Congenital elevated scapula · Woodward or Green procedure · Cavendish II–IV
- Sprengel deformity is a congenital elevation and hypoplasia of the scapula with medial rotation, caused by failure of the scapula to descend from its embryonic cervical position to the thorax during the first trimester. An omovertebral bone or fibrocartilaginous bar tethering the scapula to the cervical spine is present in around one-third of cases.
- Always screen for associated anomalies before surgery. Klippel-Feil syndrome, cervical ribs, congenital scoliosis, renal anomalies, cardiac defects and diastematomyelia or a tethered cord all coexist commonly, and several alter anaesthetic and surgical risk. Image the whole spine and obtain a renal ultrasound pre-operatively.
- Surgery serves two goals: cosmetic (the visible lump in the neck) and functional (a limited and painful shoulder abduction). The mainstay is the Woodward procedure (detaching and relocating the trapezius and rhomboid origins distally on the spinous processes) or the Green procedure (extraperiosteal release of the periscapular muscles with scapular repositioning). Both include excision of the omovertebral bone and resection of the prominent supraspinous portion of the scapula.
- The dominant danger is a traction injury to the brachial plexus as the scapula is drawn inferiorly. Protect it with intra-operative neuromonitoring, a clavicular osteotomy or morcellation in the older child, and by never over-relocating the scapula. Ideal surgical timing is between three and eight years of age; results decline and plexus risk rises in older children.
When & Why
Surgery is offered for a Cavendish grade II to IV deformity where the elevated scapula is visibly unacceptable and shoulder abduction is limited. The aim is twofold: a cosmetic gain (lowering the lump in the web of the neck) and a functional gain (more pain-free abduction by removing the bony block and repositioning the scapula). Grade I disease is observed.
Cavendish grade 3 or 4 deformity with a visible, cosmetically unacceptable neck lump and limited shoulder abduction; a symptomatic omovertebral bone restricting abduction or causing pain; significant functional limitation of abduction interfering with daily activities.
Cavendish grade 2 deformity the family finds cosmetically unacceptable after counselling about the scar; progressive loss of abduction in a growing child within the ideal age window; restricted abduction with a confirmed bony block (prominent supraspinous fossa or omovertebral bar).
Absolute: a stiff, pain-free shoulder with a mild grade 1 deformity in a near-mature adolescent; an uncorrected tethered cord or major undiagnosed spinal anomaly until neurosurgical evaluation is complete; a medically unfit child with an unoptimised cardiac or renal anomaly. Relative: age greater than about 8 years; severe Klippel-Feil with a very short stiff neck; a very mild grade 1 deformity found incidentally.
Goals of surgery (discuss both with the family): - Cosmetic — to lower the visible lump in the web of the neck and improve shoulder-girdle symmetry.
- Functional — to improve shoulder abduction by removing the bony block (omovertebral bone and prominent supraspinous portion) and repositioning the scapula so scapulothoracic rhythm can work. Timing of surgery. The ideal window is between three and eight years of age. The scapula and surrounding soft tissues are still mobile, allowing a larger and safer descent, and neuromuscular adaptation is better. Beyond about eight years the soft tissues stiffen, the brachial plexus tolerates stretch poorly, and both the neurological risk and the recurrence rate rise. Counsel families of late presenters honestly that correction is less predictable, and that observation may be the better choice for a stiff, mild deformity in an adolescent. Work-up — screen the whole child. Sprengel deformity is rarely isolated. Image the cervical and thoracic spine (Klippel-Feil, cervical ribs, congenital scoliosis), obtain a renal ultrasound, and arrange an echocardiogram and an MRI of the spine if there is any neurological sign, to exclude diastematomyelia or a tethered cord. A tethered cord alters anaesthetic technique and may need neurosurgery first. Examine the neurological system and document baseline shoulder abduction and contour. Consent specifically for: a brachial plexus traction injury (the most feared complication, usually transient but occasionally permanent), the long posterior scar, incomplete correction or recurrence, winging of the scapula, infection, and a period of immobilisation. Set realistic expectations — the contour improves but rarely normalises. Setup. Prone over chest and pelvic rolls with the head in a headrest and the affected arm draped free; lateral decubitus is an acceptable alternative. General anaesthesia with a secure airway — Klippel-Feil and cervical anomalies make intubation difficult, so plan the airway with the anaesthetist. Intra-operative neuromonitoring (somatosensory or motor evoked potentials) is strongly recommended to guard the brachial plexus throughout.
The Operation
The goal is to free the tethered scapula, excise the omovertebral bone, remove the prominent supraspinous block, and relocate the scapula distally to the level of the contralateral side while protecting the brachial plexus and the spinal accessory nerve. The exposure is laid out in full as the first steps below — this is the heart of the operation.
Operative sequence — Woodward procedure
- Prone over chest and pelvic rolls, head in a headrest, affected arm draped free so the scapula can be manipulated.
- General anaesthesia with a difficult-airway plan (Klippel-Feil); brachial plexus neuromonitoring on throughout.
- Mark a long posterior midline incision from the lower cervical spinous processes (around C4 to C5) to the mid-thoracic spine (around T8), curving gently toward the elevated scapula.
- Incise skin and subcutaneous tissue in line with the mark.
- Raise broad skin and subcutaneous flaps laterally to expose the trapezius, the rhomboids and the elevated, hypoplastic scapula — carry the flaps far enough laterally to define the medial border of the scapula and the omovertebral attachment.
- Keep the flaps thick enough to avoid necrosing the long posterior flap.
- Palpate the superomedial border of the scapula for the firm bony or cartilaginous omovertebral bar running up to the cervical spine (usually to the C4 to C7 spinous or transverse processes or laminae).
- Define its proximal and distal attachments, then excise it completely in an extraperiosteal fashion, staying away from the vertebral canal.
- Complete removal frees the scapula from its tether; any fragment left behind causes the deformity to recur and keeps abduction restricted.
- Working from the midline, detach the origins of the trapezius and then the rhomboids extraperiosteally from the spinous processes, creating one continuous musculotendinous sheet that can be relocated as a unit.
- Identify and protect the spinal accessory nerve (CN XI) as it runs on the deep (anterior) surface of the trapezius — keep a finger on it as you elevate; division denervates the trapezius and ruins the result (shoulder droop, winged scapula).
- Extraperiosteal (not subperiosteal) mobilisation is what gives the muscle sheet its mobility; beware the dorsal scapular nerve and artery along the medial border of the scapula, deep to the rhomboids.
- Expose the superior border of the scapula. The supraspinous portion (the bone above the scapular notch) is often hooked or prominent and projects above the superior border.
- Resect it subperiosteally, removing the bony block to abduction, while protecting the supraspinatus muscle and tendon and the suprascapular nerve.
- Leaving this prominence behind blocks abduction and wastes the gain from relocation.
- In the older child (roughly greater than 6 to 7 years) perform a clavicular osteotomy or morcellation through a small separate incision — gently crack the clavicle in a few places so the shoulder girdle can descend.
- This shortens the rigid bony ring of the thoracic outlet and decompresses the brachial plexus as the scapula descends, substantially reducing the risk of a traction palsy.
- The younger child often does not need this step, because the soft tissues are more yielding.
- Bring the freed scapula and the attached trapezius and rhomboid sheet distally to the level of the contralateral scapula — never lower. Over-relocation is what injures the plexus.
- Reattach the muscle origins to the spinous processes more distally (two to three levels below their original position) using non-absorbable sutures through bone or fascia.
- Confirm the neuromonitoring traces stay stable before fixing the position.
- Achieve haemostasis and place a drain.
- Close in layers over the relocated muscle mass with an absorbable deep layer and a skin closure aimed at the least conspicuous scar.
- Apply a well-padded dressing and immobilise the arm in a sling or shoulder immobiliser.
As the scapula is relocated inferiorly the clavicle and shoulder girdle descend with it, stretching the brachial plexus (upper trunk) through the thoracic outlet — a traction palsy is the most feared complication. Protect it with three measures together: intra-operative neuromonitoring, a clavicular osteotomy or morcellation (especially in the older child), and by never relocating the scapula more distally than the contralateral side. If the traces change during descent, release the scapula immediately, exclude a systemic cause with the anaesthetist, add a clavicular osteotomy if not already done, and accept a smaller safe descent over a full descent that leaves a permanent palsy.
The spinal accessory nerve runs on the deep (anterior) surface of the trapezius, descending from the posterior triangle to innervate it segmentally. It is endangered when the trapezius is detached from the spinous processes and reflected laterally. Identify it and keep a finger on it throughout elevation; division denervates the trapezius, producing shoulder droop, lateral winging and a painful weak shoulder.
Centre the long incision on the spine so the final scar lies in the midline, partly hidden by the head and the dependent shoulder, and raise broad subcutaneous flaps laterally to fully expose the elevated scapula and the spinous processes above and below it — the whole trapezius and rhomboid mass must be mobilised as one sheet.
Bring the scapula down to match the contralateral side and no further. Over-relocation is the single manoeuvre most likely to stretch the brachial plexus. A partial improvement that does not injure the plexus is far better than a full descent that leaves a permanent palsy.
The Green procedure achieves the same goals by a different route. Through a similar posterior incision, the periscapular muscles (levator scapulae, rhomboids and the omovertebral connection) are released extraperiosteally off the scapula rather than from the spinous processes. The freed scapula is repositioned distally and held there with skeletal traction (a wire through the scapula to the opposite iliac crest or to a rib) for several weeks while the muscles heal at their new length. The omovertebral bone is excised and the prominent supraspinous portion resected exactly as in the Woodward. It is less commonly performed today but remains a valid option, particularly when the muscle origins are unfavourable for the Woodward relocation.
- Woodward
- 1961 (Woodward)
- Green
- 1957 (Green)
- Woodward
- Detach and relocate the origins of trapezius and rhomboids distally on the spinous processes
- Green
- Extraperiosteal release of muscles off the scapula, then reposition with skeletal traction
- Woodward
- Excised
- Green
- Excised
- Woodward
- Resected
- Green
- Resected
- Woodward
- Reattachment of the muscle mass to the spinous processes
- Green
- Skeletal traction to the opposite iliac crest or ribs
- Woodward
- Optional adjunct in the older child
- Green
- Recommended adjunct in the older child
- Woodward
- Most widely used
- Green
- Less commonly used
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 4 weeks | Sling or shoulder immobiliser (drain removed when output is minimal) | Hand and finger active motion only; examine the arm neurologically on recovery and at each visit | | 2 | 4 to 6 weeks | Removable sling, weaning | Gentle active and active-assisted range of motion begins once the muscle mass has healed | | 3 | 6 to 12 weeks | Sling for heavy tasks only | Progressive abduction and forward flexion; periscapular strengthening (trapezius, serratus anterior, rhomboids); scar care from 2 to 3 weeks | | 4 | 3 months onward | None | Strengthening and graded return to full activity and sport | Children usually return to school within one to two weeks in the sling, avoiding physical education and contact activity, and to sport and full activity at around three months once range and strength are restored. Improvement in abduction continues for six to twelve months. Outcomes. The most reproducible gain is in active shoulder abduction, typically around 30 to 40 degrees; removing both the omovertebral bone and the prominent supraspinous portion contributes. Results are best in younger children with mobile soft tissues. Cosmetic improvement is meaningful for grades 3 and 4 but rarely normalises completely, and the permanent posterior scar is a trade-off that must be discussed before surgery. Complications
- Recognition
- Post-operative arm weakness, reduced shoulder or elbow flexion, sensory change or reduced reflexes; may first appear on intra-operative neuromonitoring
- Prevention
- Neuromonitoring, clavicular osteotomy or morcellation, never over-relocate, avoid the older stiff child
- Management
- Most are transient neurapraxia — observe and therapy; a persistent deficit warrants urgent nerve conduction studies and peripheral nerve service review
- Recognition
- Persistent scapular elevation or recurrence of the neck lump during growth
- Prevention
- Complete omovertebral excision, secure distal reattachment, operate within the ideal age window
- Management
- Counsel and observe if mild; revision is difficult and reserved for significant recurrence
- Recognition
- A widened, raised or keloid scar along the midline of the back
- Prevention
- Careful layered closure, avoid flap tension, discuss the scar pre-operatively
- Management
- Silicone gel and scar massage, intralesional steroid for hypertrophy, surgical revision rarely
- Recognition
- Prominence of the medial border off the chest wall, weakness of overhead activity
- Prevention
- Protect the long thoracic and spinal accessory nerves during dissection
- Management
- Most improve with time and therapy; persistent winging is observed and very rarely reconstructed
- Recognition
- Trapezius palsy with shoulder droop, lateral scapular winging and a painful shoulder
- Prevention
- Identify the nerve on the deep surface of the trapezius and protect it during elevation
- Management
- Explore and repair or graft if recognised early; prolonged physiotherapy and support if late
- Recognition
- Erythema, swelling, pain, purulent discharge or a fluctuant collection
- Prevention
- Meticulous haemostasis, a drain, perioperative antibiotics
- Management
- Wound swab and oral antibiotics for superficial infection; evacuation and washout for a haematoma or deep infection
- Recognition
- Dorsal scapular or suprascapular nerve deficit, or vascular injury during clavicular or scapular work
- Prevention
- Stay extraperiosteal and on the correct plane, protect named nerves
- Management
- Recognise and repair vascular injury intra-operatively; observe nerve palsies with therapy
Special situations - Older child (greater than 8 years). Soft tissues and plexus are less yielding, so recurrence and traction-palsy risk both rise. Counsel honestly that the result is less predictable; make clavicular osteotomy or morcellation routine, use neuromonitoring throughout, and never over-relocate — a partial improvement is safer than a forced full descent. In a stiff, pain-free adolescent with a mild deformity, observation is often the better choice.
- Bilateral deformity. May be staged or simultaneous depending on anaesthetic fitness and surgeon preference; each side is treated on its own merits using the Cavendish grade and functional deficit, and the second side is planned once the first has healed and the abduction gain is clear.
- Syndromic and Klippel-Feil. Anticipate a difficult airway, address a tethered cord before elective scapular surgery, and let coexisting congenital scoliosis, renal and cardiac anomalies shape peri-operative care — manage the whole child, not just the scapula.
Viva & Exam Focus
SPRENGELSPRENGEL — clinical features and associations
WOODWARDWOODWARD — operative steps
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 5-year-old girl is referred with a right Sprengel deformity, Cavendish grade 3, an omovertebral bone on imaging and shoulder abduction limited to 90 degrees. How do you manage her?”
“A 10-year-old boy presents with a previously untreated Sprengel deformity, Cavendish grade 3. His parents want to know whether anything can still be done. How do you counsel and manage him?”
“During a Woodward procedure the intra-operative neuromonitoring traces deteriorate as you bring the scapula distally. What do you do?”
Indication & timing
- Cavendish grade 2 to 4 deformity that is visible and limits shoulder abduction
- Ideal age window 3 to 8 years; over about 8 years the recurrence and plexus risk rise
- Screen first: spine imaging, renal ultrasound, exclude a tethered cord
Exposure
- Prone, long posterior midline incision curving toward the elevated scapula
- Broad subcutaneous flaps to expose trapezius, rhomboids and the scapula
- At risk: spinal accessory nerve (deep surface of trapezius), brachial plexus
Core operation
- Excise the omovertebral bone completely and extraperiosteally
- Detach trapezius and rhomboid origins as one extraperiosteal sheet
- Resect the prominent supraspinous portion; add clavicular osteotomy in the older child
Finish
- Relocate to the level of the contralateral side — never over-relocate
- Reattach the muscle mass more distally on the spinous processes
- Immobilise in a sling 4 to 6 weeks; neurological review at every visit
Background & Evidence
Embryology. The scapula forms in the mesenchyme of the upper limb bud at a cervical level (around C4 to C5). During the first trimester it descends caudally to its final thoracic position opposite the second to seventh ribs, reaching this position by about the eighth week of gestation. Sprengel deformity results from a failure of this descent, so the scapula remains high, hypoplastic and adducted (rotated so its glenoid faces inferiorly and its inferior angle faces the spine). An omovertebral connection is thought to tether the scapula and prevent descent in around one-third of cases. The omovertebral bone. Present in around one-third of Sprengel deformities, it is a bone, cartilage or fibrous band running from the superomedial border of the scapula to the spinous processes, transverse processes or laminae of the lower cervical vertebrae (usually C4 to C7). It tethers the scapula and limits abduction, so it must be excised at operation; it lies close to the vertebral canal, so dissection stays extraperiosteal and away from the spinal canal. Periscapular muscles — origins and innervation | Muscle | Origin | Innervation | Role in the procedure | |--------|--------|-------------|------------------------| | Trapezius | Ligamentum nuchae and spinous processes C7 to T12 | Spinal accessory nerve (CN XI) | Origin detached and relocated distally in the Woodward procedure | | Rhomboid major and minor | Spinous processes T1 to T5 (major), ligamentum nuchae C7 to T1 (minor) | Dorsal scapular nerve | Origin detached and relocated distally in the Woodward procedure | | Levator scapulae | Transverse processes C1 to C4 | Dorsal scapular nerve and C3 to C4 | Released from the medial border of the scapula | | Serratus anterior | Ribs one to nine | Long thoracic nerve | Preserved; winging if injured | | Supraspinatus | Supraspinous fossa | Suprascapular nerve | Fossa resected if prominent, tendon protected | Nerves at risk - Spinal accessory nerve (CN XI) — enters the posterior triangle then runs on the deep (anterior) surface of the trapezius, innervating it segmentally; endangered when the trapezius is detached and reflected laterally; division denervates the trapezius (shoulder droop, winged scapula, weak overhead elevation).
- Dorsal scapular nerve — arises from the C5 root, pierces the scalenus medius and runs with the deep branch of the transverse cervical (dorsal scapular) artery along the medial border of the scapula deep to the rhomboids; injury weakens scapular retraction.
- Long thoracic nerve — arises from C5, C6 and C7 roots and descends on the superficial surface of serratus anterior; injury causes a winged scapula, so keep the dissection off the chest wall over serratus anterior. The brachial plexus and thoracic outlet. As the scapula is drawn inferiorly the clavicle and entire shoulder girdle descend with it, lengthening the path of the brachial plexus through the thoracic outlet. The plexus, particularly the upper trunk, is vulnerable to a traction injury. A clavicular osteotomy or morcellation shortens the rigid bony ring of the thoracic outlet and decompresses the plexus during descent, and intra-operative neuromonitoring detects impending traction before it becomes permanent. The prominent supraspinous portion. In many Sprengel scapulae the supraspinous portion (the bone above the scapular notch) is hooked or prominent and projects above the superior border. It can impinge on the chest wall and block abduction even after the omovertebral bone is removed; resecting it subperiosteally (protecting the suprascapular nerve and the supraspinatus tendon) removes the bony block and improves the gain in abduction. Cavendish classification
- Severity
- Very mild
- Description
- Deformity invisible, shoulder appears normal
- Typical management
- Observation
- Severity
- Mild
- Description
- Visible as a lump in the web of the neck when dressed
- Typical management
- Surgery if cosmetically unacceptable
- Severity
- Moderate
- Description
- Visible lump, shoulder elevated, obvious in clothing
- Typical management
- Surgical correction indicated
- Severity
- Severe
- Description
- Shoulder very high, scapula near the occiput
- Typical management
- Surgical correction indicated
Key evidence. The Woodward procedure (described 1961) relocates the scapula by detaching the origins of the trapezius and rhomboids from the spinous processes and reattaching the muscle mass more distally; it is the most widely performed operation today. The Green procedure (described 1957) releases the periscapular muscles extraperiosteally from the scapula and repositions the freed scapula with skeletal traction to the opposite iliac crest or ribs. Reported outcomes consistently show gains in active shoulder abduction of around 30 to 40 degrees and a meaningful cosmetic improvement in the majority of grade 3 and 4 deformities operated within the ideal age window, with the best results in younger children with mobile soft tissues. Cosmetic correction is generally good for grades 3 and 4 but rarely completely normalises the contour, and the brachial plexus traction injury remains the most feared complication, over-represented in older children and in over-relocation.
References
Congenital elevation of the scapula
- An early detailed clinical and pathological description of congenital elevation of the scapula
- Documented the omovertebral bone and the associated cervical and spinal anomalies
- Provided the foundation for the later classifications and operative procedures
Congenital elevation of the scapula
- Introduced the four-grade (I to IV) classification of cosmetic severity
- Remains the standard grading system used to guide surgical indication
- Reported operative results and emphasised the importance of the omovertebral bar
Congenital elevation of the scapula. Surgical correction by the Woodward procedure
- Reviewed the results of the Woodward procedure in a clinical series
- Reported gains in shoulder abduction and meaningful cosmetic improvement
- Emphasised excision of the omovertebral bone and the prominent supraspinous portion of the scapula
Sprengel deformity
- Comprehensive review of the embryology, classification, associated anomalies and surgical treatment of Sprengel deformity
- Summarised outcomes of both the Woodward and Green procedures
- Highlighted the importance of screening for Klippel-Feil syndrome and spinal anomalies before surgery
The congenital undescended scapula. Surgical correction by the Woodward procedure
- Reported the largest single-centre series of Woodward procedures (21 undescended scapulae in 20 patients)
- Analysed functional and cosmetic outcomes with emphasis on complete omovertebral bone excision
- Demonstrated that results correlate with age at surgery and severity of the Cavendish grade