Winged Scapula

 

Classification

 

Primary

 

Due to scapulothoracic articulation disorder

 

1.  Neurological Origin

 

A.  Spinal Accessory Nerve / Trapezius palsy

B.  Long Thoracic Nerve /  Serratus Anterior palsy

C.  Dorsal Scapular Nerve / Rhomboids palsy (rare)

 

2.  Osseous Origin

 

Osteochondromas (tangential x-rays, CT useful)

Fracture malunions

 

3.  Soft Tissue Origin

 

Muscular Origin

- traumatic ruptures of Serratus Anterior

- iatrogenic during thoracotomy

 

Secondary

 

Due to GHJ articulation disorders

A.  Erb's palsy

B.  Deltoid fibrosis

C.  Painful conditions i.e. RC tear, fracture, impingement

 

Voluntary

 

Rare

 

Trapezius Winging / Spinal Accessory Nerve

 

Anatomy

 

C3, 4

-  supplies Sternocleidomastoid

-  then runs in posterior triangle of neck to supply Trapezius (Upper 1/2)

 

Aetiology

 

Stab wounds to neck

Operations on posterior triangle (Lymph node biopsy)

Traction injuries

 

History

 

Pain

- will attempt to compensate by using levator scapulae

- can lead to disabling pain and spasm

- pain can also be from secondary effects (impingement / radiculopathy / Brachial plexus traction)

 

Examination

 

Shoulder depressed

- scapula translated lateral 

- inferior angles rotated laterally

 

Trapezius wasting

- unable to shrug shoulders

- weakness with protraction

 

Non operative management

 

Reasonable for a time for traction injury

- physio

- wait 6 - 12 weeks

 

Operative

 

1.  Neurorrhaphy

- direct repair for open laceration

 

2.  Nerve Graft

 

3.  Levator scapulae and Rhomboid transfer

- Eden-Lange procedure

- most common

 

Technique

- L. Scapulae to medial acromion

- R. minor upper 1/3

- R. major middle 1/3

 

4.  Scapulothoracic Fusion

- reasonable pain relief

- poor function

- high complication rate

 

Serratus Anterior winging / Long Thoracic Nerve

 

Anatomy

 

C 5, 6, 7 from Roots

- runs down posterior axillary wall

- deep to fascia

- posterior to midaxillary line

- supplies Serratus Anterior

 

Action

- boxer's muscle

- protracts scapula

 

Origin

- fleshy slips

- upper 8 or 9 ribs

 

Insert

- costal aspect medial margin

 

Aetiology

 

Surgery

- shoulder or neck operations

- 1st rib resection

- mastectomy

 

Carrying loads on shoulder

 

Trauma

 

Repetitive microtrauma - swimming

 

Examination

 

Winging of scapula

- scapula medial

 

Management

 

1.  Nerve Transfer 

- TDN to LTN

 

2.  Stabilisation of scapula / Marmor-Bechtol transfer

- transferring sternocostal head Pectoralis major to inferior corner scapula

- require fascia lata extension