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A 72-year-old male presents with left shoulder and scapular pain after a fall 2 months ago. A clinical picture is shown in Figure A. Which of the following is most likely affected?
Nerve roots C4-7
Nerve roots C6-7
Cranial nerve XI
Nerve roots C3-5
Cranial nerve XII
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The clinical photo is consistent with lateral scapular winging, which is caused by damage to the spinal accessory nerve, or cranial nerve XI.
Lateral scapular winging is a rare condition caused by trauma to cranial nerve XI, or the spinal accessory nerve. The spinal accessory nerve has a superficial course in the posterior triangle of the neck, placing it at risk during traumatic injuries to the arm or neck. EMG studies are an important tool for appropriate diagnosis, and are often repeated every three to six months to test for improvement. Initial treatment is non-operative, with procedure such as the Eden-Lange transfer or scapulothoracic fusion being reserved for refractory cases.
Shin et al. discuss traumatic brachial plexus injuries in adults. They urge surgery to be considered in the absence of clinical or electrical evidence of recovery or when spontaneous recovery is impossible.
Meininger et al. review scapular winging. They discuss that medial scapular winging caused by damage to the long thoracic nerve is the most common cause of primary scapular winging. With regards to lateral scapular winging, the most common cause is iatrogenic injury to the spinal accessory nerve during cervical lymph node biopsy or mass excision.
Figure A shows an example of lateral scapular winging caused by damage to the spinal accessory nerve, or cranial nerve XI. There is lateral displacement of the scapula with the superior angle more lateral to the midline than the inferior angle. In contrast, Illustration A shows medial scapular winging, caused by damage to the long thoracic nerve. Notice the medial border lifting off the posterior thoracic wall along with the medial and superior translation of the right scapula when compared to the normal left side.
Answers 1, 2, 4, 5: Damage to these nerves will not cause lateral scapular winging.
Shin AY, Spinner RJ, Steinmann SP, Bishop AT.
J Am Acad Orthop Surg. 2005 Oct;13(6):382-96. PMID: 16224111 (Link to Abstract)
Meininger AK, Figuerres BF, Goldberg BA
J Am Acad Orthop Surg. 2011 Aug;19(8):453-62. PMID: 21807913 (Link to Abstract)
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A 42-year-old male sustains a flail chest injury and subsequently undergoes operative stabilization of his chest wall. At first follow-up, the inferior angle of his ipsilateral scapula translates medially with any attempt at overhead activity. Injury to which of the following structures would cause this abnormality?
Spinal accessory nerve
C8 and T1 nerve roots
Upper and lower subscapular nerves
Long thoracic nerve
The clinical vignette describes medial scapular winging, which is seen after injury to the long thoracic nerve.
Medial scapular winging due to a long thoracic nerve palsy can be seen after repetitive stretching in athletes, with direct compression injury, or even iatrogenically during surgical procedures to the lateral thorax. Injury to the long thoracic nerve will eliminate the function of the serratus anterior, which acts to protract the scapula laterally and upward and stabilize the vertebral border of scapula. This results in upper extremity weakness in forward elevation or abduction as the scapula is not stabilized against the thorax.
Meininger et al. report that lesions of the long thoracic nerve and spinal accessory nerves are the most common cause of scapular winging, although numerous underlying etiologies have been described. They report patients describe diffuse neck pain, shoulder girdle discomfort, upper back pain, and weakness with abduction and overhead activities. They also report that most cases are treated nonsurgically.
Wiater et al. review injuries to the spinal accessory nerve which causes dysfunction of the trapezius and subsequent lateral scapular winging. They note that the superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury, and iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Most injuries are treated nonoperatively, but the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.
Illustration A shows a clinical photo of medial scapular winging, while illustration B shows a clinical photo of lateral scapular winging. Illustration C shows the long thoracic nerve during a rib fixation procedure, with the nerve sitting directly on top of the serratus anterior. The trapezius is overlying the scapula at the bottom of the photo, and the patient's head is to the right of the photo.
Answer 1: Damage to the spinal accessory nerve would cause lateral winging.
Answer 2: Damage to C8 and T1 would not cause scapular winging.
Answer 3: Damage to the upper and lower subscapular nerves would affect the teres major and subscapularis muscles.
Answer 4: Damage to the thoracodorsal nerve would affect the latissimus dorsi.
Wiater JM, Bigliani LU.
Clin Orthop Relat Res. 1999 Nov;(368):5-16. PMID: 10613148 (Link to Abstract)
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A collegiate swimmer develops medial winging of the scapula. If the EMG and nerve conduction studies are abnormal, the most likely nerve roots to be involved are?
C7, C8, T1
C6, C7, C8
C5, C6, C7
C4, C5, C6
C3, C4, C5
Classic medial winging of the scapula is due to paralysis of the serratus anterior muscle which is supplied by the long thoracic nerve which holds the scapula to the chest wall and prevents the inferior angle of the scapula from migrating medially. It is innervated by the long thoracic nerve (C5, 6, 7).
Surgical treatment may include partial pec major transfer. Lateral winging may be caused by spinal accessory nerve palsy (CN XI, also ventral ramus C2,3,4). The nerve may be injured during neck surgery. This causes trapezius weakness, allowing the inferior pole of the scapula to migrate laterally. The modified Eden-Lange procedure may be used for this type of winging.
Gregg et al. describes paralysis of the serratus muscle in young athletes which they felt was due to repetitive traction. Full recovery usually occurs in an average of 9 months, and they recommend that surgical methods of treatment should be reserved for patients in whom function fails to return after a two-year period.
Foo et al. describes a larger cohort of 20 patients again treated expectantly with observation and physical therapy. They reported consistent recovery but that it can take up to 2 years.
Illustration A shows a clinical photo of medial scapular winging. Illustration V is an instructional video of scapular winging. It begins with a clinical video of the condition.
Foo CL, Swann M
J Bone Joint Surg Br. 1983 Nov;65(5):552-6. PMID: 6643557 (Link to Abstract)
Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M.
J Bone Joint Surg Am. 1979 Sep;61(6A):825-32. PMID: 479228 (Link to Abstract)
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A patient presents complaining of right shoulder pain and weakness following a neck exploration surgery. On exam, he is noted to have winging of the scapula. His EMG shows denervation of the trapezius muscle. This condition is best described as:
Lateral winging due to spinal accesory nerve injury
Medial winging due to spinal accesory nerve injury
Lateral winging due to long thoracic nerve injury
Medial winging due to long thoracic nerve injury
Scapular dyskinesia due to cervical radiculopathy
The clinical presentation is consistent with lateral scapular winging due to iatrogenic injury to the spinal accessory nerve.
Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. Causes include traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Serratus anterior paralysis, such as from the long thoracic nerve, results in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective.
The review by Kuhn et al. classifies scapular winging as primary, secondary, or voluntary. Primary scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial conditions and resolves after the primary pathologic condition has been addressed.
Romero et al described the Eden-Lange procedure with lateral transfer of the levator scapulae and rhomboid muscles which can be helpful for lateral winging. They report satisfactory long-term results for the treatment of isolated paralysis of trapezius, but in the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function.
Levy et al describe a clinical forward elevation lag sign for trapezius palsy with resulting "Triangle sign" in the prone position which differentiates this from serratus winging.
Levy O, Relwani JG, Mullett H, Haddo O, Even T.
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):573-6. Epub 2009 May 7. PMID: 19423363 (Link to Abstract)
Romero J, Gerber C
J Bone Joint Surg Br. 2003 Nov;85(8):1141-5. PMID: 14653596 (Link to Abstract)
Kuhn JE, Plancher KD, Hawkins RJ.
J Am Acad Orthop Surg. 1995 Nov;3(6):319-325. PMID: 10790670 (Link to Abstract)
Case example of a pectoral is tendon transfer for long thoracic nerve palsy.
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Injury to the long thoracic nerve can result in which of the following clinical entities?
Teres minor atrophy
Latissimus dorsi atrophy
Medial scapular winging
Lateral scapular winging
Medial scapular winging is a problem resulting from failure of the serratus anterior muscle to function properly in holding the scapula against the thoracic wall. The serratus anterior muscle originates at the upper surface of the top 8-9 ribs and inserts along the length of medial border of the scapula; it is innervated by the long thoracic nerve, which is comprised of fibers from the roots of the C5, 6 and 7 levels. Lateral winging is caused most commonly by a trapezius palsy, and rarely by a palsy of the rhomboids.
Kibler has written numerous papers on the role of the scapula. He notes that while scapular dyskinesia may result from nerve injuries, it may also be a result of muscle inhibition from other shoulder pathology such as rotator cuff or labral pathology.
The reference by Martin notes that most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. If there is no recovery, patients become candidates for corrective surgery.
Am J Sports Med. 1998 Mar-Apr;26(2):325-37. PMID: 9548131 (Link to Abstract)
Martin RM, Fish DE
Curr Rev Musculoskelet Med. 2008 Mar;1(1):1-11. PMID: 19468892 (Link to Abstract)
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A 21-year-old male who is training to become a professional mixed martial artist complains of weakness with forward flexion of the right arm. Four months ago, he sustained several blows and kicks to his right upper extremity, torso, and flank during consecutive training sessions. Physical exam shows the deformity shown in Figure A. Which of the following muscles labeled in Figure B is most likely deficient and leading to his symptoms?
The patients presentation is consistent with medial scapular winging, which is caused by a long thoracic nerve palsy and serratus anterior muscle deficiency. The serratus anterior muscle is shown with the letter D in Figure B.
The serratus anterior muscle draws the scapula forward and abducts the scapula. Medial scapular winging is a result of serratus anterior weakness and can be a result of nerve palsy, direct-blow trauma (most likely the case in this patient's presentation), microtrauma-induced strain, fatigue from repetitive tensile use, or muscle inhibition secondary to underlying glenohumeral pathology.
Kibler et al (2003) notes that most of the abnormalities in scapular motion and position can be treated by physical therapy to relieve symptoms and to reestablish strength and activation patterns.
Kibler et al (2002) tested the inter/intrarater reliabilities of physicians and physical therapists detecting the presence of scapular dyskinesis in 26 videotaped subjects. They concluded that abnormal shoulder motion could be detected after appropriate education.
Answer 1: A - Trapezius is the antagonist to serratus anterior, and when unopposed causes the scapula to be pulled medially.
Answer 2: B - Teres major
Answer 3: C - Latissimus
Answer 5: E - Infraspinatus
Kibler WB, McMullen J.
J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51. PMID: 12670140 (Link to Abstract)
Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J
J Shoulder Elbow Surg. 11(6):550-6. PMID: 12469078 (Link to Abstract)
A patient develops shoulder dysfunction and is noted to have medial winging of the scapula. If the EMG shows an abnormaility, which nerve is most likely to be involved?
Medial scapular winging is usually due to loss of serratus anterior function due to long thoracic nerve palsy.
Injury to the long thoracic nerve can occur during repetitive trauma, penetrating trauma, surgery, prolonged pressure due to positioning, or inflammatory processes. This results in superior elevation and medial translation of the scapula, with medial rotation of the inferior pole due to loss of serratus anterior muscle function. The patient will develop pain due to compensation by other periscapular muscles, with impaired arm elevation. The diagnosis of long thoracic nerve can be confirmed with EMG, with serial examinations every 3 months to follow recovery, which occurs in most cases within 1 year depending on etiology. For those patients with symptomatic serratus winging for longer than 1 year with EMG evidence of denervation, surgical options such as scapulothoracic fusion, fascial sling suspension, or muscle transfer can be considered.
Kuhn et review different causes of scapular winging. They classify the condition as primary, secondary, or voluntary. Primary scapular winging may be due to neurologic injury, pathologic changes in the bone, or periscapular soft-tissue abnormalities. Secondary scapular winging occurs as a result of glenohumeral and subacromial conditions and resolves after the primary pathologic condition has been addressed. Voluntary scapular winging is not caused by an anatomic disorder and may be associated with underlying psychological issues.
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This video shows an Eden Lange Transfer for Trapezius Palsy that was caused by i...
Educational video describing the cause of winging of the scapula and treatment m...