To observe the clinical results of Woodward’s procedure for the treatment of congenital hyperscapularism in children. Methods From December 2002 to June 2007, 21 cases of congenital hypercapraxia were treated, 14 males and 7 females. The average age at surgery was 6 years old, the youngest was 2 years old and the oldest was 15 years old, and the scapula was on average 3 cm higher than the contralateral side. 10 cases were complicated by other systemic deformities, with spine and rib deformities being the most common. All cases were treated with the Woodward procedure. Results All cases were successfully followed up. The average follow-up was 2 years and 6 months (6 months-4 years). None of the cases had combined brachial plexus nerve injury. Conclusion The Woodward procedure is easy to perform, with minimal injury and satisfactory postoperative cosmetic and functional improvement, and is a better procedure for the treatment of congenital hypertrophic scapulae in children. Congenital high scapularity, also known as Sprengel’s deformity, was first described by Eulenburg in 1863 and four cases by Sprengel in 1891. The disease is the result of incomplete descent of the scapular girdle during embryonic development, with abnormalities of both the scapula and the muscles [1]. The main clinical manifestations are limited upper extremity abduction and supination and asymmetry of both shoulders. Many authors [2, 3] believe that the Woodward procedure has the advantage of less injury and better results. The Woodward procedure has been used in our hospital since December 2002 to treat congenital high scapula in children and has achieved good clinical results. 1. Materials and methods From December 2002 to June 2007, we treated 21 cases of congenital high scapula in children, 14 male cases and 7 female cases. There were 18 cases on the left side and 3 cases on the right side. The age range at the time of surgery was 2 to 15 years, with a mean of 6 years. All children showed limited abduction and supination of the upper extremity, and the abduction and supination angle ranged from 60° to 120°, with an average of 90°. The difference in shoulder height between the two sides ranged from 2 to 6 cm, with an average of 3 cm. 10 children had other deformities, including scoliosis in 2 cases, spina bifida in 2 cases, cervical hemivertebrae in 2 cases, and rib deformity in 2 cases (rib fusion in 1 case and forked ribs in 1 case). The Cavendish classification criteria were as follows: Grade I: The deformity was mild, with the shoulder joints on both sides at the same level, and the appearance was not obvious. Degree II: Both shoulder joints were nearly at the same level, and the deformity could be seen when wearing clothes. Grade III: The shoulder joint is 2-5cm higher than the opposite side, and the deformity is obvious. Grade IV: Very serious, the scapula can reach the occipital bone. According to Cavendish classification, there were 3 cases of grade II, 17 cases of grade III and 1 case of grade IV. After general anesthesia, the skin and subcutaneous tissues were cut, and the starting point of the large and small rhomboid muscles were peeled from the spinous process, turned up, and the whole muscle membrane was turned outward. The scaphoid vertebrae are exposed and cut from the superior angle of the scapula, or in the case of fibrous strips, also cut. The trapezius muscle is cut and the assistant assists in pushing down on the scapula and suturing the trapezius muscle and the greater and lesser rhomboids back down to the spinous process. The upper free edge of the trapezius muscle was sutured, and the deep fascia was appropriately sutured downward, and the lower part of the trapezius muscle was overlapped and sutured. 3. Results All 21 children were followed up for 6 months to 4 years, with an average of 2.5 years. After surgery, there was a significant improvement in appearance compared with the preoperative period, with an average downward shift of the scapular height of 3 cm. The abduction and supination function of the affected shoulder joint improved to varying degrees, from an average of 90° to an average of 140° (range 90°-180°), with an average increase of 50°. 4.Discussion Regarding the appropriate age for surgery of congenital hypertelorism, previous reports in the literature mostly agree that surgery should be performed at a younger age, and the results are better at the age of 3-6 years. If the age is younger than 3 years, the anatomy is not very clear, which makes the surgery more difficult. If the deformity is older than 6 years of age, the deformity is already quite severe, the muscle tissue is less elastic, and the contracture is heavier, so forcing the surgery to pull down will increase the chance of brachial plexus nerve injury. Some literature advocates that surgery within 4 years of age is appropriate. It has also been reported in the literature that the age of the child at the time of surgery has no effect on the postoperative outcome, while the concurrent cervical spine deformity has a negative prognostic impact. In this group of cases, it was found that the postoperative improvement in appearance and function was better in younger children than in older children, and early surgical correction was advocated. In this group, there were three 2-year-old children and five 3-year-old children, all of whom achieved good postoperative results. The relationship between the morphology of the shoulder vertebrae and the surrounding tissues, spiral CT scanning and 3D reconstruction imaging, can provide a three-dimensional image of the lesion, which helps to understand the pathological changes comprehensively before surgery. Intraoperative dissection revealed that the affected scapula was smaller than the normal scapula and rotated in the sagittal position. In all cases, there was an abnormal connection between the scapula and the spine, in 2 cases the scaphoid vertebrae (1 with a complete bony connection and 1 with a cartilaginous connection at the scapula), and in the remaining 19 cases the fibrous contracture band. In both cases, the shoulder vertebrae were located between the internal superior border of the scapula and the spinous process of the cervical vertebrae, with the outer fibrous sheath. The soft tissue pathology was mainly manifested by contracture of the muscles of the scapular band, especially the rhomboid and rhomboid muscles, so the contracted muscles were released sufficiently during surgery to bring the scapula down to as close to a normal position as possible. 4 children underwent resection of the suprascapular portion of the scapula at the same time as the inferior displacement of the scapula, while the rest underwent inferior displacement of the scapula only. When performing suprascapular resection, care should be taken to protect the acromion and glenoid to avoid excessive resection, which may affect the function of the shoulder joint. When performing scapular subluxation, it is not recommended to pull down the lower angle of the scapula to the level of the normal side, but to take the scapular post as the reference point, and after pulling down both sides of the scapular post can be basically level. The Woodward procedure adopts a straight incision, and the downward displacement of the scapula is achieved by the downward displacement of the rhomboid muscle and the starting point of the spinal edge of the large and small rhomboid muscles, which cleverly use the myofascial flaps of the rhomboid and large rhomboid muscles as the driving force for the downward displacement and refixation of the scapula. Exposure of the superior and medial scapular margins is also accessed through the fascial gap, resulting in less transection of the muscles, less trauma and less bleeding compared to the Green procedure. The median dorsal incision scar is small, which is especially desirable in younger children. Brachial plexus nerve injury is a serious complication of surgical treatment. There is controversy as to whether to perform clavicle osteotomy. Some authors believe that clavicle osteotomy provides a better orthopedic result and reduces the risk of postoperative brachial plexus injury. Most authors believe that clavicle osteotomy should not be used as a routine treatment for congenital hypertelorism and that the decision should be made on a child-by-child basis. None of the children in this group underwent clavicle osteotomy, and none of them developed postoperative brachial plexus nerve injury. The main point is that the intraoperative pulling of the scapula downward should be moderate, not deliberately pursuing the pulling down of the lower angle of the affected scapula to the same level as the opposite side. As long as the muscles and soft tissues around the scapula are completely released during surgery, the height can be significantly improved compared to the preoperative level.