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17 Scapular region

The scapular region is on the superior posterior surface of the trunk

and is defined by the muscles that attach to the scapula (shoulder Rhomboid major muscle
blade). These muscles can be divided into:
Rhomboid minor muscle
Levator scapulae muscle
• extrinsic muscles, which join the axial to the appendicular
skeleton (trapezius, latissimus dorsi, levator scapulae, rhomboid Supraspinatus muscle
minor, and rhomboid major); Infraspinatus muscle
• intrinsic muscles, which join the scapula to the humerus (deltoid, Quadrangular space
supraspinatus, infraspinatus, teres minor, teres major, and
subscapularis).
Axillary nerve
The principal structural support is from the scapula, a flat triangular Posterior circumflex
bone. The costal (anterior) surface of the scapula overlies ribs II to humeral artery
VII, and its three borders are superior, medial (vertebral), and
lateral (axillary), The lowest point is the inferior angle, and
the lateral point is the lateral angle. A transverse spine of scapula
divides the posterior surface of the scapula into a smaller Circumflex
supraspinous fossa above and a larger infraspinous fossa below. scapular artery
As it continues laterally, this spine forms the acromion (the bony
high point of the shoulder). The subscapular fossa is on the
anterior surface of the scapula. At the lateral angle of the scapula the
Teres minor muscle
shallow, oval-shaped glenoid cavity articulates with the head of the
Teres major muscle
humerus at the glenohumeral joint.
Latissimus dorsi muscle
MUSCLES
The muscles of the scapular region (Figs 17.1 and 17.2) join the Figure 17.1 Scapular muscles (posterior view)
upper limb to the posterior trunk and facilitate many movements at
the shoulder. They can be divided into three groups (Table 17.1).

• The superficial extrinsic muscles join the axial skeleton (chest wall
and rib cage) to the appendicular skeleton (bones of the upper
limb). The two muscles in this group are the trapezius and
latissimus dorsi. The large, triangular trapezius muscle slightly
overlies the broad latissimus dorsi muscle. Together, these Suprascapular nerve
muscles originate from the entire length of the thoracic vertebral Suprascapular artery
Coraco-acromial ligament
column (CVII, TI to TXII) and insert laterally onto the clavicle,
scapula, and humerus. Supraspinatus tendon
• The deep extrinsic muscles (levator scapulae, rhomboid major,
and rhomboid minor) elevate and retract the scapula. The
strap-like levator scapulae muscle is deep to the
sternocleidomastoid muscle (see Chapter 13) and trapezius Biceps brachii
muscles and joins the upper medial border of the scapula to the tendon
transverse processes of the upper cervical vertebrae. The
rhomboids also originate on the medial border of the scapula, Axillary nerve
with the rhomboid minor being more superior than the
rhomboid major muscle. These muscles attach to the spinous Posterior circumflex
processes of the upper thoracic vertebrae. humeral artery
• The deep ‘intrinsic’ or true scapular muscles are the deltoid,
Inferior subscapular
supraspinatus, infraspinatus, teres minor, teres major, and nerve
subscapularis muscle. The deltoid muscle, which has three parts
(clavicular, acromial, and spinal), is superior and forms the Thoracodorsal Subscapularis
roundness of the shoulder over the glenohumeral joint. Inferior to nerve muscle
deltoid are four scapular muscles – the supraspinatus, Thoracodorsal artery Teres major muscle
infraspinatus, teres minor, and subscapularis – which originate
from the scapula and insert laterally on the humerus, forming a
protective covering (rotator cuff) over the glenohumeral joint. Figure 17.2 Scapular region (anterior view)

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The rotator cuff muscles rotate the humerus to enable actions The quadrangular space contains the axillary nerve and posterior
such as throwing a baseball. In conjunction with the latissimus circumflex humeral artery and is bordered superiorly by the inferior
dorsi muscle, the teres major muscle, which is just inferior to the border of the teres minor, inferiorly by the teres major, and medially
rotator cuff muscles, helps form the posterior axillary fold. The by the long head of triceps brachii muscle, and laterally by the shaft
anterior axillary fold is formed by the pectoralis muscles; the axilla of humerus.
lies between these folds. The triangular of auscultation is a small triangular gap in the
musculature, a good place to listen to posterior lungs with a
NERVES stethoscope when the shoulder is protracted. The triangle is between
The skin of the scapular region receives sensory information from the horizontal border of latissimus dorsi, the medial border of the
the medial branches of the posterior rami of cervical nerves C4 to scapula, and the inferolateral border of the trapezius.

UPPER LIMB
C8 and thoracic nerves T1 to T6 (see Chapter 26). The skin over the
lateral scapular area overlying the deltoid muscle is innervated by ■ CLINICAL CORRELATIONS
branches of the superior lateral cutaneous nerve of arm, which is a Scapular fracture
branch of the axillary nerve. Motor innervation to the muscles of Injuries to the scapula are not common because of the triangular
the scapular region is almost entirely by branches of the brachial structure and its supporting spine. The scapula is also protected by
plexus (see Chapter 16): the large number of muscles that cover, surround, and insert onto
it. A scapular fracture is a highly significant injury clinically because

Scapular region
• the dorsal scapular nerve (levator and rhomboid muscles) is from only high-velocity injuries or great force can fracture the scapula
the anterior ramus of C5; (Fig. 17.3). A patient with a scapular fracture therefore has a high
• the suprascapular nerve (supraspinatus and infraspinatus risk of other potentially life-threatening injury (e.g. pneumothorax,
muscles) is from the superior trunk; hemothorax, pulmonary contusion), so particular attention must be
• the four other nerves to this region (the superior and inferior paid to the A, B, C of trauma:
subscapular, thoracodorsal, and axillary) are branches of the
posterior cord and supply the subscapularis, teres major, • Airway,
latissimus dorsi, deltoid, and teres minor muscles. Only the spinal • Breathing,
root of accessory nerve [XI], which innervates trapezius, does not • Circulation.
originate from the brachial plexus.
In the emergency setting all patients should first be assessed to
ARTERIES determine whether their airway is patent (without obstruction).
Blood is brought to the scapular region by a network of arteries, The quality of breathing is then carefully evaluated. After this, the
which form the scapular anastomosis: circulatory system of the patient (e.g. pulses, capillary refill) is
examined. The entire initial survey of the patient takes a few
• muscles medial and superior to the scapula receive blood from the
dorsal scapular, transverse cervical, and suprascapular arteries,
which are branches of the subclavian artery, and also from the
acromial artery, which is a branch of the axillary artery; Superior angle
• muscles anterior and lateral to the scapula are supplied by the Spine of scapula
subscapular, circumflex scapular, and posterior circumflex
Coracoid process
humeral arteries, which are derived from the axillary artery.

The extensive arterial anastomosis at the scapular region provides a

collateral circulation, so if one vessel is blocked or damaged, many Acromion
others can provide blood to the region. This anastomosis helps
preserve the upper limb during injury.

VEINS AND LYMPHATICS Humerus

Venous drainage of the scapular region is by veins that correspond
to the arteries. Each of these veins drains – directly or indirectly –
into the axillary or subclavian veins. Lymphatic drainage of the
scapular region is to the axillary and supraclavicular lymph nodes.

ANATOMICAL SPACES
Three openings in the scapular region – the triangular space, the
quadrangular space, and the triangle of auscultation – contain
important neurovascular structures or are of clinical relevance. Scapula Transverse fracture line
The three-sided triangular space contains the circumflex scapular Inferior angle
artery and is bordered laterally by the long head of the triceps
brachii, inferiorly by the teres major, and superiorly by the teres
minor muscle. Figure 17.3 Common site of scapular fracture

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seconds. Once vital functions are confirmed, a full examination, the sensation of a crunching feeling beneath the surface of the skin,
including a complete neurovascular examination, is carried out. is indicative of a pneumothorax. On completion of the trauma
Any problem discovered during the initial ABC survey warrants survey, and if there are no other life-threatening injuries, the
emergency treatment before the next step can be performed. clinician can carefully examine the upper lateral back. Radiographs
Most patients with scapular fracture experience extreme upper of the scapula in two views will show the fracture line.
back pain and cannot lie comfortably; they hold the injured limb in Treatment of most scapular fractures is conservative and consists
adduction against the chest wall. In addition, because of the high of immobilization of the affected limb and pain control, and
likelihood of associated pulmonary injury, they might have follow-up by an orthopedist. Fractures that damage the nerve and
respiratory symptoms (shortness of breath, inability to breathe, blood supply of the affected limb, open fractures, and fractures
pain on deep inspiration). Tenderness on palpation is invariable, as involving the glenohumeral joint space should be referred to a
UPPER LIMB

are ecchymoses (bruises) or abrasions. Sometimes, crepitance, and specialist for treatment, which in many cases is surgical.

MNEMONICS
Rotator cuff muscles and their insertion on humerus: SITS
(Supraspinatus, Infraspinatus, Teres major, Subscapularis)
(Greater tubercle) (Lesser tubercle)
Scapular region

Transverse scapular ligament: Army goes over the ‘bridge’, Navy goes under the ‘bridge’
(Suprascapular Artery over the ligament, suprascapular Nerve under the ligament)

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SCAPULAR REGION – SURFACE ANATOMY

UPPER LIMB
Trapezius muscle

Scapular region
Acromion (of scapula)

Spine of
scapula

Deltoid muscle

Infraspinatus Teres minor

muscle muscle

Teres major
muscle

Triangle of
ascultation

Inferior angle
(of scapula)

Latissimus Lateral head of

dorsi muscle triceps brachii muscle

Long head of triceps

brachii muscle

Figure 17.4 Scapular region – surface anatomy. Right posterior view of the scapular region of a young male. Observe the muscles that are visible 187
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SCAPULAR REGION – SUPERFICIAL DISSECTION

Occipital artery
Sternocleidomastoid
muscle
UPPER LIMB

Greater occipital
nerve
Great auricular nerve

Lesser occipital
nerve Posterior
supraclavicular nerve
Scapular region

Descending part Spine of scapula

of trapezius muscle
(upper fibers)

Deltoid muscle

Medial cutaneous
branch of cervical Infraspinatus muscle
posterior ramus

Transverse part of Superior lateral

trapezius muscle cutaneous nerve of arm
(middle fibers)

Long head of triceps

brachii muscle
Medial cutaneous
branch of
intercostal nerve Teres minor muscle

Ascending part of Terminal branch of

trapezius muscle intercostobrachial
(lower fibers) nerve

Teres major muscle

Rhomboid
major muscle Basilic vein

Lateral cutaneous
branch of intercostal
Lateral cutaneous nerve
branch of
posterior rami
Medial cutaneous
nerve of forearm

Latissimus
dorsi muscle Ulnar nerve

Figure 17.5 Scapular region – superficial dissection. Right posterior shoulder and middle superficial back. The trapezius muscle converges on the spine of the
188 scapula, and the superior margin of the latissimus dorsi muscle overlaps the inferior angle of the scapula and the most inferior part of the teres major muscle
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SCAPULAR REGION – INTERMEDIATE DISSECTION

Occipital artery Sternocleidomastoid

muscle

Greater occipital
Trapezius muscle (cut)
nerve

UPPER LIMB
Splenius capitis
muscle Spine of scapula

Trapezius muscle
(cut)
Trapezius tendon

Scapular region
Levator scapulae Infraspinatus muscle
muscle

Rhomboid minor Deltoid muscle

muscle

Accessory nerve [XI]

Teres minor muscle

Dorsal scapular
Superior lateral
artery
cutaneous
nerve of arm

Dorsal scapular
Circumflex scapular
nerve
artery in triangular space

Long head of
Rhomboid major
triceps brachii
muscle

Teres major muscle

Trapezius muscle Basilic vein

(cut)

Lateral cutaneous
branch of intercostal
Latissimus dorsi nerve
muscle

Brachial artery

Ulnar nerve

Cutaneous branches
of posterior rami Medial head of
triceps brachii

Medial cutaneous
nerve of forearm

Figure 17.6 Scapular region – intermediate dissection. Right posterior shoulder with the trapezius cut and removed to show the muscles deep to it in the
scapular region. The underlying levator scapulae and rhomboid muscles are seen converging on the medial border of the scapula 189
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SCAPULAR REGION

TABLE 17.1 SCAPULAR MUSCLES*

Muscle Origin Insertion Innervation Action Blood supply
UPPER LIMB

Superficial extrinsic
muscles
Trapezius Medial third of superior Lateral third of posterior Spinal root of accessory Elevates scapula Transverse cervical artery,
nuchal line, external clavicle, medial nerve [XI] and C3, C4 (descending part), dorsal scapular artery
occipital protuberance, acromion, superior edge retracts scapula
ligamentum nuchae, of spine of scapula (transverse part),
spinous processes of depresses scapula
CVII to TXII (ascending part); rotates
scapula (descending &
Scapular region

ascending parts acting

together)

Latissimus dorsi Spinous processes of TVII Floor of intertubercular Thoracodorsal nerve Extends, adducts and Thoracodorsal artery
to TXII, thoracolumbar sulcus of humerus (C6, C7, C8) medially rotates arm,
fascia, iliac crest, lower draws shoulder
three to four ribs downward and backward

Deep extrinsic muscles

Levator scapulae Posterior tubercles of Medial border of scapula Dorsal scapular nerve Elevates the scapula Dorsal scapular artery,
transverse processes above base of spine of (C5) and C3, C4 medially, inferiorly transverse cervical artery
CI to CIV scapula rotates glenoid cavity

Rhomboid minor Ligamentum nuchae, Medial border of scapula Dorsal scapular nerve Retracts and stabilizes Dorsal scapular artery
spinous processes of at base of spine of (C4, C5) the scapula
CVII, TI scapula

Rhomboid major Spinous processes of Medial border of scapula Dorsal scapular nerve Retracts and rotates Dorsal scapular artery
TII–TV below base of spine of (C4, C5) scapula to depress the
scapula glenoid cavity

Intrinsic muscles
Deltoid Lateral third of anterior Deltoid tuberosity of Anterior and posterior Clavicular part – flexes Posterior circumflex
clavicle, lateral acromion, humerus branches of axillary nerve and medially rotates arm; humeral artery, deltoid
inferior edge of spine of (C5, C6) acromial part – abducts branch of thoraco-
scapula arm; spinal part – acromial artery
extends and laterally
rotates arm

Supraspinatus Supraspinous fossa of Superior facet of greater Suprascapular nerve Initiates arm abduction, Suprascapular artery
scapula tubercle of humerus (C4, C5, C6) acts with rotator cuff
muscles

Infraspinatus Infraspinous fossa of Middle facet of greater Suprascapular nerve Lateral rotation of arm, Suprascapular artery
scapula tubercle of humerus (C5, C6) (with teres minor)

Teres minor Upper two-thirds of Inferior facet of greater Posterior branch Lateral rotation of arm, Circumflex scapular
posterior surface of tubercle of humerus of axillary nerve adduction artery
lateral border of scapula (C5, C6)

Teres major Posterior surface of Medial lip of Inferior subscapular Adducts and medially Circumflex scapular
inferior angle of scapula intertubercular sulcus nerve (C6, C7) rotates arm artery

Subscapularis Subscapular fossa Lesser tubercle of Superior and inferior Medially rotates arm and Subscapular artery,
humerus subscapular nerves adducts it lateral thoracic artery
(C5, C6, C7)

*Main nerve root is indicated in bold

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SCAPULAR REGION – DEEP DISSECTION 1

Greater occipital
nerve

Lesser occipital
nerve Sternocleidomastoid

UPPER LIMB
muscle

Splenius capitis
muscle Great auricular nerve

Trapezius muscle
Suprascapular artery
(cut)

Scapular region
Levator scapulae Supraspinatus muscle
muscle

Deltoid muscle (reflected)

Rhomboid minor
muscle
Infraspinatus muscle

Accessory nerve [XI]

Axillary nerve

Rhomboid major Posterior circumflex

muscle humeral artery

Teres minor muscle

Dorsal scapular
nerve Long head of triceps
brachii muscle

Dorsal scapular Circumflex scapular artery

artery

Teres major muscle

Latissimus dorsi Brachial artery

muscle

Medial head of triceps

brachii muscle

Cutaneous Median nerve

branches of
posterior rami

Ulnar nerve

Figure 17.7 Scapular region – deep dissection 1. Right posterior shoulder with the trapezius muscle removed and the posterior deltoid muscle cut and
reflected laterally to show the muscles immediately attached to the scapula (supraspinatus, infraspinatus). Note the window in the rhomboid major muscle
showing the dorsal scapular artery and nerve. The axillary nerve, with the posterior circumflex humeral artery is visible under the relected deltoid 191
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SCAPULAR REGION – DEEP DISSECTION 2

UPPER LIMB

Acromioclavicular joint
Levator scapulae
muscle
Suprascapular artery
Scapular region

Supraspinatus Transverse scapular

muscle (cut) ligament

Suprascapular nerve
Rhomboid minor
muscle Deltoid muscle (cut)

Teres minor muscle

Tendon of trapezius
Posterior circumflex
humeral artery

Axillary nerve
Dorsal scapular
nerve
Circumflex scapular
artery

Rhomboid major Teres major muscle

muscle
Long head of
triceps brachii

Trapezius Infraspinatus muscle

muscle (cut)

Brachial artery

Median nerve
Latissimus dorsi
muscle
Ulnar nerve

Figure 17.8 Scapular region – deep dissection 2. Right shoulder with the trapezius muscle removed and posterior half of the deltoid muscle reflected laterally.
Note that the central parts of the supraspinatus and infraspinatus and teres minor muscles have been removed to show the anastomosis between the
suprascapular artery and the circumflex scapular branch of the subscapular artery. Part of the rhomboid major muscle has been removed to show the dorsal
192 scapular nerve
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SCAPULAR REGION – OSTEOLOGY

Supraspinous fossa

Vertebra VII
(vertebra prominens) Superior angle Spine of scapula Acromion

UPPER LIMB
Base of spine Clavicle Head of humerus Anatomical neck

Scapular region

Medial border Infraspinous fossa Lateral border Glenoid cavity of

of scapula of scapula lateral angle of scapula
Inferior angle Neck of scapula

Figure 17.9 Scapular region – osteology. Posterior view of the articulated right scapula showing its position on the upper posterior rib cage, along with the
proximal humerus 193
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SCAPULAR REGION – PLAIN FILM RADIOGRAPH (LATERAL OR ‘Y’ VIEW)

Acromion
UPPER LIMB

Clavicle
Scapular region

Head of humerus

Coracoid process

Glenoid fossa

Lateral border
of scapula

Rib

Lung

Figure 17.10 Scapular region – plain film radiograph (lateral or ‘Y’ view). The humeral head sits centrally in the glenoid fossa with respect to the coracoid
process (anterior) and acromion process (posterior). When there is displacement of the head of humerus towards the coracoid or acromion process, this
194 suggests anterior or posterior dislocation, respectively.
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SCAPULAR REGION – CT SCAN (AXIAL VIEW) AND MRI SCAN (CORONAL OBLIQUE VIEW)

Brachiocephalic artery

Medial clavicle Esophagus Left subclavian vein

Subscapularis Right brachiocephalic Left common Left axillary vein

muscle Rib I vein Trachea carotid artery Lung with contrast

UPPER LIMB
Scapular region
Infraspinatous Supraspinatus Thoracic vertebrae Medial margin Lateral margin
muscle muscle of scapula of scapula

Serratus anterior Rhomboid major Trapezius muscle Spine of scapula

muscle muscle

Figure 17.11 Scapular region – CT scan (axial view). The scapula is completely surrounded by muscles. This provides extensive protection to the scapula and
also enables its mobility in supplementing the movements of the upper limb

Coracoclavicular Distal clavicle

ligament
Trapezius muscle
Coracoid process
Supraspinatus muscle

Deltoid muscle
Spine of scapula

Elements of Supraspinaous fossa

brachial plexus

Axillary vein and

artery region
Infraspinatus
muscle
Pectoralis major
muscle
Teres minor muscle

Teres major
Subscapularis and latissimus
muscle dorsi muscle
195
Figure 17.12 Scapular region – MRI scan (coronal oblique view). In the view here, note how the appearance of the scapula is similar to that in the ‘Y’ view
plain film radiograph