Winged Scapula: Clinical and Electrophysiological Features and Common Causes Based on 20 Years of Experience in a Referral Center in Turkey.

PURPOSE: Winged scapula (WS) is a functionally disabling problem and it occurs because of neurogenic causes frequently. The authors aimed to assess WS patients by physical and electrodiagnostic examinations as well as some further investigations and define the common causes of WS. METHODS: The authors reviewed clinical and neurophysiological findings of 52 patients who were referred for electrodiagnostic examination because of WS in the period of 20 years. RESULTS: The mean age was 39 (range, 11-73) years and 32 were male patients. Right side was involved in 60% of patients (n = 31). According to electrodiagnostic examinations, 44 patients (85%) had neurogenic causes; 29 spinal accessory nerve palsy (17 occurred after surgical procedure), nine long thoracic nerve palsy (four occurred after strenuous activity), two dorsal scapular nerve (both neuralgic amyotrophy), one long thoracic nerve and spinal accessory nerve (relevant with strenuous trauma), one spinal accessory nerve and dorsal scapular nerve palsies (after surgical procedure and radiotherapy), one C5-7 radiculopathy (avulsion), and one brachial plexopathy (obstetric trauma). Five patients (10%) had muscle-related findings (four facio-scapulo-humeral dystrophy and one Duchenne muscular dystrophia) and three patients (5%) had normal findings (bone-joint related). CONCLUSIONS: This study presents a relatively large series of patients with WS because of several causes from a referral tertiary EMG laboratory. The authors found that spinal accessory nerve palsy after neck surgery is the most common cause and long thoracic nerve palsy is the second common cause of unilateral WS. Electrodiagnostic examinations should be performed in WS patients to establish exact diagnosis and reveal some coexistence of WS causes.

Neurolysis of the distal segment of the long thoracic nerve for the treatment of scapular winging due to serratus anterior palsy: a continuous series of 73 cases.

BACKGROUND: Serratus anterior (SA) palsy following mechanical injury to the long thoracic nerve (LTN) is the most common cause of scapular winging. This study aimed to identify the factors influencing the outcome of neurolysis of the distal segment of the LTN. We hypothesized that poor results are due to duration before surgery and to persistent scapulothoracic dysfunction. METHODS: A retrospective study was conducted. The inclusion criteria were partial or complete isolated noniatrogenic SA paralysis of at least 4-month duration with preoperative electrophysiologic assessment confirming the neurogenic origin without signs of reinnervation. RESULTS: Seventy-three patients were assessed at 45 days, 6 months, and 24 months after neurolysis of the distal segment of the LTN. At the last follow-up, improvement was excellent in 38 (52%), good in 22 cases (30%), moderate in 6 (8%), and poor in 7 (10%). No patient showed deterioration in outcomes since the beginning of follow-up. Scapular winging was no longer present in 46 cases (63%), while it was minimal in 23 (31.5%). In 4 cases (5.5%), winging was similar to the preoperative condition. DISCUSSION: The best outcomes occurred in patients who presented without compensatory muscle pain and who were treated within 12 months of paralysis. Beyond this time frame, neurolysis can still provide useful functional improvement and avoid palliative surgery. CONCLUSION: Neurolysis of the distal segment of the LTN is a safe and reliable procedure. This technique allows treatment of SA muscle palsy and corrects scapular winging with excellent or good outcomes in 82% of cases.

Shrug radiographs for the diagnosis of long thoracic nerve palsy in traumatic brachial plexus injury.

BACKGROUND: Preoperative diagnosis of long thoracic nerve (LTN) palsy is important for shoulder reconstruction after a traumatic brachial plexus injury (BPI). In the present study, we developed an objective diagnostic method for LTN palsy for patients with traumatic BPI. METHODS: This is a retrospective review of 56 patients with traumatic BPI who had been receiving treatment at a single institution for over 8 years. The patients were divided into 2 groups: an LTN palsy group (n = 30) and a no palsy control group (n = 26). The LTN palsy group had 21 different palsy types with 4 and 5 C5-7 and C5-8, whereas the no palsy group had 18 different palsy types with 5 and 3 C5-6 and C5-8, respectively. Preoperative plain anteroposterior radiographs were taken in shoulder adduction and shrug positions. Scapulothoracic (ST) upward rotation and clavicle lateral (CL) rotation angles were measured on X-rays. The differences between the adduction and shrug positions for the respective angles were calculated and defined as ΦST and ΦCL, respectively. The differences in the ΦST and ΦCL values due to the presence or absence of LTN palsy were examined, the cutoff values of ΦST and ΦCL for the diagnosis of LTN palsy were determined, and further sensitivity and specificity were calculated. RESULTS: Both ΦST and ΦCL were significantly decreased in the LTN palsy group compared with the no palsy control group. The sensitivity and specificity for LTN palsy were 0.833 and 1.000 for ΦST and 0.833 and 0.840 for ΦCL, respectively, when the cutoff value was set as ΦST = 15° and ΦCL ≤ 24°. CONCLUSION: Dynamic shrug radiographs provide a useful objective diagnosis of LTN palsy after traumatic BPI.

Winged scapula following axillary thoracotomy with long thoracic nerve preservation.

Winged scapula is a rare condition caused by injuries to the long thoracic nerve (LTN) and accessory nerves. A 69-year-old man underwent surgery for right lung cancer. Video-assisted thoracic surgery was converted to axillary thoracotomy at the fourth intercostal space. The latissimus dorsi was protected, and the serratus anterior was divided on the side anterior to the LTN. Two months after discharge, he presented with difficulty in elevating his right arm and protrusion of the scapula from his back. Active forward flexion of the right shoulder was limited to 110° and abduction to 130°. He was diagnosed with winged scapula. After 6 months of occupational therapy, the symptoms improved. The LTN may have been overstretched or damaged by the electric scalpel. We recommend an increased awareness of the LTN, and to divide the serratus anterior at a site as far as possible from the LTN to avoid postoperative winged scapula.

Scapular winging on Exercise Cambrian Patrol: three soldiers in three days - an occupational risk?

Exercise CAMBRIAN PATROL is an internationally recognised, arduous patrolling exercise held annually in Mid-South Wales. The 2017 iteration of the exercise generated three uncommon shoulder injuries in three consecutive days, all of which were thought to have a similar aetiology. This article presents a case series of three instances of scapular winging in soldiers carrying heavy weight. We review the relevant anatomy and pathophysiology of long thoracic nerve injury and discuss management strategies of scapular winging. Occupational health considerations are reviewed, with respect to carrying large amounts of weight over distance and difficult terrain within the armed forces, along with discussion of a novel weight distribution system (VIRTUS) which has recently been brought into service by the British Army.

Anatomy, Etiology, and Management of Scapular Winging.

Scapular winging is a painful and debilitating condition. The composite scapular motion of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. The most common causes reported in the literature for scapular winging are dysfunction of the serratus anterior from long thoracic nerve injury causing medial winging or dysfunction of the trapezius from spinal accessory nerve injury causing lateral winging. Most reviews and teaching focus on these etiologies. However, acute traumatic tears of the serratus anterior, trapezius, and rhomboids off of the scapula are important and under-recognized causes of scapular winging and dysfunction. This article will review the relevant anatomy, etiology, clinical evaluation, diagnostic testing, and treatment of scapular winging. It will also discuss the differences in diagnosis and management between scapular winging arising from neurogenic causes and traumatic muscular detachment.

Initial Electromyography Fails to Predict Long-Term Outcome of Isolated Serratus Palsy.

BACKGROUND AND AIMS:: The course of isolated serratus palsy is difficult to predict, especially if, in initial electromyographic examination, long thoracic nerve function is totally absent. How initial electromyography correlates with long-term outcome of isolated serratus palsy is unknown. We evaluated initial electromyographic examinations of isolated serratus palsy patients and compared these to their long-term outcome. We hypothesized that long-term outcome after electromyographic examination-verified partial nerve injuries is better than that seen in cases of total nerve injuries. PATIENTS AND METHODS:: We retrospectively reviewed 90 patients with isolated serratus palsy and with initial electromyographic examination treated by brace or observation only, by determining pain, range of motion, and degree of scapular winging after a mean follow-up of 17.8 years. RESULTS:: Initial electromyographic examination showed total denervation in 21 cases (22%), partial severe denervation in 30 (33%), and partial moderate or slight denervation in 39 (44%). Recovery of serratus muscle function occurred in 17/21 cases (81%) of total denervation and in 47/69 cases (68%) of partial denervation, p = 0.247. Mean flexion in total denervation recovered to 152° and in partial to 157°, p = 0.301, and abduction to 173° and 174°, p = 0.970. In total denervation, 60% of patients were pain-free, in partial, 48%, p = 0.338. The duration of scapular winging among those 42 who subjectively recovered averaged 15.1 months, in 13 patients with total denervation 15.9 months, and in 29 patients with partial denervation 14.7 months (p = 0.599). CONCLUSION:: Initial electromyographic examination does not predict clinical outcomes: ROM, pain, scapular winging and strength, but partial denervation may negatively predict subjective outcome.

Scapular Winging Caused by Combined Palsy of the Spinal Accessory Nerve and the Long Thoracic Nerve: A Case Report.

CASE: A 37-year-old man with scapular winging, caused by combined palsy of the spinal accessory nerve and the long thoracic nerve, was successfully treated with a pectoralis major transfer to substitute for the serratus anterior muscle, and with levator scapulae and rhomboid muscle transfers to substitute for the trapezius muscle. CONCLUSION: The serratus anterior paralysis was thought to have occurred secondary to traction of the long thoracic nerve by the unsupported scapula following the spinal accessory nerve palsy. Even with combined paralyses of the serratus anterior and trapezius muscles, combined muscle transfers that substitute for the paralyzed muscles can improve shoulder function.

MR neurography (MRN) of the long thoracic nerve: retrospective review of clinical findings and imaging results at our institution over 4 years.

OBJECTIVE: Long thoracic nerve (LTN) injury can result in ipsilateral serratus anterior palsy and scapular winging. Traditional means of evaluating patients with suspected LTN injury include physical examination and electrodiagnostic studies. The purpose of our study is to describe high-resolution magnetic resonance (MR) findings in patients with clinical suspicion of LTN neuropathy. METHODS: In this HIPAA-compliant, IRB-approved, retrospective study, two radiologists reviewed MR imaging performed for long thoracic neuropathy. Clinical presentation, electrodiagnostic studies and MR imaging of 20 subjects [mean age 37 ± 13 years; 25% (5/20) female] were reviewed. Observers reviewed MR imaging for LTN signal intensity, size, course, presence or absence of mass and secondary findings [skeletal muscle denervation (serratus anterior, trapezius, rhomboid) and scapular winging]. Descriptive statistics were reported. RESULTS: Clinical indications included trauma (n = 5), hereditary neuropathy (n = 1), pain (n = 8), winged scapula (n = 6), brachial plexitis (n = 4) and mass (n = 1). Electrodiagnostic testing (n = 7) was positive for serratus anterior denervation in three subjects. Abnormal LTN signal intensity, size, course or mass was present in 0/20. Secondary findings included skeletal muscle denervation in the serratus anterior in 40% (8/20), trapezius in 20% (4/20) and rhomboid in 20% (4/20). In 5% (1/20), an osteochondroma simulated a winged scapula, and in 2/20 (10%) MR showed scapular winging. CONCLUSIONS: High-resolution MR imaging is limited in its ability to visualize the long thoracic nerve directly, but does reveal secondary signs that can confirm a clinical suspicion of LTN injury.

Long Thoracic Nerve Injury Caused by Overhead Weight Lifting Leading to Scapular Dyskinesis and Medial Scapular Winging.

Scapular winging represents a rare phenomenon that most commonly results from nerve damage to either the long thoracic nerve, spinal accessory nerve, or, less commonly, the dorsal scapular nerve. This injury results in an abnormal scapulohumeral interaction during kinetic motion known as scapular dyskinesis. In this case report, the patient presented with scapular dyskinesis and medial scapular winging caused by overhead weight-lifting exercises, and a long thoracic nerve injury was diagnosed. Physicians are encouraged to consider long thoracic nerve damage in a patient with a history of repetitive overhead movements who presents with scapular dyskinesis and the corresponding restriction of overhead arm motions. Potential mechanisms of injury and treatment options are also discussed.

[Scapula alata following a gunshot injury]. / Scapula alata na een schotverwonding.

BACKGROUND: The clinical condition "winged scapula" (scapula alata) is frequently not recognized as such. The accompanying symptoms are often attributed to more frequently occurring shoulder disorders, which can lead to unnecessary surgical procedures. CASE DESCRIPTION: A 41-year-old man was shot during a robbery 3 years ago, resulting in a complete paraplegia from the fourth thoracic vertebra downwards. Within a year of the attack, during rehabilitation towards wheelchair use, he developed pain around his right shoulder. He also had diminished strength when extending his right arm and problems with trunk balance. These symptoms were long thought to be caused by shoulder overuse during wheelchair use, but turned out to be a consequence of injury to the long thoracic nerve. CONCLUSION: Shoulder symptoms due to scapula alata can be caused be a penetrating wound leading to nerve injury. The treatment of patients with a scapula alata calls for a multidisciplinary approach.

A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy.

BACKGROUND: In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes. METHODS: A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence. RESULTS: (1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P = .009) and had lower active forward elevation (P < .001) and ASES scores (P = .0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3 years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores. CONCLUSIONS: Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.

Outcome of transfer of the sternal head of the pectoralis major with its bone insertion to the scapula to manage scapular winging.

HYPOTHESIS: The purpose of this study was to evaluate the outcome of transfer of the sternal head of the pectoralis major with its bone insertion to the inferior pole of the scapula for symptomatic winging. METHODS: Our study included 51 patients with serratus anterior dysfunction secondary to chronic muscle or long thoracic nerve injury. Indications included pain, scapular winging, and limited active motion after failed conservative management. All patients underwent transfer of the sternal head of the pectoralis major with its bone insertion to the scapular inferior pole. Computed tomography scan was performed at 3 months postoperatively to evaluate bone healing. RESULTS: At an average follow-up of 29 months (range, 12-46 months), 45 patients had complete and 6 patients had partial resolution of the scapular winging. Patients had significant improvements in their shoulder abduction, forward flexion, and pain levels (P < .01). The mean shoulder Constant score improved from 49 preoperatively to 82 postoperatively; the shoulder subjective value improved from 60% to 84%; and the Disabilities of the Arm, Shoulder, and Hand score improved from 58 to 14 (P < .01). Computed tomography scans at an average of 3 months postoperatively demonstrated full healing in 41 patients and partial healing in 10. CONCLUSION: Pectoralis major transfer of the sternal head with its bone insertion to the inferior pole of the scapula is a reliable transfer to stabilize and to restore the function of the scapula in patients with symptomatic winging. This technique allows the ability to directly transfer the tendon to the scapula with bone-to-bone healing, leading to faster healing and a quicker return to unrestricted activities.

Lateral Pectoral Nerve Injury Mimicking Cervical Radiculopathy.

The lateral pectoral nerve (LPN) is commonly injured along with the brachial plexus, but its isolated lesions are rare. Here, we present a case of an isolated LPN lesion confused with cervical radiculopathy. A 41-year-old man was admitted to our clinic because of weakness in his right arm. Previous magnetic resonance imaging (MRI) examination revealed right posterolateral protrusion at the C6-7 level. At the initial assessment, atrophy of the right pectoralis major muscle was evident, and mild weakness of the right shoulder adductor, internal rotator, and flexor muscles was observed. Therefore, electrodiagnostic evaluation was performed, and a diagnosis of isolated LPN injury was made. Nerve injury was thought to have been caused by weightlifting exercises and traction injury. Lateral pectoral nerve injury can mimic cervical radiculopathy, and MRI examination alone may lead to misdiagnosis. Repeated physical examinations during the evaluation and treatment phase will identify the muscle atrophy that occurs 1 or more months after the injury.

Scapula alata: description of a physical therapy program and its effectiveness measured by a shoulder-specific quality-of-life measurement.

BACKGROUND: To date, there are no published outcomes-based treatment programs to guide clinicians when managing patients with scapula alata. The purposes of this study were to describe a physical therapy program in patients with scapula alata and to evaluate its effect using a shoulder-specific quality-of-life measurement. METHODS: In this case series and retrospective study, 22 patients (11 female patients) with a median age of 34 years (interquartile range, 28-44 years), diagnosed with scapula alata caused by injury to the long thoracic nerve, were successively referred as outpatients to a physical therapy program at a university hospital. The program included (1) physical examination, (2) thoracic brace treatment, and (3) muscular rehabilitation. The treatment frequency and duration were determined individually. The effect was evaluated by a shoulder-specific quality-of-life questionnaire, the Western Ontario Rotator Cuff (WORC) Index. The WORC Index is grouped into 5 domains: physical symptoms, sport/leisure time, work, lifestyle, and emotional health. RESULTS: The results showed a highly significant improvement (P < .001) from pretest to post-test as measured by all 5 domains in the WORC Index. CONCLUSIONS: This study described in detail a physical therapy program; the program showed significant benefit. Further research is needed before recommending the program as a potential treatment option.

Dorsal scapular neuropathy causing rhomboids palsy and scapular winging.

Most cases of scapular winging (SW) are attributed to either long thoracic or spinal accessory nerve lesions. Dorsal scapular nerve lesions are quite rare and the literature contains very few case reports of SW secondary to rhomboid paralysis. We are reporting the unusual case of a young patient who developed right-side scapular winging due to dorsal scapular neuropathy and rhomboids palsy, and we highlight the role of conservative treatment and rehabilitation for cases of mild/medium injury to the dorsal scapular nerve or to the rhomboid muscles. For those cases, physiotherapy is recommended, and this is mainly aimed at strengthening the trapezius in order to compensate for rhomboids weakness.