Figure - available from: European Journal of Orthopaedic Surgery & Traumatology
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Plain X-ray of left shoulder—Lateral view: normal bony signal of the scapula, clavicle, proximal humerus, left side of the rib cage and lung. A red oval demonstrates the anatomic location of the abscess with no abnormal bone or soft tissue shadows
Source publication
Subscapular space is an uncommon site for abscess formation. There are only seven reports of subscapular abscesses in the literature. Only three of these cases are reported in children. We recently treated a child with subscapular abscess. We performed the literature search using a combination of the keywords: subscapular, scapular, abscess and inf...
Citations
... Spontaneous abscesses involving the sternocleidomastoid muscle are infrequently observed in the clinical setting; however, other locations, such as the subscapularis muscle or biceps muscle, have been reported, which gives us a notion of the spontaneity of the presentation of this clinical entity [1][2][3]. The presence of abscess has been correlated with risk factors such as patients' immunocompromised status, trauma, intravenous drug use, and even malnutrition. ...
Patient: Male, 61-year-old
Final Diagnosis: Abscess sternocleidomastoid • infection
Symptoms: Erythema • neck pain • swelling
Clinical Procedure: —
Specialty: Infectious Diseases • General and Internal Medicine • Orthopedics and Traumatology
Objective
Rare coexistence of disease or pathology
Background
Spontaneous abscesses are generally typical in patients with significant risk factors and have been linked to numerous muscle groups. The sternocleidomastoid muscle, however, piqued our interest as an unusual location, especially in this patient who, other than diabetes mellitus, had no associated risk factors or signs of trauma.
Case Report
A 61-year-old man appeared with neck pain, erythema, and swelling that had been present for 9 days and for which he had previously been examined in the Emergency Department. He was discharged on oral doxycycline after initial computed tomography (CT) of the neck revealed infiltration without collection. He returned with worsening symptoms and new-onset fever and chills. Vital signs were normal on assessment, with no evidence of trauma. Swelling was observed near the right sternocleidomastoid muscle insertion. A repeat CT scan of the neck revealed an abscess 2.5 cm in diameter. He was originally treated with empiric antibiotics before being moved to targeted medications. Incision and drainage were completed without complication. The patient was given a 6-week course of oral antibiotics.
Conclusions
Spontaneous intramuscular abscesses are uncommon in people who have had no previous trauma or other known risk factors, but could be encountered in diabetic patients with non-optimal blood glucose levels, due to bacteremia. As a result, these cases require a high level of suspicion to be recognized and treated early. The scarcity of literature on this illness makes determining the cause challenging. However, by highlighting this case, we intend to raise awareness and facilitate early diagnosis and treatment.
... 1-8 It is often diagnosed late due to its rarity and indistinct presentation. [1][2][3][4][5] There are nine cases reported in the literatures, four of them involved paediatric patients. The subscapularis muscle is deeply seated within the periscapular muscles. ...
Introduction: Subscapular abscess is an extremely rare condition. To our knowledge there were nine reports on subscapular abscess in the literature, four of them happened paediatric patients. The signs and symptoms could be very subtle making the diagnosis is difficult and often delayed. Case description: We share a rare case of isolated subscapularis abscess with no glenohumeral involvement of a healthy 9-year-old boy following blunt trauma to the shoulder treated with antibiotics and percutaneous drainage with good outcome. Conclusion: Subscapular abscess should be suspected in a child present with fever and shoulder pain. Magnetic resonance imaging is the best modality for diagnosis as plain radiograph would not give any diagnostic help. Surgical drainage combined with antibiotics are the mainstay of treatment. However, percutaneous drainage is one of treatment options especially in paediatric patient as demonstrated in our report.
... It also presents a clinical scenario in which practitioners of manual therapy in frozen shoulder should be aware of the risk of subscapular abscess in patients undergoing recent infection therapy Background Subscapular abscess is an uncommon condition. Predisposing conditions include an immunocompromised state, recent infection, diabetes, end-stage renal disease, intravenous (IV) drug use, and trauma to the shoulder area causing hematoma formation [1][2][3][4]. Staphylococcus aureus (S. aureus) is the most common etiologic agent [1][2][3][4][5][6][7][8], and other less-common pathogens include Haemophilus In uenzae (H. in uenza) [9]. However, there are no reported cases of Escherichia coli (E. ...
... Predisposing conditions include an immunocompromised state, recent infection, diabetes, end-stage renal disease, intravenous (IV) drug use, and trauma to the shoulder area causing hematoma formation [1][2][3][4]. Staphylococcus aureus (S. aureus) is the most common etiologic agent [1][2][3][4][5][6][7][8], and other less-common pathogens include Haemophilus In uenzae (H. in uenza) [9]. However, there are no reported cases of Escherichia coli (E. ...
... It has been described in only a few case reports. Predisposing conditions for this type of abscess include an immunocompromised state, recent infection, diabetes, endstage renal disease, IV drug use, and trauma to the shoulder area causing hematoma formation [1][2][3][4]. In a subscapular abscess, S. aureus is most commonly identi ed. ...
Background:
Subscapular abscess is a rare condition usually secondary to immunocompromised state and recent infection. Staphylococcus aureus (S. aureus) is the most common etiologic agent. To the best of our knowledge, we present the first case of a patient with a frozen shoulder performing manual therapy, which resulted in an Escherichia coli subscapular abscess.
Case presentation: A 72-year-old male was referred from the respiratory department with pain and a limited range of motion in the left shoulder. He complained that the pain was exacerbated with popping sound during manual therapy for frozen shoulder two weeks ago. Magnetic resonance imaging revealed a large intramuscular complicated fluid collection at the level of the subscapularis muscle 10.0 × 5.2 × 11 cm in size, and a bloody but turbid pus-like discharge was observed upon aspiration. He underwent urgent surgical drainage. The cultures from the abscess fluid revealed extended-spectrum beta-lactamases (-) E. coli. After 4 weeks of Ceftazidime intravenous treatment, symptoms of the patient had improved.
Conclusions: This case highlights the risks of aggressive manual therapy in severe frozen shoulder. It also presents a clinical scenario in which practitioners of manual therapy in frozen shoulder should be aware of the risk of subscapular abscess in patients undergoing recent infection therapy
... Otit sonrası gelişen subskapular apsede Haemophilus influenzae Tip B izole edilmiştir [2] . Literatürde en sık metisiline duyarlı S. aureus (MSSA) etken olarak bildirilmiştir [1,[3][4][5][6] . Bazı olgularda ise MRSA izole edilmiştir [4,7,8] . ...
... Omuz hareket kısıtlılığı olması nedeniyle septik omuz artrit ile ayırıcı tanısı yapılmalıdır; glenohumeral eklemde infeksiyon bulgularının olmaması subskapular apse lehine düşünülebilir. Ayrıca benign ve malign kitlelerin ekartasyonu da yapılmalıdır [6] . Operasyon öncesi yapılacak MRG tanı, ayırıcı tanı ve apse drenaj planının yapılabilmesi açısından oldukça önemlidir. ...
Subscapular abscess is a rare but serious clinical condition due to the small number of cases in the literature requiring early diagnosis and urgent surgical intervention. We aimed to present a case of spontaneous subscapular abscess causing methicillin-resistant Staphylococcus aureus septicemia, which was diagnosed and treated early, without trauma or surgical intervention.
... The subscapularis muscle is an infrequent location of abscess formation, and the diagnosis of an abscess within the subscapularis muscle is often difficult [1,2]. Because of its rarity, few reports are available on the treatment methods for abscesses located in the subscapularis muscle. ...
... However, careful attention is required since it may hematogenously lead to infection in other organs. To date, only five cases of subscapularis intramuscular abscess diagnosed using CT, MRI, or autopsy findings have been reported (Table 1) [1][2][3][4][5]. Immunocompromised states, such as diabetes [4] or hematoma due to shoulder trauma [3,5], which are thought to be the sources of infection, have been reported as predisposing conditions. ...
... Immunocompromised states, such as diabetes [4] or hematoma due to shoulder trauma [3,5], which are thought to be the sources of infection, have been reported as predisposing conditions. However, as in the present case, cases without any underlying disease have also been reported [1,2]. ...
Background:
Abscess formation in the subscapularis muscle is a rare clinical condition. Few reports are available regarding the treatment methods and surgical approaches for subscapularis intramuscular abscesses. Here, we describe a case of subscapularis intramuscular abscess that was treated successfully via surgical drainage using a new approach, the "dorsal subscapularis approach".
Case presentation:
A 67-year-old woman presented to our hospital with complaints of fever and disturbance of consciousness. Two days prior to visiting our hospital, right shoulder pain and limited range of motion in the shoulder were noted. Cerebrospinal fluid examination and contrast-enhanced computed tomography (CT) imaging on admission revealed a right subscapularis intramuscular abscess with concomitant bacterial meningitis. The patient's clinical symptoms improved after antibiotic administration for 3 weeks, but the right shoulder pain persisted. Contrast-enhanced CT imaging performed after antibiotic administration revealed an abscess in the right shoulder joint space, in addition to a capsule of the abscess in the right subscapularis muscle. We performed open surgical drainage for the abscess, which had spread from the subscapularis muscle to the glenohumeral joint. Using the deltoid-pectoral approach, we detected exudate and infected granulation tissue in the joint cavity. Furthermore, we separated the dorsal side of the subscapularis muscle from the scapula using a raspatory and detected infected granulation tissue in the subscapularis muscle belly. We performed curettage and washed as much as possible. After surgery, antibiotic administration continued for 2 weeks. The patient's right shoulder pain subsided and CT performed 2 months after surgery revealed no recurrence of infection.
Conclusions:
The present case indicated that a subscapularis intramuscular abscess could lead to severe concomitant infections of other organs via the hematogenous route. Thus, early detection and treatment are necessary. Moreover, in this case, surgical drainage using a dorsal subscapularis approach was beneficial to treating the abscess, which had spread from the subscapularis muscle to the glenohumeral joint.
Background
An intramuscular abscess of the subscapularis is a rare phenomenon but important pathology for surgeons to be aware of because clinical deterioration can be rapid and diagnosis difficult. The presentation often mimics other common shoulder pathologies with subacute shoulder pain and stiffness. Early diagnosis, antibiotics and surgical drainage are critical to reduce the spread and joint destruction.
Methods
A search of PubMed and Google Scholar databases identified cases of subscapular intramuscular abscess. Data collected about each case included patient demographics, presentation, pathology, surgical treatment and outcome. The authors report one additional subscapular abscess case.
Results
Data from 17 cases of subscapular abscess were found, 16 in the literature and one case described by the authors. Sixteen of 17 cases (94.1%) presented with shoulder pain and reduced range of motion worsening over a mean of 6.7 days prior to presentation. Surgical approaches utilised included a posterior inferomedial approach, deltoid-pectoral approach and one posterior inferolateral approach.
Discussion and conclusions
From the limited data available regarding subscapular intramuscular abscess, the authors make the following recommendations: (1) Empirical antibiotics covering Staphylococcus aureus +/− methicillin-resistant Staphylococcus aureus, (2) drainage is indicated in all cases; and (3) tendon-sparing approaches can access an abscess in most locations within the subscapular space.
Infections of the subscapular space are very infrequent entities, which is why their diagnosis (for which it is crucial to carry out magnetic resonance imaging or, failing that, computerized tomography) can prove complicated. This difficulty in making the diagnosis conditions the speed of treatment (surgical draining that can be accompanied by antibiotherapy), which is crucial for the medium and long-term prognosis. We present the case of a patient who developed a spontaneous subscapular abscess that was drained using a delto-pectoral approach, with the subscapular space accessed via a medial route to the coracoids. The relevance of this case lies in its singular character and in the description of an approach that has only been used in two prior cases in the literature.
