Scapular Winging

Topic updated on 04/29/15 7:49pm

  •  Two types based on direction of top-medial corner of scapula
    • medial winging
      • serratus anterior (long thoracic nerve 
    • lateral winging
      • trapezius (CN XI - spinal accessory nerve)
  • Differentiating medial and lateral winging
    • history
      • medial winging
        • usually seen in young athletic patient
        • far more common
      • lateral winging 
        • history of neck surgery (lateral is usually iatrogenic)
    • physical exam
      • medial winging  
        • medial spine of scapula moves upward and medial
      • lateral winging  
        • medial spine of scapula moves downward and lateral
  • Scapula serves as the attachment site for 17 muscles
    • function to stabilize the scapula to the thorax, provide power to the upper limb, and synchronize glenohumeral motion.
  • Normal motion
    • elevation and upward rotation 
      • by trapezius muscle. 
    • scapular protraction (anterior and lateral motion) 
      • by serratus anterior and pectoralis major and minor muscle
    • scapular retraction (medial motion)
      • by rhomboid major and minor muscles.
Medial Winging
  •  Introduction
    • caused by deficit in serratus anterior  due to injury to the long thoracic nerve (C5,6,7  
    • Mechanisms of injury to long thoracic nerve
      • iatrogenic from anesthesia
        • 10% of patients with medial scapular winging had prior surgery
      • repetitive stretch injury (most common)
        • increased risk with head tilted away during overhead arm activity
        • e.g., weight lifters, volleyball players
      • compression injury
        • direct compression of nerve at any site, including the lateral chest wall seen with contact sports and trauma
      • scapula fracture 
  • Presentation
    • symptoms
      • shoulder and scapula pain
      • weakness when lifting away from body or overhead activity
      • discomfort when sitting against chair
    • physical exam 
      • superior medial scapula elevates and migrates medial  
  • Treatment
    • nonoperative
      • observation, bracing, and serratus anterior strengthening
        • indications
          • observation for a minimal of 6 months- wait for nerve to recover
        • technique
          • bracing with a modified thoracolumbar brace
    • operative
      • pectoralis transfer  
        • indications
          • failure of spontaneous resolution after 1-2 years
Lateral Winging
  •  Introduction
    • caused by deficit in trapezius due to spinal accessory nerve injury (CNXI) 
    • often caused by an iatrogenic injury (by general surgery or neurosurgery looking for lymph nodes in posterior neck) 
  • Physical exam
    • superior medial scapula drops downward and lateral
      • shoulder girdle appears depressed or drooping
  • Treatment
    • nonoperative
      • observation and trapezius strengthening
    • operative options include
      • nerve exploration
        • indications
          • iatrogenic nerve injury
      • Eden-Lange transfer  
        • lateralize levator scapulae and rhomboids (transfer from medial border to lateral border) 
      • scapulothoracic fusion


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Qbank (8 Questions)

(SBQ07.9) 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: Topic Review Topic

1. Lateral winging due to spinal accesory nerve injury
2. Medial winging due to spinal accesory nerve injury
3. Lateral winging due to long thoracic nerve injury
4. Medial winging due to long thoracic nerve injury
5. Scapular dyskinesia due to cervical radiculopathy

(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? Topic Review Topic
FIGURES: A          

1. Nerve roots C4-7
2. Nerve roots C6-7
3. Cranial nerve XI
4. Nerve roots C3-5
5. Cranial nerve XII

(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? Topic Review Topic

1. Spinal accessory nerve
2. C8 and T1 nerve roots
3. Upper and lower subscapular nerves
4. Thoracodorsal nerve
5. Long thoracic nerve

(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? Topic Review Topic

1. C7, C8, T1
2. C6, C7, C8
3. C5, C6, C7
4. C4, C5, C6
5. C3, C4, C5

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

1. Teres minor atrophy
2. Infraspinatus atrophy
3. Latissimus dorsi atrophy
4. Medial scapular winging
5. Lateral scapular winging

(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? Topic Review Topic
FIGURES: A   B        

1. A
2. B
3. C
4. D
5. E

(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? Topic Review Topic

1. Suprascapular
2. Axillary
3. Long thoracic
4. Thoracodorsal
5. Radial

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