KODAGU INSTITUTE OF MEDICAL SCIENCES,

MADIKERI

DR
MAMATHA.Y
ASSOCIATE PROFESSOR
DEPARTMENT OF ANATOMY
 CLASSIFICATION AND
MORPHOMETIC PARAMETERS OF
SPINE OF SCAPULA
 A pitcher steps back, winds up, and the force through the lower body is
coordinated by the scapula to throw the ball. This is depicted in the stills of
the pitcher in the BELOW image.

The beautiful overhand pitch that facilitated win was not

only made possible by hard work and practice,
BUT
 also by a pivotal bone in your anatomy - the scapula, which
is more commonly referred to as the shoulder blade

 critical for stabilizing and permitting sport movements,

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such as throwing, swimming, rowing.
 Overall, the scapula

coordinates the large

forces

from your back and lower

body into efficient motion
through the arm and hand.

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 The scapula is located on
our back and has a triangular
shape that looks like a blade,
hence the common reference,
shoulder blade.

Although it is primarily a flat

bone, the scapula also
contains three projections,
the a.c. processes,
the acromion, coracoid
processes , spinous
process(1)

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 The scapular spine (SS) is a prominent
plate of bone and provides elegant
reinforcement to the scapula.

 The spine is triangular, and flattened

from above downward, its apex being
directed toward the vertebral border.

 It begins at the vertical [vertebral or

medial border] - smooth, triangular
area and gradually elevated, ends in
the acromion, which overhangs
the shoulder-joint.(1)
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 It presents two
surfaces
 Superior surface
 Inferior

 Three borders.
 Anterior
 Posterior
 lateral

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 NEED FOR THE STUDY
 Frankle M, et.al(2005): Scapular fractures are rare
injuries which consist of 1 % of all fractures and 5 % of
shoulder girdle fractures .
 Most of the scapular fractures are neck and body fractures
 only 6 % of scapular fractures are scapular spine
fractures(2)

 Armodios M(2005): With the worldwide application of

reverse total shoulder arthroplasty, incidence of SS
fractures as a result of complications of this procedure is
relatively high (0.9%–10%)

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 Most of it neglected, possibly because SS fractures are frequently
grouped with fractures of the scapular body or acromion.
BUT
 Those fractures that enter the spino-glenoid notch are clearly
different from isolated acromial fractures and therefore should be
identified and treated differently.(3)

 Burke CS et al(2006): States that SS - demonstrated to be the most

useful region for screw fixation for reverse total shoulder arthroplasty
prosthesis on account of more bone stock and cortical thickness
which increase screw pullout strength.

 However, there exists a significant variability in SS morphology, and

knowledge of shape and dimension is critically important for these
procedures.(4)
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 Mohammed As-Sultany et.al(2008): SS mal-union has been shown
to reduce subacromial space and alter normal kinematics of the
acromioclavicular and scapulothoracic joints.

AND

 Surgical management for SS fracture is recommended especially in

young, fit, and active patients.
 During these surgical procedures, detailed knowledge of SS is
fundamentally important to minimize overlying tissue irritation, aid
in fracture reduction, and improve the mechanics of the bone–plate
construct.(5)

 On review of literature – observed- less study conducted

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 OBJECTIVES
 The objective of this study was to classify the
SS(scapular spine) morphologically

 To provide baseline data of specific geometrical

parameters of scapular spine according to
osteologic features.

 To evaluate the asymmetry of parameters

bilaterally

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 Methodology
 The present study - 100 dry adult human
scapula
 Age and sex of the donors were unknown

 Types of scapula were classified into five types

– morphologically(6)

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 Type 1- Fusiform shape
(tapered at both ends and wide
in the middle)

 Type 2- Slender rod shape (thin

throughout)

 Type 3- Thick rod shape

(thick throughout)

 Type 4- Wooden club shape Fig1: Scapular spine classification

(gradual thickening from (schematic):
medial to lateral edge)

 Type 5- Horizontal S-shape

(“S” shaped spine)

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 MORPHOMETRIC MEASUREMENTS

 Nine bony landmarks described for their

relevance to regions of interest for scapular
fixation were chosen and marked (fig 1, 2)

 Measurements were taking using digital vernier

caliper and thickness of spine was taken using
thickness measuring guage micrometer

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  The parameters were as Fig2: Describes the location of the bony landmark
follows:

 AE (superior border of SS):

length of SS measured from the
medial edge of the scapula
where it meets with the SS to
the lateral edge of the acromion

 AD: length of SS measured

from the medial edge of the
scapula where it meets with the
SS to the corner of the
acromion;

 AC (base border of SS):

distance from the medial edge
of the scapula where it meets
with the SS to the edge of the
spinoglenoid notch;

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Fig 2
  BC (lateral border of SS):
height of the spine at the
lateral edge;

 FG and HI: height of the

spine at point G and I;

 J, K, L: midpoints of FG,
HI, and BC.

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Fig 2(contd)
  Data Analysis and Statistics
 All data are presented as mean and standard deviation (SD).

 Descriptive statistics was used to describe demographics and

measurement variables of all scapulae.

 Categorical variables are expressed as frequencies and

percentages. Unpaired “t” test was used to compare types
considering a P-value<0.05 as statistically significant.

 The Statistical Package for Social Sciences (SPSS, version 20.0)

was used for the analysis of the data.

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 RESULTS

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 TYPE II- Slender

TYPE I-Fusiform

TYPE III- thick rod

TYPE IV- Wooden club

19 Fig: 3-showing different types of SS

 RESULTS TYPE TOTAL(100) SIDE N(%)

RIGHT(50) 19(38)
 Based on morphological I
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classifications: (Table1,fig 3). LEFT(50) 16(32)

 Type 1-Fusiform shape (35%) RIGHT(50) 05(10)

II
 Type 2-Slender rod shape 16
LEFT(50) 11(22)
(16%) was the least
RIGHT(50) 12(24)
 Type 3-Thick rod shape(21%). III
21
LEFT(50) 09(18)
 Type 4-Wooden club shape (28%)
IV
 Type 5-Horizontal S-shape (0%) -- RIGHT(50) 14(28)

were the least common. 28

LEFT(50) 14(28)
NIL
V
NIL
NIL

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 TABLE 2: Length and height Distribution and Measurements of the Scapular Spine Based on
Body Side among different types of scapula.
TYPES
SIDE N(%) AE AD AC BC FG HI
Mean+SD Mean+SD Mean+SD Mean+SD Mean+SD Mean+SD

TYPE 1
RIGHT(50) 19(38) 127.8(8.4) 121.9(7.7) 80.5(4.3) 39.5(4.2) 25.0(2.8) 30.2(3.7)

LEFT(50) 16(32)
127.9(7.4) 120.5(7.5) 82.7(5.4) 37.4(7.2) 23.9(2.8) 24.3(2.3)

TYPE II RIGHT(50) 05(10) 115.7(3.3) 107.7(4.14) 69.66(4.8) 36.1(2.3) 26.24(3.3) 28.86(2.2)

LEFT(50) 11(22) 124.7(12.2) 114.7(10.7) 78.9(7.4) 38.0(6.9) 22.3(2.7) 24.6(2.7)

TYPE III RIGHT(50) 12(24) 140.6(10.1) 124.4(7.5) 88.6(7.0) 44.1(4.5) 26.2(6.2) 28.6(3.3)

LEFT(50) 09(18) 126.1(13.9) 119.8(14.9) 82.9(11.6) 37.9(7.4) 23.1(2.9) 24.6(4.3)

TYPE IV RIGHT(50) 14(28) 120(8.1) 116.7(8.0) 71.1(6.4) 39.9(4.4) 27.6(3.0) 33.5(4.2)

LEFT(50) 14(28) 123.0(9.8) 115.0(11.2) 79.6(7.3) 32.8(6.7) 22.8(1.9) 23.4(2.9)

TYPE V RIGHT(50)
-- -- -- -- -- --
0
0 --- --- --- --- --- ---
LEFT(50)

21 “”P”” value > 0.05 – statistically insignificant

 SIDE N(%) BC FG HI J K L
Mean+SD Mean+SD Mean+SD Mean+SD Mean+SD Mean+SD

TYPE 1 RIGHT(50) 19(38) 39.5(4.2) 25.0(2.8) 30.2(3.7) 3.9(1.0) 4.0(1.0) 8.2(2.0)

LEFT(50) 16(32) 37.4(7.2) 23.9(2.8) 24.3(2.3) 3.1(1.2) 3.5(1.31) 7.4(1.4)

TYPE II RIGHT(50) 05(10) 36.1(2.3) 26.24(3.3) 28.86(2.2) 3.4(0.8) 3.8(1.3) 6.6(1.3)

LEFT(50) 11(22) 38.0(6.9) 22.3(2.7) 24.6(2.7) 2.8(0.7) 2.8(0.7) 6.5(2.2)

TYPE III RIGHT(50) 12(24) 44.1(4.5) 26.2(6.2) 28.6(3.3) 3(1.4) 3(1.4) 7(2.0)

LEFT(50) 09(18) 37.9(7.4) 23.1(2.9) 24.6(4.3) 3.6(1.4) 3.6(1.4) 8.2(1.9)

TYPE IV RIGHT(50) 14(28) 37(4.4) 27.6(3.0) 33.5(4.2) 4(1.6) 4(1.3) 8(1.9)

LEFT(50) 14(28) 32.8(6.7) 22.8(1.9) 23.4(2.9) 4.0(1.3) 4.2(1.3) 7.2(0.9)

RIGHT(50) 05(10) 36.1(2.3) 26.2(3.3) 28.8(2.2) 3.4(0.8) 3.8(1.3) 6.6(1.3)

TYPE V
LEFT(50)
-- -- -- -- -- --
0

RIGHT(50)
0 --- --- --- --- --- ---
Table 3: Height and Thickness Measurements of the Scapular Spine Based on Body Side
22 among different types of scapula.
 DISCUSSION
 In this study, we successfully classified 100 SSs into 5 types based on their morphological
features. Few studies have reported morphological anatomy of SS.
 Our results demonstrate that the variation of SS is not a rare occurrence. Spines were
classified into Type 1-Fusiform shape(35%), Type 2-Slender rod shape(16%), Type 3-
Thick rod shape(21%), Type 4-Wooden club shape(28%), and Type 5-Horizontal S-
shape(0%).
 Among the classified SS, Types 1 (35%) was the most common, followed, with Type 2
(16%) being the least common.

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  Sanjay G et al(2004) : The SS - regarded as an optimal
region to support screw, pin, or wire purchase for fracture
fixation stabilization because of the adequate bone stock.
 Furthermore, there exists a direct relationship between an
increased screw pullout strength and the stability of the implant
fixture with increased cortical thickness
 Similarly, besides violent voluntary contraction of muscles, it has
been believed that the fragility associated to the SS was one of the
main reasons of avulsion fractures(7)
 Our study showed that the thickness of the landmarks of Types 2
and were much thinner than those of types of Types 1, 3, and 4.
Types 2 and 5 might be more prone to fracture than other types
because of its anatomical architecture
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 .

 Park M(2008) : opines that type 5 SS classification obliquely

crosses the dorsal surface of the scapula like a horizontal “S,”
with a half forward cranial and the other half forward caudal.
Although the other 4 types cross in a line from the vertical border
to the scapular neck, the contour of Type 1 tappers at both
ends with a wide middle region.

 Therefore, the contours of Types 5 and 1 reflect a more complex

morphology than the other 4 types, eventually presenting a worse
scenario with the presence of a fracture. (8)

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  Tubbs et al(2007): found the SS to be well-suited for posterior
spinal fusion graft and successfully utilized it in posterior lumbar
interbody fusion surgery- as an osteo-myocutaneous flap.

 The SS - versatile used in many areas of the body due to the ease
of harvesting, minimal donor site morbidity and as reliable blood
supply to this bone.

 More importantly, estimating bone availability as well as

familiarizing with the morphological features of the spine
is essential for an appropriate contouring and fitting of the bone
graft to the defects to ensure the best functional outcome.

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  Lantry J M(2012): it is an enormous challenge for the
surgeon to bend and rotate the plate to fit the contour of
type 1 & 5 types.
 Surgical time is delayed, there exists an increase in overlying
tissue irritation, and it ends up aggravating the mechanics of
the bone–plate construct. Furthermore, hardware removal
rate is approximately 7.1% due to either implant-related
discomfort or failure.
THUS
 Familiarizing with the morphological features may offer
substantial benefits for the orthopedist in preoperative
planning, and using pre contoured locking plates may be an
additional aid during surgery(9)

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  Recently, it has been shown that the stability of the glenoid
construct would be further enhanced by placing a longer
posterior glenoid screw through the spinoglenoid notch and into
the spine of the scapula. However, the study was limited by a
significant variability in bone quality and size(11,12).

 Our study supplements this research by not recommending the

addition of a longer posterior glenoid screw for Types 2 and 5,
especially Type 2, because of the preexisting thinning spine.

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  Nonunion of the scapular spine at the base of the acromion
caused persistent pain and significant limitation of function.
BECAUSE

 The sagging of the lateral spine and acromion effectively

produced narrowing of the supraspinatus outlet and
secondary impingement of the rotator cuff.

 Although scapular spine fractures are rarely seen, they must

take place in the differential diagnosis of impingement
syndromes of the shoulder.(13)

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 Conclusion
 In conclusion, the present study classified and measured SS
morphology on 100 dry adult human scapula.
 Type 1 was the most common, while Type 5 was the least
common.
 The contours of Types 5 and 1 were more complex than the
other 3 types.
 Types 2 and 5 were much thinner than the other types; therefore,
we believe these types to be more prone to fracture.
 The presented data provides precise and well-sorted information
about SS variation and localization in South Indian population. This
supplements existing reports which contribute to a thorough
understanding of the human SS.

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  With advancement in surgical approaches – shoulder
arthopathies, and scapular spine fractures it becomes
important to have thorough prior knowledge of
morphological and morphometric parameters of SS
 Reduce in surgery time, additional aid for the surgeon ,
decrease the future complications like malunion, tissue
irritation etc.,

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 ACKNOWLEDGEMENT

 I would like thank our respected Director and Dean for

allowing me to attend this conference and making this
presentation possible.

 I Hereby would like to convey my heartfelt thanks to all my

dear colleagues and also non teaching staff of our department
KoIMS, Madikeri for their support throughout this study.

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edition.Elsiver Publishers.p.no.206.
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arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study
of sixty patients. J Bone Joint Surg Am 2005; 87:1697–1705.
 3.Armodios M.Reverse Shoulder Arthroplasty Indications, Technique, and Results.
Techniques in Shoulder and Elbow Surgery 6(3):135–149, 2005
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fixation. J Shoulder Elbow Surg 2006; 15:645–648.
 5.As-Sultany M, Tambe A, Clark DI. Nonunion of a scapular spine fracture: case report and
management with open reduction, internal fixation, and bone graft. Int J Shoulder Surg. 2008;
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 8. Park AY, DiStefano JG, Nguyen TQ, et al. Congruency of scapula
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 10.Tubbs RS, Wartmann CT, Louis RG, Jr, et al. Use of the scapular spine in
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 11.Codsi MJ, Iannotti JP. The effect of screw position on the initial fixation
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 12. Klein SM, Dunning P, Mulieri P, et al. Effects of acquired glenoid bone
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arthroplasty. J Bone Joint Surg Am 2010; 92:1144–1154.
 13.Cem Copuroglu,Levent Tan Elif Copuroglu Mert Ciftdemir and Mert Ozcan.
Pseudo-arthrosis of the spine of the scapula: a case report with a delayed
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 THANK YOU

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