Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Images
https://upload.orthobullets.com/topic/3062/images/winging.jpg
https://upload.orthobullets.com/topic/3062/images/scapular_winging..jpg
https://upload.orthobullets.com/topic/3062/images/medial_3.jpg
https://upload.orthobullets.com/topic/3062/images/medial_1.jpg
https://upload.orthobullets.com/topic/3062/images/lateral_3.jpg
https://upload.orthobullets.com/topic/3062/images/lateral_2.jpg
https://upload.orthobullets.com/topic/3062/images/clinical photo - medial winging.jpg
https://upload.orthobullets.com/topic/3062/images/lateral_scapular_winging.jpg
https://upload.orthobullets.com/topic/3062/images/lateal.jpg
https://upload.orthobullets.com/topic/3062/images/medial_2.jpg
  • summary
    • Scapular winging is a dysfunction involving the stabilizing muscles of the scapula resulting in imbalance and abnormal motion of the scapula.
    • Diagnosis is made clinically with the presence of excessive medializing scapular retraction (medial winging) or excessive lateralizing scapular protraction (lateral winging).
    • Treatment is generally observation, physical therapy and activity modification or operative depending on etiology of winging and presence of identifiable neurological lesion.
  • Epidemiology
    • Anatomic location
      • 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
        • inferior 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
Card
1 of 2
Question
1 of 16
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options