Shoulder Resources

Scapular winging (R) Scapular winging (R)

• Primary
• Neurological
• i. Accessory nerve
• ii. Long thoracic nerve
• iii. Dorsal scapular nerve
• Osseous
• i. Osteochondromas
• ii. Malunion
• Soft tissue
• i. Contractures
• ii. Muscle avulsion
• iii. Muscle agenesis
• iv. Bursitis
• Secondary to shoulder pathology
• Voluntary

Observe first from behind with arms at side.
Look for a static deformity, atrophy of the trapezius, medial border of scapula (rhomboids).
Observe during forward elevation, for scapulothoracic rhythm and dynamic deformity.
Palpate for crepitus.
Then test for winging during resisted motion.

Accessory palsy
The spinal accessory nerve emerges from the sternocleidomastoid muscle to run across the posterior triangle and enter the trapezius (the cervical plexus nerves enter the posterior triangle behind SCM). It contains segments from C1-5. The trapezius is also innervated by cervical plexus nerves C3-4 which supply proprioception and occasionally some motor function. Injury can be caused by blunt trauma, traction or penetrating trauma. Surgical misadventure can occur during biopsy of nodes in the posterior cervical triangle. After injury the patient's shoulder is depressed and the scapula is translated laterally with the inferior angle rotated laterally. The patient tries to compensate for this by increased use of the rhomboids and levator scapulae, which can be lead to painful spasm. On examination there is trapezius wasting, inability to shrug and weakness on elevation and abduction of the arm. The diagnosis can be confirmed by EMG studies. Initial treatment consists of physiotherapy to maintain a full range of shoulder movement, thus preventing a frozen shoulder.

Surgical treatment, in the event of no recovery, can be grouped into three options:
• Scapulothoracic fusion
• Static fascial slings
• Dynamic transfers
Scapulothoracic fusions lead to a drastic decrease in shoulder ROM, and fascial slings stretch out over a period of a couple of years. Thus, dynamic transfers are preferred.
The preferred procedure is the Eden-Lange transfer (remember as the NZ transfer), which consists of transferring the insertions of the levator and rhomboids with attached bone blocks laterally (By around 5cm). Bigliani reported good or excellent results in 87% of the 23 patients in his series.

Serratus anterior winging
The long thoracic nerve (C5-7) originates from the roots of the brachial plexus, and runs down the medial wall of the axilla, anterior to the mid axillary line to innervate serratus anterior.
Damage is usually due to blunt trauma or stretching, and has been reported in almost all sports. Brachial neuritis also commonly affects this nerve. Prolonged bed rest has been reported to trigger dysfunction of the nerve.
When the LTN is injured, the scapula assumes a position of superior elevation and the inferior angle rotates medially.
Patients complain of pain from other muscles which are in spasm from trying to compensate for the actions of serratus.
Pushing against a wall and attempted elevation above the head magnify symptoms.
Initial treatment consists of ROM exercises.
Most injuries of the LTN recover within a year. If there is no recovery and symptoms warrant it a muscle transfer can be performed. The one most commonly employed is the Marmor-Bechtol transfer, which uses the sternocostal head of pectoralis major, prolonged by a 7 inch tube of fascia lata, passed through a foramen created at the inferior angle of the scapula. This operation has success rates of 70-90% in the literature.

Rhomboid major and minor winging
These muscles are innervated by the dorsal scapular nerve (C5) which runs deep to levator, on serratus posterior superior.
Palsy of these muscles is a rare cause of winging.
The clinical picture is similar to that seen in trapezius palsy, with the shoulder slightly depressed, the scapula laterally translated and the inferior angle rotated laterally.
Treatment is nonsurgical with trapezius strengthening exercises in most cases.
Occasionally a fascial sling operation is used to connect the lower border of the scapular to the spinal muscles and latissimus dorsi.

Osseous problems
Osteochondromas are the commonest tumours of the scapula, and if found on the deep surface of the scapula may produce a fixed winging and scapular crepitus.
EMG findings are normal; XR and CT scans demonstrate the abnormality.
Treatment is resection of the abnormal bone.

Muscular problems
Agenesis of various parascapular muscles may occur e.g. in Poland syndrome, but is usually not a functional problem.
Avulsion of the serratus has been reported, and surgical reattachment is indicated.

Bursal origin
Rarely the scapulothoracic articulation can be affected by a bursitis. This causes a painful impairment of scapulothoracic rhythm, and can be addressed with NSAIDs or surgical bursectomy.

Secondary winging

Contractural winging
Contractures around the glenohumeral joint produce a secondary winging as the patient attempts to place the arm in the desired position.
One example is seen in obstetric brachial plexus palsy when the arm can assume an ad ducted and internally rotated posture. When attempting to abduct and externally rotate the arm, the superior corner of the scapula can project away from the chest wall at the upper margin of the trapezius, producing the “scapular sign of Putti”.
Contractural winging can also occur with deltoid fibrosis, which may occur secondary to multiple deltoid injections.

Glenohumeral pathology
Secondary scapular winging may occur with frozen shoulder, instability and impingement. Patients with painful shoulders may reflexively limit glenohumeral motion and attempt to compensate with increased scapulothoracic motion. This fatigues the periscapular muscles, and weakening of the muscles leads to fatigue.

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