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CASE REPORT

Snapping Scapula Secondary To Elastofibroma: A Case Report

Chowdhry M*, Bismil Q, Blackburn SC, Little N, Ricketts DM
*
Orthopaedic department of Brighton and Sussex University Hospitals NHS Trust

Address for Correspondence:
Majid Chowdhry
12 Woodfield Grove, Streatham, London, SW16 1LR
E-mail: m.chowdhry@doctors.org.uk
Tel: 07920112030

 

Abstract:

Snapping scapula is an uncommon symptom associated with shoulder pain and reduced movement. Elastofibroma is a rarer cause of snapping scapula.1 We describe a rare cause of snapping scapula: benign elastofibroma at the inferior pole of the scapula. This was not demonstrated by CT scanning but the lesion was successfully treated by excision, and histology determined the diagnosis of elastofibroma.
Keywords: snapping scapula, elastofibroma.

J.Orthopaedics 2007;4(2)e11

Introduction:

Snapping or clicking beneath the scapula is an uncommon symptom. We present an unusal cause: elastofibroma of the chest wall. 

Elastofibromas are uncommon, benign, slow-growing connective tissue tumours; and are often periscapular.  They rarely cause scapular snapping.1  

Diagnostic difficulties arise in their illusiveness with the use of CT scans. MRI has proven to be a much better form of imaging. 5

Case Report:

A 61-year-old right handed businesswoman presented with a 5 month history of painful snapping of the left scapula.  There was no history of trauma.  On examination scapulothoracic crepitus was observed. There was a 4 x 4cm hard, smooth-surfaced lump at the lower pole of the scapula, partially tethered to the underlying ribs.  The patient was generally fit and well, the general examination was unremarkable and the right scapula was normal. 

Fig.1 CT formatted saggital view of Left scapula

Radiographs of the scapula, including a scapular lateral view were normal. CT scan of the left shoulder was also normal (figure 1, 2).      

 


 

Fig.2 CT axial view of the inferior angle of the left scapula.

At operation under general anaesthesia, an oblique incision over the lower pole of the scapula was used to visualise the tumour.  The lesion was attached to the periosteum of the ribs and the external fascia of the rib cage, and extended into subscapular space. The tumour was excised and sent for histology.  The lump was composed of a heterogeneous mixture of collagen, elastic fibres and fibroblasts; consistent with a diagnosis of benign elastofibroma. 

At six week follow-up, the surgical site has healed and the patient reported that the painful clicking had resolved.  She had returned to work.  She has had no recurrent scapular clicking or pain.

Discussion :

The causes of snapping scapula are classified as: deformity or exostosis of the thoracic cage; an abnormal relationship between the scapula and the thoracic cage secondary to poor posture; lesions of the scapulothoracic muscles; lesions of the subscapular bursae; and lesions of the scapula itself.  Lesions of the scapula include: increased anterior inclination of the superior angle; osseous or fibrocartilaginous nodules on the anterior aspect of the superior angle; tumours of the anterior surface of the body of the scapula; Sprengel deformity and malunited fractures.1 

Elastofibroma is an uncommon benign primary tumour of soft tissues2 .It usually arises deep to the lower scapular pole;3 is often bilateral;3 and consists of a mixture of collagen, elastic fibres and fibroblasts.3 

A literature search revealed that elastoma of the chest wall has been infrequently described as a cause of snapping scapula. Less than 20 cases have been described in the literature2-4. 

Literature describes CT findings of elastofibroma as typically poorly defined changes in the soft tissue, which although characteristic of elastofibroma, donít always definitively diagnose the lesion. MRI is more superior in this respect, showing more clearly the same alternating high and intermediate signal intensities on T1-weighted imaging that can be enhanced by using gadolinium.5 

Our case presented with the triad of: lump at inferior scapular pole, pain and snapping.  The presence of the triad of inferior pole lump, pain and snapping favour this diagnosis.  CT may not always demonstrate the lesion, in which case MRI is a better investigation to perform

Reference :

  1. Canale ST.  Campbellís Operative Orthopaedics.

  2. Majo J, Gracia I, Doncel A, Valera M, Nunez A, Guix M.  Elastofibroma dorsi as a cause of shoulder pain or snapping scapula.  Clin Orthop Relat Res. 2001 Jul;(388):200-4.

  3. Cohen I, Kolender Y, Isakov J, Chechick A, Meller Y.  [Elastofibroma, a rare cause of snapping scapula syndrome].  Harefuah. 1999 Oct;137(7-8):287-90, 350.

  4. Nielsen T, Sneppen O, Myhre-Jensen O, Daugaard S, Norbaek J. Subscapular elastofibroma: a reactive pseudotumor.  J Shoulder Elbow Surg. 1996 May-Jun;5(3):209-13.  

  5. Abe S, Miyata N, Yamamoto Y, Yamaguchi T, Tamakawa M. Elastofibroma Dorsi: CT, MRI and pathologic findings. Plastic and Reconstructive Surgery. 1999 Dec;104(7):2121-2126

 

This is a peer reviewed paper 

Please cite as : Chowdhry M :Snapping Scapula Secondary To Elastofibroma: A Case Report

J.Orthopaedics 2007;4(1)e11

URL: http://www.jortho.org/2007/4/2/e11

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