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Introduction
  • A dysfunction involving the stabilizing muscles of the scapula resulting in imbalance and abnormal motion of the scapula
  • Types of scapular winging
    • defined by the direction of the superomedial corner of the scapula
    • medial scapular winging  
      • etiology
        • dysfunction of the serratus anterior (long thoracic nerve  
          • weak protraction of the scapula
          • excessive medializing scapular retraction (rhomboid major and minor) and elevation (trapezius)
      • epidemiology
        • young athletic patient
        • more common than lateral
    • lateral scapular winging  
      • etiology
        • dysfunction of the trapezius (cranial nerve XI - spinal accessory nerve)
          • weak superior and medializing force on the scapula
          • excessive lateralizing scapular protraction (serratus anterior, pectoralis major and minor)
      • epidemiology
        • usually iatrogenic (history of neck surgery)
Anatomy
  • Scapulothoracic articulation
    • not a true joint
    • attached to thorax via ligaments at the acromioclavicular (AC) joint
    • suction mechanism created by serratus anterior and subscapularis holds scapula closely to thorax
    • allows scapular movement against the posterior rib cage
      • contributes to glenohumeral joint positioning and mechanics
  • Stabilizing muscles
    • scapula serves as attachment site for 17 muscles
      • function to stabilize scapula to the thorax, provide power to the upper limb and synchronize glenohumeral motion
    • serratus anterior  
      • originates from ribs 1-8 and inserts on anteromedial border of scapula
        • total 7-10 slips
      • primary motion is scapular protraction (anterior and lateral motion)
      • innervated by long thoracic nerve
        • ventral rami of C5, C6, C7
      • blood supply
        • superiorly: long thoracic artery
        • inferiorly: thoracodorsal artery branches
      • three parts with different functions
        • upper: downward rotation (glenoid down), stabilizes superior scapula
        • middle: scapular protraction
        • lower: upward rotation and abduction
    • trapezius  
      • originates from medial third superior nuchal line, external occipital protuberance, nuchal ligament and C7-T12 spinous processes
      • inserts on lateral third clavicle, acromion and scapular spine
      • primary motion is upward rotation and elevation of the scapula
      • innervated by spinal accessory nerve
        • cranial nerve XI
      • three parts with different functions
        • upper: upward rotation and elevation
        • middle: scapular retraction and adduction
        • lower: downward rotation and depression 
    • rhomboid major and rhomboid minor  
      • rhomboid major originates from T2-T5 spinous processes and inserts onto medial scapular border, just below insertion of rhomboid minor
      • rhomboid minor originates from C7 and T1 spinous processes and inserts onto medial scapular border, near base of scapular spine
      • primary motion is scapular retraction
      • innervated by dorsal scapular nerve
    • levator scapulae 
      • originates from C1-C4 transverse processes and inserts onto medial border of scapula at the level of the scapular spine
      • primary motion is elevation of the scapula and downward rotation to tilt the glenoid cavity inferiorly
      • innervated by C3-C4 cervical plexus with contributions from dorsal scapular nerve
  • Nerves 
    • long thoracic nerve 
      • arises from ventral rami of C5, C6 and C7
      • anatomic variations
        • C4 contribution in 13%
        • absence of C7 contribution in 8%
      • travels posterior to the axillary vessels and brachial plexus
      • runs superficially to the serratus anterior, giving branches to each slip
      • crow's foot
        • point where the long thoracic nerve intersects the most dominant and inferior serratus branch of the thoracodorsal artery
    • spinal accessory nerve (cranial nerve XI)
      • spinal and cranial portions join to form the accessory trunk
      • accessory trunk traverses the jugular foramen, crosses laterally over the internal jugular vein to innervate the sternocleidomastoid
      • enters posterior triangle of the neck to innervate the trapezius
Medial Scapular Winging
  •  Pathophysiology
    • deficit in serratus anterior function due to injury to the muscle itself or to the long thoracic nerve   
    • mechanical
      • traumatic avulsion of the serratus anterior
      • displaced fractures of the inferior pole of the scapula
    • neurologic
      • traction nerve injury
        • > 50% of the cases
        • repetitive stretch injury is most common
          • gradual onset of weakness and winging
          • increased risk with head tilted away during overhead arm activity, repetitive throwing, prolonged abduction
          • weight lifters, volleyball players
        • can be acute injury with immediate winging in cases of high-energy trauma (motorcycle accident)
      • compressive nerve injury
        • acute
          • blunt trauma to the chest wall, head or neck (contact sports, motor vehicle accidents)
          • sudden depression of the shoulder girdle (fall)
        • chronic
          • sites of compression
            • scalene muscles
            • subcoracoid between coracoid and 1st or 2nd rib (carrying heavy objects on shoulder)
            • inflamed bursae (subcoracoid, subscapular, accessory and supracoracoid)
            • anteroinferior scapular border
      • direct nerve injury
        • iatrogenic
          • 10% of patients had prior surgery
          • radical mastectomy / axillary lymph node dissection
          • thoracic surgery
          • chest tube placement for pneumothorax
        • penetrating injury to chest wall
      • neuralgic amyotrophy (brachial neuritis) 
        • presents with isolated unilateral palsy of the long thoracic nerve in 22%
        • consider in patients without clear traumatic onset and with antecedent immunological insult and/or inflammatory response
  • Presentation
    • vague, nonspecific shoulder girdle pain and fatigue
      • base of neck, scapula and deltoid
    • muscle spasms
    • weakness when lifting away from body and overhead activity
    • discomfort sitting against a chair
    • may have neurologic symptoms due to traction on brachial plexus
    • subjective shoulder instability
      • failure of the scapula to provide a stable platform for rotation of the glenohumeral joint 
  • Evaluation
    • physical examination 
      • superior medial scapula elevates and protrudes posteriorly and medially  
        • worsened by forward arm flexion
      • abduction often limited to 90° or less
      • weakness of forward arm flexion and abduction
      • wasting of anterior scalene triangle 
        • due to atrophy of the sternocleidomastoid muscle
      • scapular stabilization
        • manual stabilization of the scapula often improves pain and increases flexion and abduction
    • diagnostic studies
      • electromyography
        • helps assess involvement of long thoracic nerve versus a mechanical cause of winging (serratus anterior avulsion)
  • Treatment
    • nonoperative
      • observation, physical therapy and activity modification
        • indications
          • observe for a minimum of 6 months, ideally 18 months to 2 years
            • wait for nerve to recover
        • technique
          • physical therapy for serratus anterior strengthening, stretching
          • avoid painful or heavy lifting activities
          • bracing with a modified thoracolumbar brace can be considered
            • poor compliance and little benefit
        • outcomes
          • majority of patients will spontaneously resolve with full return of shoulder function and resolution of winging by 2 years
    • operative
      • early repair of serratus anterior avulsion
        • indications
          • mechanical disruption of the serratus anterior muscle (avulsion) and/or its insertion (inferior pole scapula fractures) with symptomatic winging should undergo surgical repair acutely
      • neurolysis of the long thoracic nerve
        • indications
          • failure to improve with conservative treatment, at least 6 months
          • electromyography with signs of nerve compression (distal latency, dennervation)
        • technique
          • supraclavicular decompression as the nerve traverses the scalene muscles
        • outcomes
          • excellent improvement in pain and resolution of winging in patients who failed nonoperative management (98%)
          • better improvement in shoulder strength (flexion and abduction) compared to muscle transfers
      • muscle transfer: split pectoralis major transfer 
        • indications
          • failure to improve with conservative treatment, for 1-2 years
          • pain relief and improved shoulder function with manual scapular stabilization
        • technique
          • split pectoralis major transfer (sternal head) 
            • with or without augmentation with a fascia lata or hamstring graft
            • most effective
          • other transfers
            • pectoralis minor transfer
            • rhomboid transfer
        • outcomes
          • predictor of successful surgery is symptom relief and improved function with preoperative manual scapular stabilization
          • often have persistent shoulder abduction weakness
          • complications
            • failure of pectoralis muscle transfer attachment at scapula
            • unsatisfactory cosmesis (breast asymmetry in women)
            • infection
            • adhesive capsulitis
      • nerve transfer
        • developing area in the microsurgical field
        • technique
          • lateral branch of the thoracodorsal nerve to the long thoracic nerve
          • medial pectoral nerve with sural nerve graft to the long thoracic nerve
        • outcomes
          • shown to successfully reinnervate the long thoracic nerve
          • benefit of preserving proper muscle biomechanics
      • scapulothoracic fusion
        • indications
          • scapular winging from diffuse neuromuscular disorders
          • failed muscle transfer surgery
          • often not the first surgical treatment of choice
          • primary goal is pain relief
        • technique
          • fusion of the anterior scapula to the posterior rib cage, with wire cables and/or plates and screws
        • outcomes
          • limited increase in shoulder motion
            • ~20° gain of abduction
          • recent studies show high satisfaction levels in 82% of patients at 5-year follow up
          • complications
            • nonunion
            • pleural effusion
            • adhesive capsulitis
            • symptomatic hardware requiring removal
Lateral Scapular Winging
  • Pathophysiology
    • deficit in trapezius function due to injury to the spinal accessory nerve (CN XI) 
    • neurologic
      • iatrogenic 
        • most common
        • vulnerable in the posterior triangle of the neck
          • cervical lymph node biopsy
          • radical neck dissection
      • traumatic
        • traction injury
          • sudden lateral flexion of the neck (motor vehicle or motorcycle accidents)
        • blunt trauma
          • deep tissue massage
        • penetrating injury to the neck
  • Presentation
    • similar to medial scapular winging
    • vague, nonspecific shoulder girdle pain and fatigue
    • muscle spasms
    • weakness with overhead activity
    • discomfort sitting against a chair
    • may have neurologic symptoms from traction on the brachial plexus
    • subjective shoulder instability
      • failure of the scapula to provide a stable platform for rotation of the glenohumeral joint
    • shoulder impingement
      • inferior translation of the coracoacromial arch as scapula depresses secondary to loss of trapezius
  • Evaluation
    • physical examination
      • superior medial scapula drops downward and protrudes posterior and lateral
        • worsened by arm abduction and resisted external rotation
      • shoulder girdle appears depressed or drooping
      • asymmetry or visible atrophy of the ipsilateral trapezius
      • weakness of forward arm flexion and abduction
      • scapular stabilization
        • manual stabilization of the scapula often improves pain
    • diagnostic studies
      • electromyography
        • helps distinguish isolated spinal accessory nerve injury from other more extensive neurologic injuries
  • Treatment
    • nonoperative
      • observation, physical therapy and activity modification
        • indications
          • the role of conservative management is controversial given that most injuries are iatrogenic direct nerve injuries and warrant surgical intervention
          • elderly and sedentary patients and those without an identifiable injury should be initially treated conservatively
        • outcomes
          • predictors of a poor outcome with conservative management include inability to raise the arm above the shoulder at presentation and dominant extremity involvement
    • operative
      • exploration of the spinal accessory nerve, neurolysis, repair
        • indications
          • identifiable nerve injury diagnosed early
        • technique
          • should be performed within 20 months of injury
      • muscle transfer: Eden-Lange transfer  
        • indications
          • nerve injury diagnosed late (> 20 months from injury)
        • technique
          • transfer of the levator scapulae and rhomboid muscles from the medial border of the scapula to the lateral border, to effectively reconstruct the trapezius
      • scapulothoracic fusion
        • see above under Medial Scapular Winging
 

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(OBQ12.258) 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? Review Topic

QID: 4618
1

Spinal accessory nerve

9%

(430/4987)

2

C8 and T1 nerve roots

1%

(30/4987)

3

Upper and lower subscapular nerves

2%

(109/4987)

4

Thoracodorsal nerve

6%

(283/4987)

5

Long thoracic nerve

82%

(4084/4987)

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PREFERRED RESPONSE 5
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(OBQ12.114) 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? Review Topic

QID: 4474
FIGURES:
1

Nerve roots C4-7

17%

(683/3920)

2

Nerve roots C6-7

13%

(503/3920)

3

Cranial nerve XI

55%

(2144/3920)

4

Nerve roots C3-5

8%

(315/3920)

5

Cranial nerve XII

6%

(243/3920)

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 1207
FIGURES:
1

A

6%

(42/651)

2

B

3%

(20/651)

3

C

6%

(39/651)

4

D

79%

(516/651)

5

E

5%

(30/651)

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PREFERRED RESPONSE 4

(SBQ07SM.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: Review Topic

QID: 1394
1

Lateral winging due to spinal accesory nerve injury

80%

(798/992)

2

Medial winging due to spinal accesory nerve injury

14%

(134/992)

3

Lateral winging due to long thoracic nerve injury

3%

(26/992)

4

Medial winging due to long thoracic nerve injury

3%

(28/992)

5

Scapular dyskinesia due to cervical radiculopathy

0%

(3/992)

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PREFERRED RESPONSE 1

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

QID: 77
1

Teres minor atrophy

0%

(1/408)

2

Infraspinatus atrophy

0%

(1/408)

3

Latissimus dorsi atrophy

3%

(12/408)

4

Medial scapular winging

81%

(332/408)

5

Lateral scapular winging

15%

(60/408)

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 1224
1

Suprascapular

1%

(17/1341)

2

Axillary

0%

(3/1341)

3

Long thoracic

93%

(1252/1341)

4

Thoracodorsal

5%

(66/1341)

5

Radial

0%

(0/1341)

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(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? Review Topic

QID: 487
1

C7, C8, T1

12%

(338/2829)

2

C6, C7, C8

6%

(157/2829)

3

C5, C6, C7

65%

(1830/2829)

4

C4, C5, C6

11%

(315/2829)

5

C3, C4, C5

6%

(182/2829)

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