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Endoscopic removal of a bullet from the scapulothoracic space
CASE REPORTS Endoscopic removal of a bullet from the scapulothoracic space Christopher S. Proctor, MD, and Kristina Stanert, PA-C, Santa Barbara, CA
B ullet fragments have been arthroscopically extracted
from the elbow, hip, knee, and subtalar joints.1,2,4-7 Scapulothoracic endoscopy is a rarely used procedure that has been reported in the treatment of subscapular bursitis.3 The anatomic landmarks and technique of scapulothoracic endoscopy have been described by Ruland et al.8 This case report presents endoscopic removal of a bullet from the scapulothoracic space.
CASE PRESENTATION A 25-year-old right hand– dominant male police officer sustained a gunshot wound to the posterior aspect of the right scapula in January 1991. Radiographs revealed the bullet to be in the scapulothoracic space. The wound was superficially debrided in the emergency room, and the bullet was left in place. The patient underwent physical therapy and returned to full-duty work as a police officer in May 1991. Eight years after being shot, he had complaints of persistent pain in the right scapular region aggravated by lifting, pushing, and pulling activities. On physical examination, a well-healed gunshot entrance wound was present in the mid portion of the scapula, inferior to the scapular spine. The patient had a full range of shoulder and scapular motion that was equal bilaterally. Crepitus was present over the right scapula with motion. No mass was palpable in the scapulothoracic space. An anteroposterior radiograph of the right scapula revealed a bullet 6 cm superior to the inferior angle and 3 cm lateral to the vertebral border of the scapula (Figure 1). A lateral radiograph of the scapula demonstrated the bullet between the scapula and the ribs (Figure 2). Computed tomography showed the retained bullet to be in the medial aspect of the subscapularis muscle. At surgery, the patient was placed in the prone position with the right arm off of the edge of the table. The arm was placed in the full internal rotation position to open the scapuFrom the Department of Orthopedics, St Francis Medical Center. Reprint requests: Christopher S. Proctor, MD, Chairman, Department of Orthopedics, St Francis Medical Center, 536 E. Arrellaga St, Santa Barbara, CA 93103 (E-mail: [email protected]). J Shoulder Elbow Surg 2003;12:89-90. Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 34/2/127098 doi:10.1067/mse.2003.127098
Figure 1 Anteroposterior radiograph of the scapula demonstrating the bullet superior to the inferior angle of the scapula and lateral to the vertebral border.
lothoracic space. A 4.5-mm arthroscope was inserted in a proximal-medial portal made 3 fingerbreadths medial to the vertebral border of the scapula just below the scapular spine. A cannula was inserted through an inferior-medial working portal made medial to the vertebral border of the scapula just superior to the inferior angle of the scapula. A moderately sized area of adhesion and scarring was visualized in the subscapular space between the subscapularis and the serratus anterior. Once the adhesions were excised, a firm, scarred mass was localized within the subscapularis muscle. A single anteroposterior fluoroscopic view was used to confirm that this was the bullet. It was then exposed with a motorized shaver and removed with an arthroscopic grasper (Figure 3). Postoperatively, the patient was started on an early range-of-motion and strengthening rehabilitation program. Six weeks postoperatively, he had 90% pain relief and
89
90
Proctor and Stanert
J Shoulder Elbow Surg January/February 2003
Figure 3 Endoscopic removal of the bullet with grasping forceps after it was exposed with the motorized shaver.
Figure 2 Lateral radiograph demonstrating the bullet between the scapula and the ribs.
full range of motion and had returned to full-duty work. Sixteen months postoperatively, he continued to work full duty and was very satisfied with his surgical outcome.
DISCUSSION Arthroscopic extraction of bullets and bullet fragments has been shown to be safe and reliable for many joints.1,2,4-7 There are few indications for scapulothoracic arthroscopy. In one of only a small number of published reports on this procedure, Ciullo3 described scapulothoracic arthroscopy as being effective for the management of scapulothoracic bursitis. To our knowledge, there have been no reported cases of arthroscopy for the removal of a retained bullet or bullet fragment from the scapulothoracic space. Ruland et al8 performed a cadaveric study to identify the scapulothoracic spaces and their associated neurovascular structures. They found that the scapulothoracic articulation has 2 triangular intervals: the subscapularis space and the serratus anterior space. These spaces are divided obliquely by the serratus anterior. They also determined that the dorsal scapular nerve and artery run 1 cm medial to the vertebral border of the scapula. On the basis of these findings, they recommended that the diagnostic portal should be inferior to the spine of the scapula and 3 to 4 fingerbreadths medial to the vertebral border. Placing the portal closer to the vertebral border not only endangers the dorsal scapular artery
and nerve but also requires a more vertical position of the arthroscope, increasing the potential for penetration of the thoracic cavity. To simplify the introduction of the instruments and maximize the arthroscopy exposure, the scapulothoracic space should be opened fully by placing the patient’s hand dorsal to the thoracic spine and putting the shoulder into full internal rotation. A spinal needle should be used to establish a working portal medial to the inferior angle of the scapula. The arthroscope and instruments should not be directed superior to the spine of the scapula or medial toward the coracoid process, to avoid injury to the suprascapular nerve and artery just medial to the border of the coracoid base. Scapulothoracic arthroscopy can be performed to remove symptomatic foreign bodies with less operative morbidity than with open techniques. Although arthroscopic access to the subscapularis and serratus anterior space is possible, surgeons should be cautioned that there are no prominent anatomic landmarks within these spaces, and significant complications can occur. We thank William Oakley, MPT, and Gary W. Bradley, MD, for their contributions. REFERENCES
1. Berg EE, Ciullo JV. Arhroscopic debridement after intraarticular low-velocity gunshot wounds. Arthroscopy 1993;9:576-9. 2. Cameron SE, Travis MT, Kruse RW. Foreign body arthroscopically retrieved from the elbow. Arthroscopy 1993;9:220-1. 3. Ciullo JV. Subscapular bursitis: treatment of “snapping scapula” or “washboard syndrome.” Arthroscopy 1992;8:412-3. 4. Goldman A, Minkoff J, Price A, Krinick R. A posterior arthroscopic approach to bullet extraction from the hip. J Trauma 1987;27: 1294-300. 5. Haspl M, Bojanic I, Pecina M. Arthroscopic retrieval of metal foreign bodies from the knee joint after war wounds. Injury 1996; 27:177-9. 6. Jazrawi L, Egol KA, Astion DJ, Rose DJ. Arthroscopic removal of bullet fragments from the subtalar joint. Arthroscopy 1999;7:762-5. 7. Nikolic D, Vulovic R. Arthroscopy of the knee in war injuries. Injury 1996;27:175-6. 8. Ruland LJ, Ruland CM, Matthews LS. Scapulothoracic anatomy for the arthroscopist. Arthroscopy 1995;1:52-6.
B ullet fragments have been arthroscopically extracted
from the elbow, hip, knee, and subtalar joints.1,2,4-7 Scapulothoracic endoscopy is a rarely used procedure that has been reported in the treatment of subscapular bursitis.3 The anatomic landmarks and technique of scapulothoracic endoscopy have been described by Ruland et al.8 This case report presents endoscopic removal of a bullet from the scapulothoracic space.
CASE PRESENTATION A 25-year-old right hand– dominant male police officer sustained a gunshot wound to the posterior aspect of the right scapula in January 1991. Radiographs revealed the bullet to be in the scapulothoracic space. The wound was superficially debrided in the emergency room, and the bullet was left in place. The patient underwent physical therapy and returned to full-duty work as a police officer in May 1991. Eight years after being shot, he had complaints of persistent pain in the right scapular region aggravated by lifting, pushing, and pulling activities. On physical examination, a well-healed gunshot entrance wound was present in the mid portion of the scapula, inferior to the scapular spine. The patient had a full range of shoulder and scapular motion that was equal bilaterally. Crepitus was present over the right scapula with motion. No mass was palpable in the scapulothoracic space. An anteroposterior radiograph of the right scapula revealed a bullet 6 cm superior to the inferior angle and 3 cm lateral to the vertebral border of the scapula (Figure 1). A lateral radiograph of the scapula demonstrated the bullet between the scapula and the ribs (Figure 2). Computed tomography showed the retained bullet to be in the medial aspect of the subscapularis muscle. At surgery, the patient was placed in the prone position with the right arm off of the edge of the table. The arm was placed in the full internal rotation position to open the scapuFrom the Department of Orthopedics, St Francis Medical Center. Reprint requests: Christopher S. Proctor, MD, Chairman, Department of Orthopedics, St Francis Medical Center, 536 E. Arrellaga St, Santa Barbara, CA 93103 (E-mail: [email protected]). J Shoulder Elbow Surg 2003;12:89-90. Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 34/2/127098 doi:10.1067/mse.2003.127098
Figure 1 Anteroposterior radiograph of the scapula demonstrating the bullet superior to the inferior angle of the scapula and lateral to the vertebral border.
lothoracic space. A 4.5-mm arthroscope was inserted in a proximal-medial portal made 3 fingerbreadths medial to the vertebral border of the scapula just below the scapular spine. A cannula was inserted through an inferior-medial working portal made medial to the vertebral border of the scapula just superior to the inferior angle of the scapula. A moderately sized area of adhesion and scarring was visualized in the subscapular space between the subscapularis and the serratus anterior. Once the adhesions were excised, a firm, scarred mass was localized within the subscapularis muscle. A single anteroposterior fluoroscopic view was used to confirm that this was the bullet. It was then exposed with a motorized shaver and removed with an arthroscopic grasper (Figure 3). Postoperatively, the patient was started on an early range-of-motion and strengthening rehabilitation program. Six weeks postoperatively, he had 90% pain relief and
89
90
Proctor and Stanert
J Shoulder Elbow Surg January/February 2003
Figure 3 Endoscopic removal of the bullet with grasping forceps after it was exposed with the motorized shaver.
Figure 2 Lateral radiograph demonstrating the bullet between the scapula and the ribs.
full range of motion and had returned to full-duty work. Sixteen months postoperatively, he continued to work full duty and was very satisfied with his surgical outcome.
DISCUSSION Arthroscopic extraction of bullets and bullet fragments has been shown to be safe and reliable for many joints.1,2,4-7 There are few indications for scapulothoracic arthroscopy. In one of only a small number of published reports on this procedure, Ciullo3 described scapulothoracic arthroscopy as being effective for the management of scapulothoracic bursitis. To our knowledge, there have been no reported cases of arthroscopy for the removal of a retained bullet or bullet fragment from the scapulothoracic space. Ruland et al8 performed a cadaveric study to identify the scapulothoracic spaces and their associated neurovascular structures. They found that the scapulothoracic articulation has 2 triangular intervals: the subscapularis space and the serratus anterior space. These spaces are divided obliquely by the serratus anterior. They also determined that the dorsal scapular nerve and artery run 1 cm medial to the vertebral border of the scapula. On the basis of these findings, they recommended that the diagnostic portal should be inferior to the spine of the scapula and 3 to 4 fingerbreadths medial to the vertebral border. Placing the portal closer to the vertebral border not only endangers the dorsal scapular artery
and nerve but also requires a more vertical position of the arthroscope, increasing the potential for penetration of the thoracic cavity. To simplify the introduction of the instruments and maximize the arthroscopy exposure, the scapulothoracic space should be opened fully by placing the patient’s hand dorsal to the thoracic spine and putting the shoulder into full internal rotation. A spinal needle should be used to establish a working portal medial to the inferior angle of the scapula. The arthroscope and instruments should not be directed superior to the spine of the scapula or medial toward the coracoid process, to avoid injury to the suprascapular nerve and artery just medial to the border of the coracoid base. Scapulothoracic arthroscopy can be performed to remove symptomatic foreign bodies with less operative morbidity than with open techniques. Although arthroscopic access to the subscapularis and serratus anterior space is possible, surgeons should be cautioned that there are no prominent anatomic landmarks within these spaces, and significant complications can occur. We thank William Oakley, MPT, and Gary W. Bradley, MD, for their contributions. REFERENCES
1. Berg EE, Ciullo JV. Arhroscopic debridement after intraarticular low-velocity gunshot wounds. Arthroscopy 1993;9:576-9. 2. Cameron SE, Travis MT, Kruse RW. Foreign body arthroscopically retrieved from the elbow. Arthroscopy 1993;9:220-1. 3. Ciullo JV. Subscapular bursitis: treatment of “snapping scapula” or “washboard syndrome.” Arthroscopy 1992;8:412-3. 4. Goldman A, Minkoff J, Price A, Krinick R. A posterior arthroscopic approach to bullet extraction from the hip. J Trauma 1987;27: 1294-300. 5. Haspl M, Bojanic I, Pecina M. Arthroscopic retrieval of metal foreign bodies from the knee joint after war wounds. Injury 1996; 27:177-9. 6. Jazrawi L, Egol KA, Astion DJ, Rose DJ. Arthroscopic removal of bullet fragments from the subtalar joint. Arthroscopy 1999;7:762-5. 7. Nikolic D, Vulovic R. Arthroscopy of the knee in war injuries. Injury 1996;27:175-6. 8. Ruland LJ, Ruland CM, Matthews LS. Scapulothoracic anatomy for the arthroscopist. Arthroscopy 1995;1:52-6.