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International Journal of Morphology

versión On-line ISSN 0717-9502

Int. J. Morphol. v.25 n.4 Temuco dic. 2007

http://dx.doi.org/10.4067/S0717-95022007000400028 

 

Int. J. Morphol, 25(4):855-859,2007.

 

High Incidence of Complete Ossification of the Superior Transverse Scapular Ligament in Brazilians and its Clinical Implications

Alta Incidencia de Osificación Completa del Ligamento Escapular Transverso Superior en Brasileños y sus Implicancias Clínicas

 

*Silva, J. G.; **Abidu-Figueiredo, M.; ***Fernandes, R. M. P.; ****Aureliano-Rafael, F.; ****Sgrott, E. A.; ***Silva, S. F. & ***Babinski, M. A.

* Department of Anatomy, Biomedical Science Center, Gama Filho University, Brazil.
** Department of Anatomy, Biomedical Institute, Federal Rural University of Rio de Janeiro, Brazil.
*** Department of Morphology, Biomedical Institute, Fluminense Federal University (Rio de Janeiro), Brazil.
**** Department of Anatomy, Health Science Center, Vale do Itajai University, (Santa Catarina), Brazil.

Dirección para correspondencia


SUMMARY: The aim of this study was to verify the prevalence of the ossified superior transverse scapular ligament (STSL) on dry bones of scapulae. 221 dry bones were analyzed, (111 rights and 110 lefts), proceeding from Rio de Janeiro and of Santa Catarina, Brazil. As exclusion criterion, were not analyzed bones of children or damaged. For the quantitative analysis of the data, the software Graphad Instat was used. Fisher exact test was used considering the p 0,05 as significant. After analysis of the scapulae, 30,76% (68/ 221) presented the ossified STSL (p 0,0001) of which, 52,94% (36/68) were ossified on the right side and 47,05% (32/68) on the left one. The 153 scapulae that did not present the ossified STSL, it was observed in 19,6 % (30/153) of these bones, the superior edge varying in the transverse plan, increasing superior angulation and, modified the width and depth of the scapular incisure. This anatomical curiosity should be kept in mind by clinicians that approaches painful syndrome of the shoulder, as well as, this anatomical curiosity should be kept in mind by students that may manipulate this anatomical area.

KEY WORDS: Gross Anatomy; Variation; Scapula; Superior transverse scapular ligament.

RESUMEN: El objetivo de este estudio fue verificar la prevalencia del ligamento escapular transverso superior (LETS) osificado, en huesos secos. 221 escápulas secas (111 derechas y 110 izquierdas) fueron analizadas procedentes de Río de Janeiro y de Santa Catarina, Brasil. No fueron analizados huesos de niños o dañados. El tratamiento estadístico de los datos fue realizado con el software Graphpad Instat, siendo seleccionado el test Fisher, con un p 0.05 como significativo. El 30.76% (68/221) de las escápulas presentaron el LETS osificado (p 0,0001) de ellos, el 52.94% (36/68) correspondían a escáulas derechas y 47.05% (32/68) a escápulas izquierdas. Las 153 escápulas que no presentaron el LETS osificado, se observó en el 19.6% (30/153) de estos huesos. El margen superior que variaba en el plano transversal, incrementaba la angulación superior y modificaba así el ancho y la profundidad de la incisura escapular. Esta variación anatómica la deben tener presente los clínicos debido al síndrome doloroso del hombro, como también, los estudiantes que manipulan esta área anatómica.

PALABRAS CLAVE: Anatomía; Variation; Escápula; Ligamento escapular transverso superior.


INTRODUCTION

The suprascapular notch is roofed by the superior transverse scapular ligament (STSL) converting it into foramen in some species (Khan, 2006). In humans, this conversion is a result of the ossification of the STSL (Gardner et al, 1988; Bergman et al, 1988, Williams et al., 1989). Variations on STSL have been reported by Testut (1904) and Poirier & Charpy (1911). Calcification, partial or complete ossification and multiple bands were also discussed by Ticker et al., (1998) and related by others authors (Osuagwu et al., 2005; Khan). Moreover, others studies have been observed the prevalence of these variations (Kajava, 1924; Vallois,1925; Vallois, 1926; Gray, 1942; Lewis, 1959).

The suprascapular artery and vein pass over the superior aspect of the STSL (Antoniadis et al., 1996; Weinfeld et al., 2002). The suprascapular notch and the overlying STSL constitute a narrow foramen, with inflexible and often sharp edges, through which the suprascapular nerve must pass (Williams et al.; Weinfeld et al.). The suprascapular nerve is fixed in the osteofibrous foramen of the notch and STSL and by its distal muscular and joint connections (Gelmers & Byus, 1977; Antoniadis et al.; Weinfeld et al.). Mechanical irritation of the suprascapular nerve can occur at this location with excursions of the scapula, particularly during cross-body abduction, during a variety of activities involving movement of the upper extremity (Clein, 1975; Gelmers & Buys; Antoniadis et al.; Weinfeld et al.).

The ossification of the STSL was considered anomalous by Lewis and Harris et al., (2001), suggesting one more factor to calcification of STSL and suprascapular nerve entrapment syndrome.

In the diagnosis of suprascapular nerve entrapment syndrome, anatomical variations of the STSL sometimes feature in the hierarchy of possible etiologic factors (Callahan et al., 1991). However, this syndrome has also been described in clinical scenarios without a visible ossification of the STSL (Osuagwu et al.). Complete ossification of the STSL or suprascapular nerve entrapment syndrome has not been previously described amongst Brazilians. Therefore, the proposal of this study was to verify the prevalence of the STSL ossified in Brazilians dry bones.

MATERIAL AND METHOD

This work was performed according to the provisions of the declaration of Helsinki in 1995 (as revised in Edinburgh, 2000). Guidelines for our internal review board were found in the observations made and the protocol was approved by local Department of Morphology.

Two hundred twenty one scapulae (dry bones) were analyzed: 111 rights and 110 lefts, proceeding of the collection of three universities from Rio de Janeiro state and one university of Santa Catarina state. As exclusion criterion, were not analyzed bones of children or damaged.

The exam was performed by presence of STSL completely ossified. It was adopted like exclusion criterion all the children scapulae and the scapulae which the superior margin of bone were bilaterally damaged. All the analyzed parameters were independent of sex or race.

For the quantitative analysis of the data, the software Graphad Instat (Graphpad) was used. The tests of Kolmogorov-Smirnov were used to analyze if the data were within the normal distribution. Fisher exact test was used to verify the relation between showed in Table I. The p 0,05 was considered significant.


RESULTS

Macroscopic examination revealed that 68/221 (30,76%) of analyzed scapulae presented the ossified STSL creating a forame (Figs.1 and 2). The data obtained are considered statically significant (p 0,0001) (Table 1 and Fig.3). In this group, it was observed that 36/68 (52,94%) were ossified on the right side and 32/68 (47,05%) on the left one. In the 153 scapulae that did not present the ossified STSL, 30/153 (19,6%) have been showed the superior edge varying at transverse plan, creating a superior angulations; which, in the specimens studied, modified the form at depth and width of the scapular notch.


  Fig. 1. Posterior-superior view of the left scapula showing ossified STSL (arrow).


  Fig. 2. Posterior-superior view of the left scapula showing ossified STSL (arrow)


Fig. 3. Representative graphic of the results between waited data comparing with obtained data. 221 specimens analyzed: black co-lor= suprascapular notch (normal anatomy); gray color = ossified STSL (abnormal anatomy).

DISCUSSION

The complete ossification of the STSL converting the suprascapular notch into foramen was found in three of 60 (5%) scapulae by Poirier & Charpy. In 133 finish scapulae studied by Kajava, the foramen was present only twice (1.5%). Vallois (1925) found the foramina to occur 13 times in 200 (6.5%) scapulae of French men. In a second study Vallois, (1926) reported that Italian scapulae had foramina in 6.1% and in a series of scapulae from various sources, the incidence varied from 0% to 3.3 %. Gray found foramen in 73 of 1.151 scapulae (6.34%), but no suprascapular foramina were found in 87 Indian scapulae.

To our knowledge, this work is the first to quantify the variation of STSL ossified in Brazilians. We could observed in the subjects a significant percentage of 30.76% (68/221) considered statically significant (p< 0,0001). Comparing with other studies, we verify a high percentage of frequency at Brazilians (Poirier & Charpy; Kajava; Vallois, 1925; Vallois, 1926; Gray). About the alteration of the superior edge scapular, we can relate this to shortening or adaptation for muscular overuse that fix at superior edge, during the life. The muscles, supraspinatus and scapula elevator transit in this region can be related to the STSL calcification, associated to the muscular groupings of this region. Certain habits of life at utilization of the upper limb can also intervene at the process.

Some studies try to elucidate the alterations provoked in the structures of the human skeleton, in special at sports (Ringel et al:, Tengan et al:, Wang & Koehler). Sandow & Ilic have been discussed about the specific volleyball movements and their implications at suprascapular nerve compression. The characteristically gestures e.g. of volleyball players as abduction associate lateral (external) rotation are factors that predispose the neuropraxis. These data justify our results and the anatomical exploration of the scapular notch region and the STSL.

The most recent papers do not elucidate reasons for the STSL ossification, they only analyze that this condition promotes the suprascapular nerve syndrome (Prescher). The ossified STSL can be a risky factor at surgical explorations during a suprascapular nerve decompression (Ticker et al.).

Cohen et al. have been described a familial case of calcification of STSL affecting a 58 year old man and his son, who had STSL calcification causing entrapment neuropathy of the suprascapular nerve, clinical symptoms of pain, weakness of the external rotation and abduction, and atrophy of the supraspinatus muscle (Weinfeld et al). There are reports in the literature about bifid (Alon et al., 1998) and trifid (Ticker et al) STSL, with the former including an account of ensuing suprascapular nerve entrapment.

Rengachary et al. have been observed six different types of anatomical variations in the suprascapular notch area. These variations of the suprascapular notch and the STSL constitute potential predisposing factors to suprascapular nerve entrapment. However, Harris et al., promoted new discusses about the suprascapular notch area. They showed that conoid ligament has accessory fascicle, the lateral border of the scapular notch at the junction of the conoid and STLS. This variation is considered anomalous by Harris et al., but it is mentioned by Testut and Lewis , suggesting one more factor to calcification of STSL and suprascapular nerve entrapment.

Despite this possible relationship between suprascapular nerve entrapment syndrome and the morphological differences, in the infraspinatus or supraspinatus muscle and variations in the STLS, we were unable to correlate all the aforementioned in the subject of this case report due the poor documentation (Osuagwu et al:, Khan). The present study demonstrates that complete ossification of STSL is common and can occur usually in Brazilians.

The anatomical knowledge of the STSL ossified are of extreme importance for the clinicians that approaches painful syndrome of the shoulder, as well as, this anatomical curiosity should be kept in mind by students and surgeons that may manipulate this anatomical area.

 

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Correspondence to:

Prof. Dr. Marcio Antonio Babinski
Department of Morphology
Biomedical Center
Fluminense Federal University
Av. Hernani Mello 101
CEP 24.210-150
Niterói, Rio de Janeiro

BRAZIL

Phone: + 55 21 2587-6499 Fax:+ 55 21 2587-6121

E-mail: mababinski@gmail.com mababinski@vm.uff.br

Received: 22-07-2007 Accepted: 22-10-2007

 

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