•  Two types based on direction of top-medial corner of scapula
    • medial winging
      • serratus anterior (long thoracic nerve  
    • lateral winging
      • trapezius (CN XI - spinal accessory nerve)
  • Differentiating medial and lateral winging
    • history
      • medial winging
        • usually seen in young athletic patient
        • far more common
      • lateral winging 
        • history of neck surgery (lateral is usually iatrogenic)
    • physical exam
      • medial winging  
        • medial spine of scapula moves upward and medial
      • lateral winging  
        • medial spine of scapula moves downward and lateral
  • 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
      • iatrogenic from anesthesia
        • 10% of patients with medial scapular winging had prior surgery
      • 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 seen with contact sports and trauma
      • scapula fracture 
  • Presentation
    • symptoms
      • shoulder and scapula pain
      • weakness when lifting away from body or overhead activity
      • discomfort when sitting against chair
    • physical exam 
      • superior medial scapula elevates and migrates medial  
      • wasting of anterior scalene triangle” due to wasting of sternocleidomastoid
  • 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
      • split pectoralis major transfer (sternal head)  
        • 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 caused by an iatrogenic injury (by general surgery or neurosurgery looking for lymph nodes in posterior neck) 
  • Physical exam
    • superior medial scapula drops downward and lateral
      • shoulder girdle appears depressed or drooping
    • anterior scalene triangle wasting
      • secondary to anterior scalene atrophy
  • 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

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