Shoulder and Elbow cases scapular winging

A 28-year-old, male, left hand-dominant, factory worker, and avid weight lifter presents to clinic complaining of 1 month history of right shoulder pain that is worse when lifting weights. He also notices the pain occasionally while driving to and from work. He does not have any other medical issues and denies any history of trauma to the right upper extremity. Physical examination reveals medial rotation of the inferior border of the right scapula when the patient raises his left arm in forward flexion (Fig. 2–60). He has 5/5 strength in forward flexion, external rotation, and shoulder abduction and no asymmetry in shoulder shrug. Radiography reveals no abnormalities.

 

 

 

Figure 2–60

 

The patient’s abnormal physical examination finding is most likely due to an abnormality involving which nerve and the muscle it innervates?

1. Spinal accessory nerve/trapezius

2. Long thoracic nerve/serratus anterior

3. Dorsal scapular nerve/rhomboid major

4. Thoracodorsal nerve/latissimus dorsi

 

Discussion

The correct answer is (B). The patient has evidence of medial scapular winging on physical examination, which is caused by injury to the long thoracic nerve and dysfunction of the serratus anterior muscle. This is the most common cause of scapular winging. Lateral scapular winging, which is most commonly due to injury to the spinal accessory nerve and dysfunction of the trapezius muscle (Choice A), would present as lateral rotation of the inferior border of the scapula and may combine with difficulty to shrug (Fig. 2–61). Rhomboid palsy due to dorsal scapular nerve injury (Choice C) is a less common cause of lateral winging. Latissimus dorsi palsy (Choice D) is not involved in either medial or lateral scapular winging. Table 2–9 outlines the most common causes of scapular winging.

 

 

 

Figure 2–61

 

Table 2–9 ETIOLOGY OF SCAPULAR WINGING‌

 

Medial winging   Lateral winging

Trauma: injury to long thoracic nerve (serratus anterior palsy) from MVA, collision sports, upper extremity overuse Compression of LTN by middle scalene muscle, between clavicle and second rib, at inferior angle of scapula Iatrogenic: intraoperative positioning, injury during ACDF, mastectomy, thoracostomy tube, etc. Transient brachial neuritis, Guillain–Barré , SLE, Arnold–Chiari malformation Trauma: injury to spinal accessory nerve (trapezius palsy) or to dorsoscapular nerve (rhomboid palsy) from falls, MVA, blunt trauma in football/hockey, penetrating trauma Compression of DSN by middle scalene muscle, C5 radiculopathy Iatrogenic: cervical lymph node biopsy

From Meininger A, Figurerres B, Goldberg B. Scapular winging: an update. JAAOS. 2011;19(8):453–462.

 

What is the most likely etiology of this patient’s pain and deformity?

1. Blunt trauma

2. Penetrating trauma

3. Repetitive motion

4. Guillain–Barré syndrome

 

Discussion

The correct answer is (C). with a hobby of weight lifting and working at a factory, repetitive motion is the most likely cause of a stretch injury to the long thoracic nerve resulting in serratus anterior palsy. The long thoracic nerve may also be damaged due to positioning during various procedures involving the chest wall. Guillain–Barré syndrome (Choice D) is another possible cause of serratus anterior

palsy, but is much less common and therefore less likely to be the cause of this particular patient’s nerve injury. Choices A and B are more likely to be the cause of spinal accessory nerve injury and resultant lateral winging.

What is the most appropriate next step for this patient with medial scapular winging?

1. Electromyography of the bilateral upper extremities

2. MRI of the right shoulder without contrast

3. Arthroscopic decompression of the suprascapular nerve

4. Scapular bracing to stabilize the scapula against the thorax

 

Discussion

The correct answer is (A). The patient’s long thoracic nerve should be evaluated using electromyography (EMG) to obtain a baseline assessment of any extant nerve injury. Other initial interventions may include NSAIDs, activity modification avoiding elevation of the arm above shoulder level, and physical therapy to strengthen the rotator cuff muscles and scapular stabilizers. Scapular bracing (Choice D) is another option for conservative management of scapular winging but is often uncomfortable and difficult to enforce in terms of patient compliance. MRI (Choice B) is not indicated at this time as it would not contribute to any clinical decision-making. Entrapment of the suprascapular nerve (Choice C) would lead to atrophy of the infraspinatus and/or supraspinatus muscles, not scapular winging.

The patient undergoes an EMG showing conduction abnormalities of the long thoracic nerve. Physical therapy, stopping weight lifting, and scapular bracing do not relieve his pain. It is now approximately 1 year since his initial diagnosis.

What is the most appropriate intervention at this time?

1. Scapulothoracic fusion

2. Eden–Lange dynamic muscle transfer

3. Latissimus dorsi tendon transfer

4. Pectoralis major tendon transfer

 

Discussion

The correct answer is (D). Medial scapular winging and pain that does not respond to conservative management is an indication for operative intervention with transfer of the sternal head of the pectoralis major muscle to the inferior border of the scapula to replace the function of the serratus anterior. Eden–Lange dynamic muscle

transfer (Choice B) involves lateralization of the rhomboid muscles as well as the levator scapulae at their insertions on the scapula to act in place of the trapezius and would be indicated for lateral scapular winging caused by injury to the spinal accessory nerve. Scapulothoracic fusion (Choice A) would only be indicated if the patient continued to have pain and deformity following dynamic muscle transfer. Latissimus dorsi transfer (Choice C), while a type of dynamic muscle transfer, is not indicated for scapular winging but would be more appropriate for cases of massive rotator cuff tear.

 

Objectives: Did you learn...?

 

 

Recognize the clinical presentation of a patient with scapular winging? Distinguish between medial and lateral scapular winging?

 

Treat a patient with scapular winging?