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Winged Scapula

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Other Names

  • Winging of the scapula
  • Scapular Winging
  • Serratus Anterior Palsy
  • Trapeizus Palsy

Background

History

  • First described by Winslow in 1723[1]

Epidemiology

  • Rare clinical entity, incidence and prevalence unknown
  • Fardin et al: 15 cases in 7000 patients seen in EMG lab[2]
  • Ghormley: 1 case in 38,500 patients at Mayo Clinic[3]

Pathophysiology

  • Medial vs lateral is defined by direction of superomedial corner of the scapula
  • Medial winging
  • Lateral winging
  • Consequences
    • These muscle groups responsible for keeping the medial border of the scapula protracted against the posterior thorax
    • Denervation or paralysis leads to winging of the medial scapula

Etiology

  • Serratus Anterior Palsy
    • Most common: repetitive stretch injury represents >50% of cases (need citation)
    • Trauma (blunt trauma, depression of shoulder girlde, sudden twisting of neck or shoulder)
    • Atraumatic (infection, allergic, toxicology, muscular dystrophy)
    • Idiopathic
    • Surgical procedures (mastectomy, first rib resection, thoracotomy)
  • Trapezius Palsy
    • Traumatic (traction, MVC, direct trauma, heavy lifting, pentrating wounds)
    • Iatrogenic represents 71% of cases (cervical lymph node biopsy, cervical mass exision)[4]
    • Spontaneous or Idiopathic
  • Rhomboid Palsy
    • Trauma (entrapment, direct trauma, shoulder dislocation)

Pathoanatomy


Risk Factors

  • Sports (with documented cases)
    • Archery
    • Ballet
    • Baseball
    • Basketball
    • Weight lifting
    • Bowling
    • Football
    • Golf
    • Gymnastics
    • Hockey
    • Soccer
    • Tennis
    • Wrestling
    • Ballet[5]
  • Occupations (with documented cases)
    • Mechanic
    • Navy Airmen
    • Scaffolders
    • Welders
    • Carpenters
    • Laborers
    • Seamstress

Differential Diagnosis


Clinical Features

  • General: Physical Exam Shoulder
  • History
    • Careful review of medical history, trauma, occupation, sports, etc
    • Patient will report difficulty elevating the arm and lifting objects
    • Vague, non specific shoulder pain and fatigue
    • Subjective shoulder instability
  • Physical Exam
    • Serratus anterior palsy: inferior-medial scapula elevates, protrudes posteriorly-medially
    • Trapezius palsy: superior-medial scapula drops, protrudes posteriorly-laterally
      • Atrophy/wasting of the ipsilateral trapezius
    • Abduction limited
    • Weakness with forward flexion, abduction
  • Special Tests

Evaluation

  • The diagnosis is primarily clinical

Radiographs

Ultrasound

  • Neuromuscular ultrasound may be used to determine if muscular or neurologic pathology is present

EMG/NCS

  • Electromyography and nerve conduction studies allow for determination of the specific damaged nerve.
  • Will demonstrate:
    • Resting denervation potentials
    • Decreased motor unit recruitment
    • Polyphasic motor unit potentials during volitional activity
  • Unclear if improvement on serial EMG over time correlates with improved clinical outcome[6]

Classification


Management

Prognosis

  • Possible to recovery most or all function, typically between 1 and 24 months
  • Mild deficits, asymptomatic winging may persist after functional recovery[7]
  • Up to 25% of patients will maintain scapular winging after conservative therapy and be surgical candidates[8]

Nonoperative

  • First line treatment
  • Activity modifcation, avoiding overhead activities or painful activities
  • NSAIDS
  • Physical Therapy
    • Avoid excessive stretching
  • Consider bracing
    • Scapular Brace for serratus anterior palsy
    • Shoulder Orthosis for trapezius palsy

Operative

  • Indications
    • Failure of conservative therapy (typically 6-24 months)
  • Technique (serratus anterior)
    • Scapulothoracic arthrodesis (fusion)
    • Scapulopexy (fascial graft without fusion)
    • Dynamic muscle transfer (using head of pec major)
  • Technique (trapezius)
    • Neurolysis
    • Eden-Lange muscle transfer procedure (levator scap & rhomboid)
  • Technique (rhomboids)
    • Scapulopexy
    • Neurolysis
    • Scapulothoracic arthrodesis

Rehab and Return to Play

Rehab

  • Watson and Schenkman protocol for long thoracic nerve injury[9]
  • Acute stage
    • Denervation of the serratus anterior causes pain
    • Goals of treatment include pain reduction and ROM exercise
    • Activity modification to limit further injury to the shoulder.
  • Intermediate stage
    • Pain has subsided and the nerve is beginning to heal
    • Maintain full ROM, passive stretching prevent contracture of muscles due to the loss of serratus anterior activity.
  • Late stage
    • The serratus anterior becomes progressively stronger, shoulder mechanics improve.
    • To improve strength and overhead work, strengthening exercise of all shoulder girdle muscles
    • Avoidance of overstretching the serratus anterior should be continued.

Return to Play

  • Needs to be updated

Complications


See Also


References

  1. Winslow M. Panckouke: Chez; 1723. Sur quelques mouvements extraordinaires des omoplates et des bras, et sur une nouvelle espece de muscles
  2. Fardin P, Negrin P, Dainese R. The isolate paralysis of the serratus anterior muscle: clinical and electromyographical follow-up of 10 cases. Electromyogr Clin Neurophysiol 1978;18:379–86.
  3. Overpeck DO, Ghormley RK. Paralysis of the serratus magnus muscle caused by lesion of the long thoracic nerve. JAMA 1940;114:1994–6.
  4. Donner TR, Kline DG. Extracranial spinal accessory nerve injury. Neurosurgery 1993;32:907–11.
  5. White SM, Witten CM. Long thoracic nerve palsy in a professional ballet dancer. Am J Sports Med 1993;21:6326–628.
  6. Martin, Ryan M., and David E. Fish. "Scapular winging: anatomical review, diagnosis, and treatments." Current reviews in musculoskeletal medicine 1.1 (2008): 1-11.
  7. Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, Das M. Serratus anterior paralysis in the young athlete. J Bone Joint Surg 1979;61:825–32.
  8. Fery A. Results of treatment of anterior serratus paralysis. In: Post M, Morrey BF, Hawkins RJ, editors. Surgery of the shoulder. St. Louis: Mosby Year Book;1990. p. 325–9.
  9. Watson CJ, Schenkman M. Physical therapy management of isolated serratus anterior muscle paralysis. Phys Ther 1995;75:194–202.
  10. Kauppila LI, Vastamaki M. Iatrogenic serratus anterior paralysis. Long-term outcome in 26 patients. Chest 1996;109:31–4.
Created by:
Connor Farrell on 4 August 2019 15:51:29
Last edited:
13 November 2020 14:13:43
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