Scapular Winging

Author: Derek Moore

Topic updated on 04/10/13 10:23pm

Introduction

Two types based on direction of inferior border of scapula
- medial winging
  - serratus anterior (long thoracic nerve)
- lateral winging
  - trapezius (CN XI - spinal accesory nerve)

Anatomy

Scapula serves as the attachment site for 17 muscles
- function to stabilize the scapula to the thorax, provide power to the upper limb, and synchronize glenohumeral motion.
Normal motion
- elevation and upward rotation
  - by trapezius muscle.
- scapular protraction (anterior and lateral motion)
  - by serratus anterior and pectoralis major and minor muscle
- scapular retraction (medial motion)
  - by rhomboid major and minor muscles.

Medial Winging

Introduction
- caused by deficit in serratus anterior due to injury to the long thoracic nerve (C5,6,7)
- Mechanisms of injury to long thoracic nerve
  - repetitive stretch injury (most common)
    - increased risk with head tilted away during overhead arm activity
    - e.g., weight lifters, volleyball players
  - compression injury
    - direct compression of nerve at any site, including the lateral chest wall see with contact sports and trauma
  - iatragenic injury
    - from axillary node dissection
  - scapula fracture
Presentation
- symptoms
  - shoulder and scapula pain
  - weakness when lifting away from body or overhead activity
  - discomfort when sitting against chair
- physical exam
  - inferior border of scapula goes medial
  - shoulder girdle elevates
Treatment
- nonoperative
  - observation, bracing, and serratus anterior strengthening
    - indications
      - observation for a minimal of 6 months- wait for nerve to recover
    - technique
      - bracing with a modified thoracolumbar brace
- operative
  - pectoralis transfer
    - indications
      - failure of spontaneous resolution after 1-2 years

Lateral Winging

Introduction
- caused by deficit in trapezius due to spinal accessory nerve injury (CNXI)
- often cause by an iatrogenic injury (by general surgery or neurosurgery looking for lymph nodes in posterior neck)
Physical exam
- inferior border of scapula goes lateral
- shoulder girdle appears depressed or drooping
Treatment
- nonoperative
  - observation and trapezius strengthening
- operative options include
  - nerve exploration
    - indications
      - iatrogenic nerve injury
  - Eden-Lange transfer
    - lateralize levator scapulae and rhomboids (transfer from medial border to lateral border)
  - scapulothoracic fusion

Please Rate Educational Value!

4.0

Average 4.0 of 9 Ratings

Qbank (4 Questions)

TAG

(SBQ07.9) 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: Topic

Review Topic

1. Lateral winging due to spinal accesory nerve injury
2. Medial winging due to spinal accesory nerve injury
3. Lateral winging due to long thoracic nerve injury
4. Medial winging due to long thoracic nerve injury
5. Scapular dyskinesia due to cervical radiculopathy

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with lateral scapular winging due to iatragenic injury to the spinal accesory 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.

REFERENCES:

1. Levy O, Relwani JG, Mullett H, Haddo O, Even T. The active elevation lag sign and the triangle sign: new clinical signs of trapezius palsy. J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):573-6. PMID:19423363 (Link to Abstract)

2. Romero J, Gerber C: Levator scapulae and rhomboid transfer for paralysis of trapezius: The Eden-Lange procedure. J Bone Joint Surg Br 2003;85:1141-1145. PMID:14653596 (Link to Abstract)

3. Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. PMID:10790670 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Robert Boykin MD,

Please Rate Educational Value!

4.0

Average 4.0 of 7 Ratings

Related Videos

Surgical Treatment of Long Thoracic Nerve Palsy

Sports - Educational Presentation - Scapular Winging

Case example of a pectoral is tendon transfer for long thoracic nerve palsy.

4 weeks ago

48 views

TAG

(OBQ08.101) 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? Topic

Review Topic

1. C7, C8, T1
2. C6, C7, C8
3. C5, C6, C7
4. C4, C5, C6
5. C3, C4, C5

PREFERRED RESPONSE ▶

DISCUSSION: 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 angel 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 is 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. Illustrations V shows an instruction video of scapular winging. It begins with a clinical video of the condition.

Illustrations: A

REFERENCES:

1. Foo CL, Swann M. Isolated paralysis of the serratus anterior. A report of 20 cases. J Bone Joint Surg Br. 1983 Nov;65(5):552-6. PMID:6643557 (Link to Abstract)

2. Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979 Sep;61(6A):825-32. PMID:479228 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Jeremy Stern MD, John Badylak MD, Mark Miller MD,

Please Rate Educational Value!

4.0

Average 4.0 of 11 Ratings

TAG

(OBQ05.41) Injury to the long thoracic nerve can result in which of the following clinical entities? Topic

Review Topic

1. Teres minor atrophy
2. Infraspinatus atrophy
3. Latissimus dorsi atrophy
4. Medial scapular winging
5. Lateral scapular winging

PREFERRED RESPONSE ▶

DISCUSSION: 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 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.

REFERENCES:

1. Kibler WB: The role of the scapula in athletic shoulder function. American Journal of Sports Medicine; 1998 (26): pp 325-337. PMID:9548131 (Link to Abstract)

2. Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008 Mar;1(1):1-11. PMID:19468892 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, John Badylak MD,

Please Rate Educational Value!

4.0

Average 4.0 of 8 Ratings

TAG

(OBQ04.102) 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? Topic

Review Topic

FIGURES: A

1. A
2. B
3. C
4. D
5. E

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Incorrect Answers:
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

REFERENCES:

1. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51. Review PMID:12670140 (Link to Abstract)

2. Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):550-6. PMID:12469078 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

TAG

(OBQ04.119) 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? Topic

Review Topic

1. Suprascapular
2. Axillary
3. Long thoracic
4. Thoracodorsal
5. Radial

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Kuhn JE, Plancher KD, Hawkins RJ. Scapular Winging. J Am Acad Orthop Surg. 1995 Nov;3(6):319-325. PMID:10790670 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 6 Ratings

Videos

Surgical Treatment of Long Thoracic Nerve Palsy

Sports - Educational Presentation - Scapular Winging

Case example of a pectoral is tendon transfer for long thoracic nerve palsy.

4 weeks ago

48 views

See More Videos

Groups

ABOS II: Scapular Winging

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg. 2003 Mar-Apr;11(2):142-51. Review PMID:12670140 (Link to Abstract)
Kibler WB, Uhl TL, Maddux JW, Brooks PV, Zeller B, McMullen J. Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):550-6. PMID:12469078 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Levy O, Relwani JG, Mullett H, Haddo O, Even T. The active elevation lag sign and the triangle sign: new clinical signs of trapezius palsy. J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):573-6. PMID:19423363 (Link to Abstract)
Romero J, Gerber C: Levator scapulae and rhomboid transfer for paralysis of trapezius: The Eden-Lange procedure. J Bone Joint Surg Br 2003;85:1141-1145. PMID:14653596 (Link to Abstract)
Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325. PMID:10790670 (Link to Abstract)
Foo CL, Swann M. Isolated paralysis of the serratus anterior. A report of 20 cases. 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. Serratus anterior paralysis in the young athlete. J Bone Joint Surg Am. 1979 Sep;61(6A):825-32. PMID:479228 (Link to Abstract)
Kibler WB: The role of the scapula in athletic shoulder function. American Journal of Sports Medicine; 1998 (26): pp 325-337. PMID:9548131 (Link to Abstract)
Martin RM, Fish DE. Scapular winging: anatomical review, diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008 Mar;1(1):1-11. PMID:19468892 (Link to Abstract)
Kuhn JE, Plancher KD, Hawkins RJ. Scapular Winging. J Am Acad Orthop Surg. 1995 Nov;3(6):319-325. PMID:10790670 (Link to Abstract)

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Scapular Winging

Qbank (4 Questions)

Related Videos

Question Comments

Question Comments

Question Comments

Question Comments

Question Comments

Videos

Groups

Evidence & References Show References

Topic Comments