Scapular winging

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					                                    Scapular winging
A.       Primary                                   On examination there is trapezius wasting,
         a. Neurological                           inability to shrug and weakness on elevation
                   i. Accessory nerve              and abduction of the arm. The diagnosis can
                  ii. Long thoracic nerve          be confirmed by EMG studies.
                 iii. Dorsal scapular nerve
         b. Osseous                                Initial treatment consists of physiotherapy to
                   i. Osteochondromas              maintain a full range of shoulder movement,
                  ii. Malunion                     thus preventing a frozen shoulder.
         c. Soft tissue
                   i. Contractures                 Surgical treatment, in the event of no recovery,
                  ii. Muscle avulsion              can be grouped into three options:
                 iii. Muscle agenesis
                 iv. Bursitis                      1.       Scapulothoracic fusion
B.       Secondary to shoulder pathology           2.       Static fascial slings
C.       Voluntary                                 3.       Dynamic transfers

Evaluation                                         Scapulothoracic fusions lead to a drastic
Observe first from behind with arms at side.       decrease in shoulder ROM, and fascial slings
                                                   stretch out over a period of a couple of years.
Look for a static deformity, atrophy of the        Thus, dynamic transfers are preferred.
trapezius,   medial   border    of  scapula
(rhomboids).                                       The preferred procedure is the Eden-Lange
                                                   transfer (remember as the NZ transfer), which
Observe during forward elevation, for              consists of transferring the insertions of the
scapulothoracic rhythm and    dynamic              levator and rhomboids with attached bone
deformity.                                         blocks laterally (By around 5cm). Bigliani
                                                   reported good or excellent results in 87% of the
Palpate for crepitus.                              23 patients in his series.

Then test for winging during resisted motion.      Serratus anterior winging
                                                   The long thoracic nerve (C5-7) originates from
Accessory palsy                                    the roots of the brachial plexus, and runs down
The spinal accessory nerve emerges from the        the medial wall of the axilla, anterior to the mid
sternocleidomastoid muscle to run across the       axillary line to innervate serratus anterior.
posterior triangle and enter the trapezius (the
cervical plexus nerves enter the posterior         Damage is usually due to blunt trauma or
triangle behind SCM). It contains segments         stretching, and has been reported in almost all
from C1-5. The trapezius is also innervated by     sports. Brachial neuritis also commonly affects
cervical plexus nerves C3-4 which supply           this nerve. Prolonged bed rest has been
proprioception and occasionally some motor         reported to trigger dysfunction of the nerve.
                                                   When the LTN is injured, the scapula assumes
Injury can be caused by blunt trauma, traction     a position of superior elevation and the inferior
or penetrating trauma. Surgical misadventure       angle rotates medially.
can occur during biopsy of nodes in the
posterior cervical triangle.                       Patients complain of pain from other muscles
                                                   which are in spasm from trying to compensate
After injury the patient’s shoulder is depressed   for the actions of serratus.
and the scapula is translated laterally with the
inferior angle rotated laterally.                  Pushing against a wall and attempted elevation
                                                   above the head magnify symptoms.
The patient tries to compensate for this by
increased use of the rhomboids and levator         Initial treatment consists of ROM exercises.
scapulae, which can be lead to painful spasm.

Most injuries of the LTN recover within a year.     Secondary winging
If there is no recovery and symptoms warrant        Contractural winging
it a muscle transfer can be performed. The one      Contractures around the glenohumeral joint
most commonly employed is the Marmor-               produce a secondary winging as the patient
Bechtol transfer, which uses the sternocostal       attempts to place the arm in the desired
head of pectoralis major, prolonged by a 7 inch     position.
tube of fascia lata, passed through a foramen
created at the inferior angle of the scapula.       One example is seen in obstetric brachial
This operation has success rates of 70-90% in       plexus palsy when the arm can assume an
the literature.                                     adducted and internally rotated posture.
                                                    When attempting to abduct and externally
Rhomboid major and minor winging                    rotate the arm, the superior corner of the
These muscles are innervated by the dorsal          scapula can project away from the chest wall at
scapular nerve (C5) which runs deep to levator,     the upper margin of the trapezius, producing
on serratus posterior superior.                     the “scapular sign of Putti”.

Palsy of these muscles is a rare cause of           Contractural winging can also occur with
winging.                                            deltoid fibrosis, which may occur secondary to
                                                    multiple deltoid injections.
The clinical picture is similar to that seen in
trapezius palsy, with the shoulder slightly         Glenohumeral pathology
depressed, the scapula laterally translated and     Secondary scapular winging may occur with
the inferior angle rotated laterally.               frozen shoulder, instability and impingement.
                                                    Patients with painful shoulders may reflexively
Treatment is nonsurgical with trapezius             limit glenohumeral motion and attempt to
strengthening exercises in most cases.              compensate with increased scapulothoracic
                                                    motion. This fatigues the periscapular muscles,
Occasionally a fascial sling operation is used to   and weakening of the muscles leads to fatigue.
connect the lower border of the scapular to the
spinal muscles and latissimus dorsi.

Osseous problems
Osteochondromas are the commonest tumours
of the scapula, and if found on the deep surface
of the scapula may produce a fixed winging
and scapular crepitus.

EMG findings are normal; XR and CT scans
demonstrate the abnormality.

Treatment is resection of the abnormal bone.

Muscular problems
Agenesis of various parascapular muscles may
occur e.g. in Poland syndrome, but is usually
not a functional problem.

Avulsion of the serratus has been reported, and
surgical reattachment is indicated.

Bursal origin
Rarely the scapulothoracic articulation can be
affected by a bursitis. This causes a painful
impairment of scapulothoracic rhythm, and can
be addressed with NSAIDs or surgical


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