), the same vein and its dorsal nerve shoulder blade (n. dorsalis scapulae), which take place on a medial edge of the blade. Descending branch of cross arteries of the neck also takes part in education of the shoulder arterial circle (Fig. 3)which plays an important role in the development roundabout circulation in ligation axillary and brachial arteries.
Violation movements of the upper limbs at the shoulder joint and change the position of the blades depend on the state of the function of the muscles of the shoulder area. In connection with this disease or injury blades often cause sudden disorder movements of the shoulder joint.
There are various deviations from normal position and shape of the blade. High standing of the scapula (illness Sprengel) is reflected in the fact that one of the blades is located on 4-5 cm above the other, the bottom corner drawn to the backbone, and the lateral edge turned outwards. Sometimes deformation becomes large. High standing of the spade is not only a cosmetic defect, but also leads to significant functional impairment - restriction of movement of the shoulder joint and atrophy of the muscles of the shoulder girdle.
Conservative treatment - massage, gymnastics, use of bandages - no effect. Surgical methods of treatment are to mobilize the shovels, the reduction and fixing it at the new location (Fig. 4).
Pterygoid (navicular) the shoulder blade (scapula alata) - congenital deformity, which consists in rejecting the medial edge of the blade from the back surface of the chest. Often this deformation is bilateral and often combined with the disease Sprengel. Sometimes deviation blade backwards develops on the soil of infantile paralysis (when struck by a diamond-shaped and trapezoidal muscle).
Treatment conservative - long massage and medical gymnastics.
Heavy one-sided strain treated operatively - fix the border of the scapula in the cuts made in the sixth and seventh ribs.


Fig. 4. Operation relegated blades: 1 - skin incision; 2 - osteotomy of the coracoid process, reducing the blades and fixing her silk suture VII to the edge.
Fig. 5. Typical fractures blades: 1 - fracture anatomical cervix; 2 - fracture surgery of the neck; 3 - a fracture of the lower angle; 4 - a fracture of the upper inner corner; 5 - a longitudinal fracture.

Fractures of the shoulder blades are observed in the neck, body and Akromiylar process (Fig. 5). Diagnosis of fracture Akromiylar and hooked prongs installed by local pain and trepetanii. Fractures of the shoulder blades instead with articular cavity hanging down, and the finiteness of the damaged party becomes longer healthy. Femoral neck fractures blades are often complicated by damage ADAPTACII artery (A. suprascapularis) - hematoma, and the squeezing of nadopasana nerve (n. suprascapularis), resulting develops contracture of the shoulder joint and acute pain with the active abduction of the shoulder.
Body fractures of the shoulder is well grow and function of a limb have little impact.
Treatment of fractures of the coracoid and Akromiylar processes conducted by immobilization shoulder at 20 - 25 days in abduction bus diverting arms at 90 degrees. Fractures recommended inpatient treatment with traction in the situation of the abduction of limbs. Immobilization in these cases provide a bandage type DESA that in 5 to 6 days alternate with solitaire and begin serial physiotherapy.
Purulent processes scapular region develop mainly in fiber spaces, located between the shoulder and the chest wall; they can spread to the tissue modeltoview space, and through the latter - on fiber armpits. Particularly important in the spread purulent processes has pregabalina gap (Fig. 6).

Fig. 6. Fascia scapular region and predtopochnyj cracks (front-cut): 1 - m. trapezius; 2 - the neurovascular bundle armpits; 3 - collarbone, and so subclavius; 4 - m. pectoralis major; 5 - m. pectoralis minor; 6 - jumper between the third and fourth fascia; 7 - VIII rib; 8 - jumper between the fourth and fifth fascia; 9 - front pregabalina gap; 10 - fifth fascia; 11 - third fascia; 12 - m. serratus ant. and it fascia (the fourth); 13 - m. infraspinatus; 14 - m. subscapularis; 15 - Lopatka; 16 - rear pregabalina gap; 17 - second fascia; 18 - first fascia (fascia superficialis); 19 - m. supraspinatus.

Of inflammatory processes in the shoulder area there are phlegmon, developing in the tissues between the shoulder and the chest wall.
A. Y. Sauzon-Yaroshevich recommends to open phlegmon in predoperatinom the space of the transverse incision above the lower angle of the scapula.
From this section you can trepanation or partial resection of the blade for removing foreign phone With extensive phlegmon of the shoulder area with involvement armpit to drain predoplatnoy slit through tripartite hole (foramen trilaterum). The incision is made on the edge of the m. teres minor continue stupid by penetrate the tissue that performs foramen trilaterum, and purulent cavity intermuscular spaces blades.
In the diffuse osteomyelitis blades produce subperiosteal resection. For this purpose spend a horizontal incision at the top m. latissimus dorsi, crossing the lower angle of the scapula; the second section from the middle of the first sent up to the neck, shoulder blades. The muscles and the periosteum is removed from the blade respetaron. After subperiosteal resection blade fully regenerates 4-6 weeks due to the periosteum, but does not reach its initial size.