Anthropometry of the scapula: Clinical and

surgical considerations

Mario Gallino, MD, Eliana Santamaria, PhD, and Tiziana Doro, MS, Torino, ltaiy

Anthropometric measurements were taken on 266 genetic implications and orthopaedic surgical con-
scapulas from the “G. Marro” Egyptian skeletal siderations.
collection at the Department of Anthropology of the
Universify of Turin in Italy to study the orthopaedic MATERIAL AND METHODS
pathologic condition of the shoulder joints. Data were
The scapulas of 240 adult skeletons belonging to the
taken on the size and shape of the acromial arch in
dynastic period of Egyptian osteologic collection (“G.
relation to the inclinafion and anatomic varianfs of the
Marro”) of the Institute of Anthropology, Archaeology
acromion. The rarity of the “hooked“ form was
and Life Sciences of the University of Turin were ob-
confirmed, and two variants of the acromial vault (i.e.,
tained. The skeletal remains, recovered from archaeo-
one predominantly osseous and the other
logic excavations in the areas of Gebelein, Assiut e
predominantly fibrous) were recognized. The spatial
Aswan, Egypt, date from 3000 to 1000 years BC based
location and biomechanical importance of the
on the funeral remains found in some of the tombs.21 In
coracoid process were considered. Orientation of the
most cases it was possible to determine the sex of the
glenoid fossa furnishes an osseous base for the
skeletons with current criteria.6
stability of the scapulohumeral joint both
In 107 cases the scapular bones appeared severely
anteroposteriorly and vertically. Observations on
damaged, fractured, missing, or otherwise were not
current practices of surgical intervention on the
able to be measured and were thus excluded from
shoulder as reported in the literature and some
analysis. The following measurements rather than classic
anatomic skeletal basis of surgical access are
anthropometric measurements were determined for the
discussed [J Shoulder Elbow Surg 1998;7:284-9 7 .I
analysis of orthopaedic pathologic condition on the
remaining 266 scapulas (Figure 1): (1) maximum length
Th e d’ lmensions and geometry of the scapula are of the acromion, (2) distance from the acromion to
essential for understanding the genesis of various coracoid tip, (3) length of the coracoid process from the
pathologic conditions of the shoulder such as scapular notch to the apex, (4) maximum thickness of the
instability of glenohumeral joint, the syndrome of acromion at its anterior edge, (5) height of the acromial
subacromial impingement, and degenerative le- spine from the scapular neck to the undersurface of the
sions of the rotator cuff. Previous anatomic and acromion, (6) height of the coracoid base from the
functional studies,4, ’ ‘, 12, l7 geometric studies scapular neck to the coracoid process, a-angle formed
from standard radiographs,20 computed tomogra- by the vertical axis of the scapula with the acromial
spine, p-angle formed by the vertical axis of the scapula
phy on living populations,15 and anthropometric
with the acromial spine, a-angle formed by the vertical
measurements of the coracoacromial arch on ar-
axis of the scapula with the acromial spine, p-angle
chaeologic populations 2, 8, 9 have been published.
formed by the vertical axis of the scapula with the
This study focuses on the anthropometrics of the coracoid base, y-angle formed by the transverse axis of
highly variable scapula on a large sample of the acromion with the perpendicular axis to the axis of
archaeologic remains to consider possible patho- the scapula in the sagittal plane (“inclination” of the
acromion”), S-angle of anteversion or retroversion of the
glenoid with respect to the horizontal axis of the scapula
From Presidio Sanitaria Gradenigo di Torino, Divisione di (assuming that the degrees of retroversion are positive),
Ortopedia; Museo Egizio di Torino; Dipartimento di e-angle defined between connecting the superior and
Antropologia, Archeologia e Scienze Storico-Territoriali inferior margins of the glenoid and a tangential line to
delI’Universit6 di Torino. the axillary border of the scapula, percent cop: percent-
Reprint requests: Dott. Mario Gallino, Via Boves 10, age of posterior coverage of the glenoid by part of the
10099 San Mauro (Torino), Italy. acromion, height of the portion of the acromion that is
CopyrIght 0 1998 by Journal of Shoulder and Elbow Surgey superimposed on the glenoid in a frontal plan (ex-
Board of Trustees. pressed as percentage of the height of the glenoid, and
10.58.2746/98/$.5.00 + 0 32/l/80677 co-gle: distance from the apex of the coracoid to the

284
/ Shoulder Elbow Surg Gallino, Santamaria, and Doro 285
Volume 7, Number 3

A 6 C

Figure 1 Diagram showing measurements.

Table I Summary of results

N Mean Min Max SD

A 267 4.15 2.60 5.69 0.58

B 256 2.74 1.20 4.18 0.40
C 248 4.1 1 1.63 5.44 0.46
D 269 0.69 0.30 1.64 0.16
E 279 2.95 1.80 4.62 0.47
F 277 1.47 0.84 2.9 0.23
Alpha 284 147 122 167 a.52
Beta 284 132 110 184 9.34
Gamma 254 41 6 60 a.12
Delta 266 2 -7 13 2.90
Epsilon 266 37 10 68 12.50
% co 273 24.84 0.00 51.70 9.79

% Co, Percentage of posterior cover of the glenoid by the acromion.

medial anterior point of the circumference of the gle- values, and standard deviation are reported in
noid. Table I (linear values are reported in centimeters;
The measurements were taken with a precision caliper
angles are reported in degrees).
and an anthropologic goniometer by one of the authors
The flat acromial variant (Figure 2) was present
(M. G.). Th e d a t a were analyzed with regression and
in 48 cases of the 233 acromions evaluated, a
correlation analysis. The skeletal variants of the acro-
mion categorized as flat, curved, and hooked according
frequency of 20.6%. The curved variation was
to the classification of Bigliani et al.5 were considered. found in 169 (72.5%) cases (Figure 3) and the
hooked variety in 16 (6.9%) cases (Figure 4).
RESULTS The extension of the acromial arch defined here
The number of possible measurements for each as the sum of “a + b” (width of the acromion and
parameter, the mean, minimum, and maximum length of the coracoacromial ligament) varied be-
286 Gallino, Santamaria, and Doro f Shoulder Elbow Surg
May/June 7 998

Figure 2 “Flat” shaped acromion

Figure 4 “Hooked” acromion

which measures the ligamentous component of

the acromial arch (p < 0.052), with a coefficient
of relation of 0.193. An inverse proportion (not
shown in the figure) existed between o! and y,
significant at p < 0.05, with a coefficient of
relation of -0.3755. Between a and % co a
significant correlation was found (p < 0.2, coeffi-
cient R = 0.303). Figure 7 shows the significant
correlation between the y-angle and the percent-
age of coverage of the glenoid cavity by part of
the acromion (p < 0.05, R = 0.4950). Acromi-
ons tended to be thin; the thickness (measure-
ment d) averaged 0.67 cm with a minimum of
0.3 cm.

Figure 3 “Curved” acromion DISCUSSION

The documented homogeneity and size of the
tween 4.57 and 0.87 cm (mean 6.90 cm). The selected sample (i.e., an ancient Egyptian mortu-
percentage of the a/b relationship obtained from ary sample dated at 4000 years ago) guarantee
these data ranged from 76.27%/23.73% to the reliability of the obtained data, which are
57%/43%, with the mean at 61.26%/38.74%. comparable to those of our modern populations. In
Two precise individual categories were not appar- fact, if four generations per century is the accepted
ent because of the gradual changes occurring. mean, a maximum number of 160 generations
However, variants on either end of the contin- would be possible during which the probability of
uum were detectable (i.e., major osseous or liga- significant evolutionary mutations would be negli-
mentous development as shown in the linear re- gible.6 Although it is impossible to state an “age
gression a/b in Figure 5). Figure 6 shows range” in this material, we assume a mean longev-
significant correlation between the y-angle of ac- ity of this ancient population of 35.6 years, as
romial inclination with the fraction b/(a + b), previously stated by Marro.21 No comments can
J Shoulder Elbow Surg Gallino, Santamaria, and Doro 287
Volume 7, Number 3

b
4,5 I I

i
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4- _.--- i--.--l
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2 2,5 3 3,5 4 4,5 5 5,5 6

a
Figure 5 Linear regression a/b (p < 0.05; r = 0.2136)

otherwise be made about the relationship between comes defined by the correlation of variability
age and anatomic variants. Our data confirm that obtained by the data.
in the Egyptian population there was very little The structure of the coracoacromial arch, the
sexual dimorphism except for a difference of stat- orientation of the glenoid cavity, the spatial posi-
ure 22,23 tion of the coracoid process, and the landmarks of
The geometry of the scapula beyond a certain surgical interest are easily defined. Regarding the
proportionality of the linear dimensions in general acromial anatomic variants, Bigliani et al.5 placed
is tied to the stature of each individual and be- the relationship between the morphologic charac-
288 Gallino, Santamaria, and Doro J Shoulder Elbow Surg
May/June 1998

0.8 /

0.6
s
+
cd

c
Y
P
0.4

0 10 20 30 40 50 60 70
gamma

Figure 6 Linear regressions between expression (b/a + b) (=ligamentous component of cora-

coacromial arch) in function of y-angle (p < 0.05, r = 0.193).

teristics of the acromion into three categories: “flat” of subacromial impingement might not be due to
(17%), “curved” (43%), and “hooked” (40%). humeroacromial involvement as much as ligament
Edelson and Taitz,* following the same classifica- and rotator cuff contact (Pujadas28).
tion with archaeologic populations, reported the Edelson and Taitz* stated that the more horizon-
respective percentages of 22%, 62%, and 16%. tal acromions were most commonly associated
Our results were close to the previous statistics with osseous degenerative changes. We observed
regarding “flat” acromions (20.6%), but the fre- that a significant correlation exists between the
quency of “curved” (72.5%) and “hooked” (6.9%) acromial slope and the ligamentous development
was different. Such differences can be explained of the coracoacromial arch. In such cases the
by an absence of objective parameters for the possible conflict would be more likely against the
categorization of one morphologic characteristic ligament than the bone, and the osseous alter-
over another, especially for the curved and hooked ations would be less evident. Moreover, the impor-
categories. A typical anteriorly hooked acromion tance of the coracoacromial ligament in subacro-
is relatively rare and is seemingly a variant in the mial stenosis has developed from the presence of
development of the epiphyseal growth center of the its wide reflected portion on the undersurface of the
preacromion as stated by Edelson and Taitz.* acromion as observed by Gallino et al.14
The relationship between the variants and de- The observed relative thinness of the acromion
generative changes is not completely clear. Two should suggest that acromioplasty in open sur-
extreme situations were noted in the composition of geryz5 should be performed with caution to avoid
the acromial vault: major osseous or ligamentous excessive resection. Such precautions should also
developments, in agreement with Apoil et al.* The be exercised in the arthroscopic version of acro-
ample ligamentous participation in the develop- mioplasty,1° which may not allow a precise esti-
ment of the acromial vault (variable from 24% to mate of the amount of resected acromion. It should
43%) brings to mind that the hypothesized cause be noted that resection by use of an arthroscopic
J Shoulder Elbow Surg Gallino, Santamaria, and Doro 289
Volume 7, Number 3

i
0 10 20 40 50 60

Figure 7 Correlation between y-angle and % co (p CC 0.00005, r = 0.495).

burr is a selective and gradual method in which the

the process may be stopped at any point.
The glenoid cavity had a ,mean retroversion
angle of 2.90” in agreement with the litera-
ture.7, l3 The importance of glenoid retroversion
has been discussed by Saha.3’ More recently,
Randelli et al.,29 using computed tomography,
revealed a constant retroversion of the glenoid in
stable and unstable shoulders. Thus shoulder insta-
bility is derived from multifactorial causes (capsule,
ligament, muscular) in which congenital antever-
sion of the glenoid is only one of the etiologic
factors. Celli et al.7 underlined the importance of
excessive glenoid anteversion in association with
the subacromial problem in that it limits external
rotation of the humeral head during abduction of
Figure 8 left scapula seen from ventral aspect: glenoid
the arm. shows upward inclination in frontal plane (e-angle].
The mean angle of inclination (37.6”) corre-
sponds to an almost vertical position of the glenoid
with a slight upward inclination (Figure 8). Basma- meral instability. They reported that the angle of
jiian and Bazanr? hypothesized the importance of inclination is significant in determining recurrent
this inclination of the glenoid in preventing inferior superior and inferior dislocations.
scapulohumeral dislocation. Our data only partly A true coracoid process is present only in hu-
confirm such opinions because variations of incli- mans and in the nonhuman primates as a result of
nation were observed, as previously stated also by the adaptation of moving the upper limbs in a wide
Mallon et al.2o Neer and Foster26 introduced the range of usually anterior motion. In fact, the cora-
concept of inferior and multidirectional glenohu- coid is absent in most quadrupeds, being reduced
290 Gallino, Santamaria, and Doro J Shoulder Elbow Surg
May/June 1998

The surgical techniques that recommend trans-

porting the coracoid to the anterior rim of the
glenoid fossa to stabilize the glenohumeral joint in
recurrent dislocation16, I9 are successful because
the distance from the apex of the coracoid and the
mid-anterior point of the glenoid rim is on average
2.10 cm, with a minimum of 1.09 cm in the
smallest scapula. In such interventions the point of
application of the force of the coracobrachialis
and biceps muscles would be significantly nearer
to the geometric center of the joint and would thus
create more stability.
It is interesting to note the proportionality be-
tween the y-angle of inclination of the acromion
and the percentage of posterior articular cover-
age, which is also related to the a-angle. The
Figure 9 Posterior portal for arthroscopic cannula is situ-
a-angle, however, is not externally visible in the
ated 1 to 3 cm below posterior lateral acromial edge when living. Instead, the inclination of the acromion is
this is almost horizontal; it is close to posterior border of generally palpable, and this may be a valid land-
highly sloped acromion (dotted line). mark for posterior arthroscopic approaches. In the
more vertically oriented acromions the incision
should be made as close as possible to the pos-
to a simple thickening of the supraglenoid tubercle. teroinferior acromial border and not as classically
A representation of the coracoid as an uncinate indicated at 1 cm18 or even 3 cm below it’ (Figure 9).
process is present in most rabbits and rodents,
The authors thank Mr. Albert0 Maccario, BSc, Dr.
which maintain a certain degree of upper limb Fabio Rivolta, MS, and Dr. Cinzia Taurisano, MS, for
mobility in the forward position and in powerful their kind collaboration as statistic consultants. We are
griping. In all these animals the origin of the short indebted as well to Dr. Jerilyn Pecotte, PhD, for review-
head of the biceps is missing.3 From this perspec- ing and translating this article into English.
tive the coracoid assumes a biomechanical func-
tion of a shelf structure, which is one arm of the
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